Publications
APS Bulletin • Volume 10, Number 3, May/June 2000
History of Pain
Marcia Meldrum, PhD, Department Editor
Pain and the Medieval Physician
Fernando Salmón, MD PhD
The Middle Ages have fueled Western imagination with the most bizarre representations of human pain. Yet, paradoxically, medical historians have shown little interest in the topic. The late Roselyne Rey, in her ambitious survey History of Pain, accurately described the Middle Ages and pain as “a world to investigate” (Rey, 1993, p. 54). In a recent article, historian Esther Cohen (1995) endorsed the prevailing view that within the cultural frame provided by an all-encompassing Christian weltanschauung, pain was a neglected subject among physicians.
Religion and pain
Certainly religion permeated all spheres of medieval life. Sufferers and healers alike would have described and experienced pain within a culture pervaded by the image of a suffering Christ. Scholars incorporated this religious imagery into philosophical theory. The centrality of pain in the Christian definition of what it meant to be human — notably in Adam’s newfound ability to suffer after his fall and in Christ’s humanity as proven by his physical suffering — was accepted by the arts schools at the major universities of the 13th century. Arts and medicine faculties used Aristotle’s works of natural history to teach students that pain was essential to the definition of human beings as living animals (Borgnet, 1890Ð1898). Works from the medical tradition, such as the Hippocratic De natura hominis, were also used in the 13th century to show that pain was a defining human characteristic (Jouanna, 1975). It is not difficult to assume that the medical problem of pain was perceived as relatively insignificant.
However, I must disagree with Cohen’s reading (1995) of the attitude of late medieval physicians towards pain. In a medical practice based on Hippocratic and Galenic sources, pain was significant both in theory and in practice. Pain was understood as a cause of diseases, such as fainting disorders or abscesses, as a disease in itself, and as a major prognostic and diagnostic symptom. Well-known medical treatises in Latin and in the vernacular devoted extensive discussion to those diseases in which pain was the core symptom and to the most effective remedies to alleviate it. The widely read Thesaurus pauperum, for example, was built around a list of pain-related diseases and pain-killing drugs (De Rocha Pereira, 1973). Pain killers also appeared in other literary genres, such as the medical consilia (popular health advice tracts) and collections of medicinal recipes. The Fachprose (practical text) literature reflects the popular demand for pain relief,* as do works on common surgical techniques (McVaugh, 1998).
Pain and the university
This article focuses not on the practical treatment of pain, but on its definition as a medical entity by the physicians of the great European universities of the late 1200s and early 1300s. I argue that pain, far from a neglected problem, was an important concern of the university-trained physician in this period. The construction of pain as a distinctive medical issue helped to shape for him a cultural space and a professional arena distinct both from the practice of empirical healers and from the theoretical discussions of theologians and natural philosophers.
By 1300, medicine was a well-established branch of study at several European universities. It had a well-defined technical literature and shared with the arts a grounding in Aristotelian logic and natural philosophy. The university medical masters of Paris, Montpellier, and Bologne had already enlarged the literature by adopting a number of newly translated works by Galen. Among these works were Galen’s main treatises on pathology, De interioribus, and De morbo et accidenti, and the brief De malicia complexionis diverse (Garc’a Ballester, 1982). Pain was an important topic in each of these treatises, featured as a critical diagnostic symptom in chapters 3, 4, and 10 of De malicia and in book II of De interioribus and as a complex theoretical question in book IV of De morbo. Together with Galen’s technical works and enhanced by the Canon of Avicenna and other Islamic commentaries, these treatises were popular among the medical elite and helped to rewrite old questions about pain and to set forth new ones.
How could the university medical master of the late 13th century turn the spiritually defined experience of pain into a medical reality? The medical master began by using the twin pillars that sustained institutional medical knowledge: the authority of the ancients and the logical apparatus based on Aristotelian principles. Through reference to and reinterpretation of the ancients, the university physicians developed new doctrines attributing pain to malicia complexionis, changes in the balance of the bodily humors, or to solutio continuitatis, a break in the body’s continuity such as a wound or fracture.
