Beating the Black Death: did medieval medicine help people to survive?

It’s no coincidence that Le Forestier defined this illness in terms of sudden death. If a person died unexpectedly, they had not had a chance to confess their sins to a priest, and thus the fate of their soul was in danger. Concerns about the soul were closely bound up with anxieties about bodily health in the Middle Ages.

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It was sometimes held that illness was inflicted by God as a result of sin. Furthermore, the Church taught that in order to recover from physical sickness, one’s soul needed to be in good health. And the soul was all important – it would endure beyond death, whereas the body was but a temporary vessel.

Medieval Christians needed to prioritise the wellbeing of their souls, to decrease their time in purgatory (a place where souls were believed to satisfy past sins and be made ready for heaven) and ensure they were saved at the Last Judgement. Religion featured prominently in efforts to protect health and recover from sickness. People appealed to saints for assistance, most notably Thomas Becket, whose shrine at Canterbury was visited from the 1170s by numerous sick pilgrims seeking a miraculous cure.

Religious beliefs were also sometimes combined with magical ideas and practices. Prayers and the names of saints were written on pieces of paper or parchment that could be worn on the body to ward off illness and misfortune. The idea was that the written words had a magical potency to dispel the influence of the devil and demons. Although magic was problematic for the church, prominent religious figures still engaged in these practices. The famous healer Saint Hildegard of Bingen (1098–1179) once wrote a letter to a woman, Sibylla, to staunch her bleeding. Hildegard vehemently instructed: “O blood, restrain your flow.” Sibylla was advised to place the letter on her body, no doubt so that the words’ power could heal her.

The four humours and the role of astrology in medicine

Celestial influences on the human body encompassed not only the will of God and the saints, but also the movements of the planets, especially the Moon. It was held that each of the 12 signs of the Zodiac was associated with a particular part of the body – Pisces governed the feet, Aries governed the head, and so on. When the Moon moved into a Zodiacal sign, blood was thought to pool in that part of the body, making it dangerous to perform bloodletting and other medical procedures there.

It was understood that if a person had too much or too little of any of the four humours – blood, phlegm, yellow bile and black bile – they would become ill

Although these astrological ideas were very widespread, encapsulated in handy diagrams such as the Zodiac Man image, not all doctors subscribed to them. Writing between 1432 and 1453, French physician Jacques Despars lamented that: “The judgements of astrology are for the most part uncertain, unstable, ambiguous and often deceptive”. He advised that in urgent cases bloodletting should take place immediately, regardless of the positioning of the planets.

Bloodletting was so essential because it maintained the balance of the humours, the four fluids believed to be present inside the body. It was understood that if a person had too much or too little of any of the four – blood, phlegm, yellow bile and black bile – they would become ill.

Medieval people also believed that environmental factors and behaviour had an impact on health, in terms of the quality of the air, diet, sleep and exercise. Emotional states, known as ‘accidents of the soul’, were another factor. These ideas were inherited from the Ancient Greek author Galen, whose writings were translated into Arabic and then Latin.

Since many illnesses were potentially deadly, the best approach was prevention: staying healthy through a balanced lifestyle. When sickness did occur, attention to food and drink, exercise and other kinds of activity, as well as one’s emotions, could bring about recovery. A 15th-century English medical text advised that a man who was spitting blood should “beware of anger, and being with women, … and sour foods, and salty ones, and sharp ones, and of hard work, and of much thinking”.

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Ideas about the air were fundamental to thinking about how disease was spread. It was understood that illnesses entered the body when corrupt or poisoned air was inhaled into the lungs or transmitted through pores in the skin. This polluted air, known as miasma, was foul smelling, but could be counteracted through sweet smells such as rose scent or sandalwood. Although these ideas existed before the Black Death struck Europe in the late 1340s, this devastating plague epidemic and subsequent outbreaks caused great anxiety about noxious air. Town governments across Europe enacted public health measures against malodorous waste: in 1357, for example, the mayor and aldermen of London threatened to fine or imprison anyone who deposited animal dung or other smelly waste in the city streets.

Were there doctors in medieval times?

Who could one turn to for expert help when sick in the Middle Ages? Physicians, whose services were often expensive, would diagnose illnesses by examining a patient’s urine and pulse, and then offer advice based on the humours and lifestyle factors. Some doctors, like Taddeo Alderotti (d1295) who taught at the University of Bologna, produced advice letters for specific patients that then circulated for more general use.

