Portugalidade – Medieval Medicine

In year 711 CE the Umayyad Caliphate directed an invasion under the banner of Islam which swiftly led to the ousting of the Christian Visigoth rulers and the occupation of nearly the entire Iberian Peninsula. The indigenous people at first feared a continuing subjection but soon learned to embrace the new culture which brought many social benefits the most important of which was medical knowledge and practice.

The foundation of this knowledge had been derived by a study of classical Greek and ancient Egyptian traditions followed by the translation of works by philosophers such as Hippocrates, Aristotle, Plato and Galen to Arabic, the lingua franca of Islam, and later to other Semitic languages such as Hebrew and Aramaic. These were assembled in the House of Wisdom in Baghdad and then copied for distribution throughout the Islamic world.

It was in Baghdad that the first large teaching hospital was opened c. year 800. Known as Bimaristan it commenced a free public service to which were admitted all people regardless of ethnicity, creed or class of citizenship. Separate wards were allocated by gender for the treatment of diverse human maladies and the facilities included herbalist shops, bathing pools with hydrotherapy and prayer rooms. Swiftly, the bimaristans were opened in major Islamic cities and a travelling service by caravan was introduced for visiting smaller towns so that specialist physicians could be conveniently consulted.

Although wealthier patients could receive treatment and advice in their homes from fee-receiving doctors, the early Islamic system could truly be seen as. a forerunner of the modern Portuguese national health service (SNS).

The knowledge and use of herbs and plants for treatment was founded upon the comprehensive writings of the great Greek botanist Dioscorides. But the thirst for knowledge to combat new diseases or variants brought intensive research at medical schools with potions and medications being produced by experiment on both slaves and animals. From the East came the introduction of the derivatives of poppy and hemp as drugs and, although the consumption of alcohol was prohibited, the mixing of surgical spirit, with oil of roses, vinegar and herbs in various combinations brought relief from pain and fever.

Surgery was largely treated as a separate entity because of its attribution to battlefield wounds which were the specialty of military medics. Ophthalmology was particularly advanced and surgical interventions for cataracts were carried out using instruments of precision which were not dissimilar to those of today but without the use of anesthetics. Internal surgery was not common due to the continuing belief in Galen´s maxim of the four ruling humors which must be balanced within the body for well-being. The popular form of treatment was bloodletting by the inversion of heated cups over incisions made in the flesh. All diagnosis was preceded by a careful examination and analysis of urine.

The practice of Islamic medicine was widespread throughout conquered Iberia and available to non-Muslims as dhimmis who paid the heavy jizyah tax in order to participate in the social services and education of a Muslim state. This Golden Age of Islam lasted until the 12^th century when pressure from the armies of the Christian north commenced the reconquest which was eventually to cause the return of most Muslims to north Africa.

This coincided with the birth of Portugal as a sovereign state in year 1143 when Afonso Henriques, the first king, faced a chaos in the state of the new nation´s health. There were no hospitals, clinics or teaching schools. Medical knowledge was fragmented being largely a province of the catholic church and disseminated in monasteries by oral tradition and through tattered copies of the great classical treatises where content had been lost through repetitive translation. The larger buildings included sickbays for the monks (or nuns) which were sometimes available to the local populace who could also be received for consultations and to buy herbal medicines.

Medicine was not taught as a formal subject until the creation in 1290 of the Studium Generale in Lisbon by King Dinis. Prior to this, education in medical matters had been available at the Augustinian house of Santa Cruz in Coimbra where brethren teachers where able to relay the training which they had received in France and Italy. In 1308, the university transferred to Coimbra but relations with the municipality were discordant and its return to Lisbon in 1338 was followed by a variation in the Papal Bull of Nicholas IV issued in 1290 whereby it educated students in general practice while Coimbra concentrated on the aspects of surgery.

Post 1143, successive monarchs endeavoured to regulate the profit-motivated circulation of mendicant friars, pseudo-apothecaries, charlatans, witches and warlocks who sold pardons, medicines (often poisonous) and potions to a superstitious populace. In 1338 king Afonso IV declared that it was not enough to attend medical school to obtain a dubious certificate; in future the activities of physicians, surgeons and apothecaries must be authorized by a royal commission which would set minimum standards of professional practice by examination. Warrants were then issued stating the degree to which expertise had been achieved and in which branches of medicine was there specialisation.

Such regulation was applied to Jews and Muslims but with restrictions concerning the treatment of Christian patients and the value of fees which could be charged. In the 14^th century the number of such practicians was estimated to be 30% of warrant-holders and to this could be added a substantial number of conversos from both faiths. In the tradition of the Islamic caravan clinics, it was customary for contracts to be agreed with municipalities, monasteries and institutions whereby an itinerary of consultations was followed. This was of particular utility to Jewish doctors who functioned in a variety of social roles including that of tax collectors and administrators of estates. Some were appointed to permanent positions in the courts of royalty and aristocracy but most of them “did the rounds” and profited well from this system of collection, consultation and investment of professional fees in usury.

The cautionary foresight of king Afonso IV was immediately justified by the response of Portugal´s medical profession to the outbreak of bubonic plague – the Black Death- in 1347 which was to decimate the population during the next five years. Although there was no known cure, the lessons of isolation learned from the treatment of leprosy in Islam and the presence of specialists in pulmonology and dermatology enabled a containment of the disease and a reduction in mortality when compared to that of mediterranean countries.

This incipient national health care service was almost blown away by the expulsion of the Sephardic Jews in 1497 many of whom were an integral part of Portuguese medicine.

by Roberto Cavaleiro Tomar 22 July 2024