Syllogistic reasoning
The flexibility of syllogistic reasoning allowed academic instructors to present a wide range of subjects as questions for debate. Using the doctrinal ground established by the ancients and the techniques provided by scholasticism, the medical master analyzed the perception and nature of pain for his students. Questions such as Was pain a kind of alteration in the action of sensation? How was pain perceived? Was pain an object of the senses? Was it possible to differentiate between the cause of pain and pain itself? Could only the sense of touch feel pain? and What painful or delightful effects were provided by the objects of the senses? were common themes in the public lectures (Salmón, 1996).
Patients’ voices
But ancient philosophers and physicians were not the only source of authority for questions concerning pain. Patient voices were also invested with authority and introduced into the academic arena. In building their medical discourse around pain, the university masters used both live patient narratives and those drawn from written sources. Taddeo Alderotti (1223-c.1295), medical professor at Bologna, used examples from written material to discuss why mentally ill people did not always perceive pain and whether a large pain could conceal a smaller one (Alderotti, 1527). In lecturing on De interioribus, Bartholomew of Varignana melded patient experiences with theoretical speculation to develop a classification of the different kinds of pain (Siraisi, 1981). Dino del Garbo (d. 1327), who practiced and taught medicine at various Northern Italian schools (Del Garbo, 1502), gave greater weight to women’s experiences than to the traditional authority of the biblical curse of Eve when writing about pain in childbirth.
Practical teaching also took patient narratives about pain into account. Arnald of Villanova (d. 1311), who taught at Montpellier, advised in his Speculum medicinae that the patient’s account of pain was important to a good diagnosis (De Villanova, 1585). Bartholomew of Varignana’s classification of seven types of pain described by patients — congelativo, pulsativo, aggrativo, extensivo, frangitivo, pungitivo, and compressivo (Galen, 1490; Da Varignana, n.d.[a]) — was designed to improve the diagnosis of internal diseases.
In the medical model based on Hippocratic-Galenic principles, pain, together with inflammation, alterations of function, and changes in bodily excretions, were the signs through which the physician could recognize internal afflictions. The importance of pain to the university physician can be detected in the insistence on the practical value of discussions on this topic in the academic circles of Montpellier and Bologna, but perhaps the most consistent argument was developed by Arnald of Villanova.
Pleasure and pain
Arnald’s practical aims appear in his analysis in his commentary on Galen’s De morbo et accidenti. Following Galen’s statements, Arnald treated pleasure and pain in their relation to the five senses and their objects. He chose not to give the usual natural philosophical discussion of sense perception and the various sense objects, and he made no use of Aristotelian technical language. Instead, Arnald provided an analysis that would have clinical significance. For example, he discussed the painful effects of moving from a dark place to a very bright one and the pleasant effects of the perception of gray or green coloration (Salm—n, 1993). Arnald was interested in speculation and theory only where these resulted in clinical benefit. In his commentary on De malicia complexionis diverse in the 1290s (Garc’a Ballester & S‡nchez Salor, 1985), he devoted a long discussion to the causality of pain, presenting very subtle disquisitions about how humidity, dryness, heat, and cold could cause pain. He referred his readers to the fourth book of De morbo et accidenti where, according to Arnald, Galen explained “very subtly and profoundly” the causality of pain through the concepts of malicia complexionis and solutio continuitatis. However, Arnald strongly emphasized that his theoretical discussion was valuable only in its impact on the therapeutic choices of practitioners (García Ballester & Sánchez Salor, 1985).
Focus, better practice
Arnald’s anti-intellectualism or anti-Aristotelianism has been linked with his sympathy with the Franciscan view of intellectual life (Crisciani, 1978). His own assertions provide support for this conclusion. However, Arnald was not the author of a practical handbook like the Thesaurus pauperum or the other medical compendia; rather, he wrote highly technical commentaries on several of Galen’s more complex treatises, as well as on Hippocrates’ Canon de vita brevis. He was a master of the intellectual tools of 13th century academic life. At the same time, Arnald constantly emphasized that the main theme of his medical epistemology was the achievement of a better practice. He wanted to be seen by his audienceÑcolleagues, students, and illustrious patientsÑas forwarding this aim. His intentions are clear in his commentary on Galen’s De interioribus, which is actually a reworking of the original text. Arnaud manipulates several paragraphs in order to strengthen his own insistence on the uselessness of medical theory for its own sake (McVaugh, 1990).