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Unlike doctors, surgeons and barber-surgeons intervened manually, applying ointments and dressings, performing bloodletting, and occasionally cutting into the body for more complex surgical procedures. Medieval skeletons excavated by archaeologists – such as a male skeleton from the leprosy hospital at Winchester with an amputated left leg – sometimes indicate that major surgery took place, and that patients at least initially survived the experience.

Most of these practitioners were men, but women also gained medical expertise. In the later Middle Ages, nuns from the Franciscan monastery of Longchamp (west of Paris) are known to have practised as barber-surgeons. Women also played a vital role as midwives, with male physicians and surgeons usually only involved in complex, difficult deliveries of infants, such as posthumous Casearean sections.

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Medicines themselves were formulated and dispensed by apothecaries, who were the pharmacists of their day. Like physicians, these tradespeople could become very wealthy, charging high prices for their remedies. At the upper end of the apothecaries’ trade, they marketed drugs with exotic ingredients from far-flung places, such as opium from Thebes and alum (a metallic substance) from Sardinia or Egypt. In the 1370s, the great hospital of Santa Maria Nuova in Florence was spending more than £1,000 per year on medicines, a considerable sum.

The remedies, mostly made of natural ingredients such as aniseed and rose petals, were supplied by the apothecary Ugolino di Bonsi and distributed from the hospital’s on-site pharmacy. A less reputable figure than di Bonsi was the London apothecary John Hexham, hanged in 1415 for counterfeiting money. The inventory of Hexham’s possessions mentions a still, an essential piece of equipment for distilling liquids to produce medicines. Some larger households in the later Middle Ages possessed stills, showing that people could adopt a ‘do it yourself’ approach and make their own medical remedies at home.

Hospitals were not the primary site for the attentions of medical practitioners and the availability of their remedies in the medieval period. Hospitals were really a last resort, as they were charitable institutions that helped the sick poor who could not afford to receive treatment at home. They often followed a monastic rule, and attracted donations from Christians keen to fulfil good works to benefit their own souls. Some of the larger hospitals in cities like Paris, Nuremberg, Rome and London catered for large numbers of short-stay patients. By the first years of the 16th century, Santa Maria Nuova in Florence received a staggering 6,500 patients per year, accounting for almost 10 per cent of the urban population of 70,000.

What were medieval hospitals like?

Other hospitals were much smaller, including specialised institutions for abandoned children, the blind, those afflicted by Saint Anthony’s Fire (a disease caused by eating rye bread infected with the ergot fungus, resulting in pain, gangrene and mental confusion) and leprosy sufferers. The leprosy hospitals offered long-term care, since in the Middle Ages there was no cure for this disfiguring, debilitating disease. Because leprosy could progress slowly, some patients were well enough to play an active role in community life.

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Fourteenth-century regulations for the Enköping leprosy hospital in Sweden instructed that those “who are strong enough and able to work ought to help ... to bring in the hay and to harvest the grain”. Other leprosy hospital regulations emphasised the need for men and women to live separately, since chastity was essential in these monastic or quasi-monastic institutions. Rules for the hospital at Meaux, northeast of Paris, stated that if a leprous man was found at night with a woman he would be put on a diet of bread and water.

Although leprosy hospitals were located outside towns and cities, they remained in contact with local populations and, contrary to modern-day stereotypes, there’s little evidence that people with leprosy were excluded or stigmatised. On the contrary, the charity that supported these institutions marked the patients’ continuing inclusion in the Christian community. Jewish and Muslim populations in Europe also supported the sick within their communities. At Provins in northern France, a Jewish leprosy hospital is documented in the 13th century.

While being alive in the Middle Ages meant vulnerability to acute and chronic illnesses that modern medicine can now treat, and often having very little access to doctors and surgeons, the overriding impression is that medieval people were physically and mentally resilient and highly knowledgeable about their own health. Much medical expertise and support was provided within the local community, or was available at nearby monastic houses.

The mentally ill, for example, usually remained at home, with one of the earliest specialised mental hospitals, Saint Mary of Bethlehem in London, only active from the later 14th century. Medieval people used natural, magical and celestial resources to protect their health, and faced illness and disease with determination, pragmatism and religious faith.

Dr Elma Brenner is Wellcome Collection’s medieval specialist

This content first appeared in the March 2020 edition of BBC History Revealed