Image from the Trinity’s Digital Collections, Virtual Trinity Library, The University of Dublin
The Medieval (or Middle Ages) was a period of European history (c. 5th – 15th centuries CE) that followed the fall of the Western Roman Empire. This historical era was associated with a marked fading of the Classical cultural, technological and engineering, economic, intellectual, and political brilliance that had been cultivated by ancient Greco-Roman society.
The Middle Ages were a time of kings and castles, feudal lords and barons, peasants and hovels, Black Death, craft guilds, medieval monasteries and cathedrals, the Crusades, Viking raids, and Marco Polo. People were often poverty-stricken, illiterate, and superstitious; sanitation was poor; there were no public health services (as there had been in Roman times); and people rarely lived long enough to become old (as we now know it). Disease was blamed on a mix of worldly (e.g., humoral imbalance, miasmas), spiritual (e.g., sin, the will of God), and supernatural (e.g., astrological) factors. The powerful influence of the Catholic Christian Church was associated with the rising use of prayers and pilgrimages to improve health.
Monasteries and convents became medical centres, as their religious members were expected to take care of ‘God’s flock’ as part of their duties – generally with a mix of prayer, religious ritual, and herbal remedies. Medicinal herbs were cultivated in monastery and convent gardens for local and trade use. Wise women were consulted for herbs and healing incantations, and midwives for childbirth. The doctors, physicians, and surgeons that did exist often had very little formal education, so had learned their trade through apprenticeship and experience.
A paucity of extant literature suggests there may have been a general slowing in medical and anatomical research during this era, apart from a (well documented) progression in herbal medical knowledge. It is frequently reported that the Christian Church equated human dissection to a blasphemous desecration of the corpse, which meant that it wasn’t practiced during this era. Yet, as I’ve only recently learned (Park, 2010), the truth of this popular claim (which I’ve been known to repeat) may not be entirely correct. It now seems likely that human autopsy and the anatomical dissection of certain body parts were permitted by the Church, although these activities were not normally performed in public.
A few surviving Greco-Roman medical texts were preserved, translated, and copied in some European monasteries and convents – as well as in the Indian and Islamic medical worlds. The rarity and cost of these hand-copied manuscripts meant that they could only be accessed and read by a small number of people. These texts repeated, but generally did not question, the ancient medical doctrine, including anatomical knowledge, set down (for instance) by Hippocrates and Galen. It was then commonly believed that these Classical authors had been inspired by God, which meant their ideas were sacrosanct and could not be improved upon.
Fortunately, this apparent stasis in European medical knowledge advancement didn’t spread too far eastwards – i.e., into a part of the world that was, in general, sheltered by the umbrella of Islamic rather than Christian belief. The Medieval Islamic world was, at that time, experiencing a period of cultural, economic, and scientific prospering that is now known as the Islamic Golden Age … and medicine played an important part in this.
Ibn Sina (980-1037), for instance, or Avicenna as he was known in Europe, was a famous and influential Islamic philosopher and physician whose writings included the Canon of Medicine (c. 1030 CE) – a medical encyclopaedia that was translated from Arabic into Latin in the late 12th century, and subsequently used as a textbook in European medical schools until the late 17th century). Although O. C. Gruner’s (1929) English-language translation of the First Book of the Canon omits Avicenna’s treatise on anatomy, it shows that Avicenna was definitely aware of the body’s membranes that are now widely known as fascia. The following passage makes me wonder whether this may possibly have been the first time their structure and functioning, including their sensory role, was mentioned in writing. (Regrettably, I’m not equipped to investigate this further myself)
- When describing the body’s membranes in general …
“The membranes. These structures are formed of extremely minute interwoven filaments which are extremely delicate. Their object is (a) to form the external covering for other structures and thereby (b) preserve the form and outline of these structures, (c) to support the members [i.e., body parts or organs], (d) by means of their fibres to bind together the nerves and ligaments with the members , for instance they hold the kidneys in position, (e) to impart sensation to members which are themselves insensitive, since by providing a sensitive covering they enable the member to be aware of anything befalling it. For instance : the lung, the liver, the spleen, the kidney ; all of which are in themselves insensitive, and would not feel being touched were there not a membrane over them. A flatulent distension or an inflammatory deposit in an organ is felt by us only because the enclosing membrane, being stretched, feels it; or, in the case of an inflammatory mass, is aware of the weight.” (p. 101)
Gruner’s English-language translation of Avicenna’s originally Arabic text also contains the words ‘fascia’ and ‘fasciae’.