This was not an exclusively Arnaldian attitude. His contemporaries emphasized clinical practice in publicizing the works of Galen. For example, the medical masters expounded De morbo et accidenti as the book that presented a general understanding of disease, its causes and its symptoms. Far from pursuing knowledge for its own sake, various commentators, such as Bartholomew of Varignana and Albert of Bologna, advised their readers that their aim in building a theoretical framework was the attainment of a better practice (Da Bologna, n.d.; Da Varignana, n.d.[b]). Bartholomew justified the reading of Galen’s De interioribus because of its utilitas (Da Varignana, n.d.[a]). Jean de Saint-Amand, when presenting his abbreviation of De interioribus to the Parisian academic medical community in the 1280s, had the same practical orientation. He saw this work as the tool from which the physician learned about those afflictions that were hidden from sensory knowledge. Pain here played here an important role as a diagnostic tool (De Saint-Amand, n.d.) and thus as a key link between theory and practice.
Pain, the critical link
Pain was far from a neglected topic among university medical circles of the late medieval period. The duality of pain, as a theoretical and empirical problem, proved more important to the university-trained physicians than the imagery of spiritual martyrdom. Pain provided a critical link between the theoretical description of the human body and its workings and the practical treatment of suffering patients. To translate the experience of pain into a medical language — with the promise of a better understanding and treatment — was to take pain back from the hands of the emprical healers. To insist on the practical interest of theoretical discussions about pain was to create a medical space independent from that of the theologians and natural philosophers. Thus, pain was an important theme in the emerging rhetoric that helped to elaborate and advertise the new medicine that the universities successfully disseminated at the turn of the 13th century.
*Studies and editions of these sources can be found in Sudhoffs Archiv and in Wurzburger Medizinhistorische Forschungen.
Acknowledgment
This article is part of a project funded by the Spanish Ministry of Culture and Education (DGES PB98-0406-C02-01). I would like to thank Dr. Marcia Meldrum for revising the English and for her useful suggestions.
References
García Ballester, L., & Sánchez Salor, E. (Eds.). (1985). Arnaldi de Villanova Opera Medica Omnia, vol. XV: Commentum supra tractatum Galieni de malicia complexionis diverse. Barcelona: Universitat de Barcelona.
Jouanna, J. (Ed.). (1975). Corpus Medicorum Grecorum. I 1, 3 (Hippocrates, De natura hominis). Berlin, p. 169.
McVaugh, M. (1998). Treatment of the hernia in the later Middle Ages: Surgical correction and social construction. In R. French, J. Arrizabalaga, A. Cunningham, & L. García-Ballester. (Eds.), Medicine from the Black Death to the French Disease. Ashgate: Aldershot, pp. 131155.
McVaugh, M. (1990). The nature and limits of medical certitude at early fourteenth-century Montpellier, Osiris, 6, 7374.
Rey, R. (1993). History of pain. Paris: Editions La Découverte, p.54
Salmón, F. (1993). “La couleur dans les théories visuelles des cercles médicaux universitaires de la fin du XIIIe siècle.” In F. Touati, (Ed.), Maladies, médecines et sociétés. Paris: L’Harmattan/Histoire au Present), vol. I, pp. 159169.
Salmón, F. (1996). Academic discourse and pain in medical scholasticism (Thirteenth-Fourteenth Centuries). In S.S. Kottek & L. García Ballester (Eds.), Medicine and medical ethics in medieval and early modern spain: An intercultural approach. (pp. 136153). Jerusalem: The Magnes Press.
Siraisi, N. (1981). Taddeo Alderotti and his pupils: Two generations of Italian medical learning. Princeton, NJ: Princeton University Press, pp. 222226.
Fernando Salmón is associate professor of the history of medicine at the University of Cantabria in Santander, Spain.