- When discussing the accumulation of harmful deposits in …
“various tissues, fascia, and joints, and even in the vessel-walls (atheroma, e.g.) and nerve-sheaths occur with ill effect.” (p. 97)
- When discussing the body’s flesh (one of nine “Simple members” or “elementary tissues”) …
“The flesh. “ Flesh ” includes muscles, fasciae, tendons, ligaments, connective-tissues, and so forth all together. Flesh is that which fills up the spaces left within the members, thus imparting firmness and solidity.” (p. 101)
- When discussing the nature of ‘heavy pain’ associated with …
“an inflammatory process in an insensitive member such as the lung, the kidney or spleen. The weight of the inflammatory deposit drags on the tissues and surrounding sentient fascia and on its point of attachment. As the member is dragged on, the fascia and its point of attachment experience the sensation.” (p. 266)
- When discussing the nature of pain caused by accumulations of gas that distend …
“the subcutaneous tissues (the place between the muscles and the loose fascia or skin); (e) internal members (e.g., the muscles of the thorax.).” (p. 268)
Before anyone gets too excited about Avicenna’s purported use of the words membranes, fascia, and fasciae, it is important to remember that Gruner’s employment of them may have been influenced by his 20th century familiarity with them … and that Avicenna may not have used them himself. In which case, their inclusion in Gruner’s text may well be an artefact (i.e., a product of translation bias) introduced by his (the translator’s) selection of words that he (Gruner) believes are a suitable modern equivalent to those used by the original author – i.e., words that are likely to make sense to the translated work’s readers, in the contexts of their modern-day lifetimes. The truth of this matter will unfortunately remain hidden until a skilled Arabic/English linguist revisits Avicenna’s original work with this specific question in mind.
Maimonides (1138 – 1204 CE), also known as Abü Imrãn Müsã ibn Maymün ibn Ubayd Allãh, was a twelfth century Jewish Egyptian philosopher and physician. In his days there were few books to study from, so, as was then customary, he condensed much of his medical teaching into easily remembered oral aphorisms. This method of teaching helped his students absorb and memorise vast amounts of medical information. Maimonides’ Medical Aphorisms, constituted from twenty-five treatises, contain approximately 1,500 of these sayings, the majority of which are derived from Galen and, through Galen’s commentaries, the books of Hippocrates. The quotations below are drawn from Maimonides’ First Treatise (as translated from Arabic to English by Gerrit Bos in 2004), which was predominantly concerned with anatomy, physiology, and pathology. Maimonides attributed the information in both of these aphorisms to Galen (as noted in Boss’s sourcing notes, in the square brackets).
- Aphorism 14 …
“The ligaments with which the muscles are attached to the bones give rise to membranes that envelop the muscles and from which strands spread into the flesh of the muscles.” [Galen, De motu musculorum 1.1 (ed. Kühn, 4:37; trans. Goss, 3).] (p. 10)
- Aphorism 55 …
“The [membrane of] fat is composed of two dense, fine layers. One lying upon the other, and of arteries, veins, and not a small amount of fat. We do not find in the body of a living creature a membrane that is denser and lighter.” [Galen. De usu partium 4.9 (ed. Helmreich, 1:209; trans. May, 1:214). (p. 21)
The founding of Europe’s first university, the University of Bologna (c. 1088), heralded a gradual reawakening interest in scholarly knowledge development in that part of the world. In 1231, the Holy Roman Emperor Frederick II – who realised the importance of surgeons having a sound understanding of anatomy – decreed that medical schools were permitted to dissect at least one judicially executed human corpse every five years. By then, anatomical instruction (in accordance with Classical Galenic anatomy doctrine) was usually a normal part of the medical curriculum. Aspirant physicians and surgeons were normally required to observe one or more human dissections during their training, and, as a result of this, several European countries legalized the dissection of executed criminals so there might be enough material made available for this educational purpose.
My next article about people’s evolving understanding of the body’s soft connective tissue – which is now widely known as fascia – will resume when, in 1315, Mondino de Luzzi – an Italian physician, anatomist, and professor of surgery at the University of Bologna (whose supporters dubbed the ‘Restorer of anatomy’) – ‘performed’ the first public human dissection since Herophilus and Erasistratus last did so, at the school of anatomy in Alexandria (c. 250 BCE).
If you’re interested, you can read some more about anatomy and fascia in my newly released book, The Living Wetsuit, and at www.sueadstrum.com
- Avicenna and Gruner. O. C. (1973). The Canon of medicine of Avicenna. (O. C. Gruner Trans.). New York: AMS Press. (Original work published in 1930). Retrieved from https://archive.org/details/CanonOfMedicine/mode/2up
- Bos G. 2004. Medical Aphorisms. parallel Arabic-English edition = Kitāb al-fusūl fī al-tibb / Maimonides ; edited, translated, and annotated by Gerrit Bos. Provo, UT: Brigham Young University Press.
- Park, K. (2010). Secrets of women: Gender, generation, and the origins of human dissection. Princeton, NJ: Zone Books … also, https://news.harvard.edu/gazette/story/2011/04/debunking-a-myth/
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