Medicines in Medieval Iberia: Medical Licensing, Regulation, and Subsequent Plague Responses
Rebecca Compeau
HIST 365: Medieval Spain
Dr. Dana Wessell Lightfoot
June 23, 2021
Medieval Iberia, while having no definitive timeline, is generally accepted to have spanned from the 5th century to the early 16th century. Throughout this wide span of time many events occurred, both natural and legislated, which changed the way medicine would be viewed, practiced, and controlled in Iberia for many years to come. It is during this medieval period that medical practitioners would become increasingly regulated in their practices, with licensure becoming a key factor in a successful practice alongside standardized testing and administration of medicines. Moreover the education and training physicians received became increasingly consistent with concrete teachings to be laid out and taught in formal institutions; this method of instruction was increasingly favoured in potential physicians versus those who had received their training as an apprentice physician with no formal book learning. Jewish physicians found themselves under more intense scrutiny than their Christian peers due to longstanding prejudices and mistrust. Additionally, the effects women had on healthcare provision become evident and it is demonstrated they were even favoured over men for particular procedures. Ultimately these practices would culminate as the Black Death rolled through Iberia and medical practices were pushed to their limit; the city of Valencia was innovative in its rulings to prevent the spread of the plague as it became a pioneer in combining medical knowledge with civil legislation to protect its citizens. Over a period of roughly five centuries Iberia’s take on medicine transitioned from an unruly landscape with practitioners of questionable tutelage to one which began to resemble modern day healthcare with licensed and regulated practitioners who were held accountable for their actions; it was these formally trained physicians who guided the city of Valencia through the Black Death and worked to mitigate its devastating effects.
Testing and Administration Protocols for Medicines
Montpellier University was established in 1220 and has long since been regarded as one of the oldest medical schools in Europe (Kadaan & Angrini, 2013). In the early years of the university’s inception the medical faculties worked to establish testing methods to determine the efficacy of various medicines and establish treatments for many common ailments (McVaugh, 2017). Physicians of the time thought medicines, and their constituents, to hold innate properties such as hotness or coldness which would then work to counteract the symptoms displayed in the individual suffering an ailment; additional properties of medicines included the inherent dryness and moistness of said remedy. Medicines were carefully evaluated and tested to determine to what degree a particular dose would be effective in treating a particular ailment. Throughout the years a set of rules were established to test potential treatments to ensure the test was valid and could be repeated as necessary; canon dictated: the medicine ought to be free of any acquired quality such as artificial heat or cold that might be acquired from the environment, a patient must only be suffering from a single illness, a medicine must also be tested on patients suffering a contrary illness to that of which they are trying to cure as this will ensure it cured it in the patient desired but had no effect on the other patient, the strength of the medicine should be opposite in quality but equal in strength to the illness, and finally and given medicine must only be tested on human subjects as medicines will not produce the same effects in animals as they will in humans (McVaugh, 2017). Physicians spent much of their time training to distinguish the normal from abnormal to best recommend a course of treatment. Only after a physician had determined the issue an individual was afflicted with might they recommend or administer a medicine that was known to counteract the symptoms displayed; it was important to determine the cause of illness, lest an inappropriate or ineffective medication be used to cure the individual (McVaugh, 2017). The formal training physicians received at institutions such as Montpellier would be an important factor which distinguished them from their unqualified and amateurish counterparts who claimed to be a physician’s equal.
Medical Licensing and Regulation of Practitioners
Medieval Iberia was home to a wide variety of healthcare practitioners, with the most notable of these practitioners being physicians, surgeons, and midwives. While other healthcare providers such as barbers and apothecaries provided minor services, it was these key practitioners who provided the most necessary services and prevented the greatest loss of life. Prior to the early 14th century physicians and surgeons were not required to obtain a license to practice medicine, nor did they need to prove their adequacy to any power higher than themselves (McCleery, 2014). As direct result of the large number of unchecked healthcare providers, King Alfonso IV established a mandate in the late 1320s in which all physicians and surgeons must acquire a license to practice surgery as a means to protect his citizens from individuals who label themselves as such providers, yet lack the actual skill and wisdom to do so safely. Notably, the licensure of barbers and apothecaries was not required until 1511 and 1515 respectively. During this time of increased documentation there is a distinct lack of records concerning women in healthcare. Midwifery was the primary position women in healthcare found themselves in; while a respected and necessary aspect of healthcare, it was overlooked by those providing regulations. Furthermore throughout the 15th century in Portugal there is only one surviving document which lists a woman as a licensed surgeon (McCleery, 2014). The lack of female licensure and recognition is seen not only in physicians but in many other healthcare practices, as demonstrated by a list of over 500 practitioners of various specialties within the Crown of Aragon from 1350 to 1410 is analyzed, yet only three women appear on the list (Cabré, 2008). Nevertheless women were not without their merit in medieval Iberian healthcare for they were the preferred individuals to perform examinations of the female body, particularly virginity tests, as they were deemed to be experts in this area and would even be called upon to present their findings in a court of law (Cabré, 2008).
Of the unknown number of licenses issued in the between 1320 and 1520, approximately 1100 licensing documents have survived and these clearly demonstrate the impact one’s religion had upon their licensure (McCleery, 2014). It has been approximated that 54% of Christian physicians and surgeons had gone to the trouble of obtaining a medical license, meanwhile an estimated 85% of Jewish practitioners had obtained their license to practice. Jewish physicians and surgeons faced the greatest amount of public scrutiny as it was conjectured that Jewish physicians would poison their Christian patients if given the opportunity. Physicians, both Jewish and Christian, received a modicum of legal protection by obtaining a license to practice medicine, as the practitioner now had lawful documentation verifying their methods and knowledge had held up under the royal examination and scrutiny. In addition to legal protection licensure provided, the inflated numbers of licensed Jewish physicians can be attributed to the ruling made by King Alfonso V in 1443 which stated all Jewish medical practitioners (physicians and surgeons) must obtain a license, lest they be imprisoned if caught practicing medicine without such documentation (McCleery, 2014). Unfortunately Iberian rulers did not have the foresight to understand the drastic effects of such extreme regulation of Jewish physicians in combination with the mass exodus of Jewish peoples from Iberia in the late 15th century as this would lead to desperate cities granting licenses to uneducated healers in the early 16th century in the wake of the Black Death as it rolled through the land (McCleery, 2014).
Plague Responses in Valencia
The city council of Valencia took several approaches in their attempts to combat the Black Death as it waged its war on the city. Initially the Valencian city council had associated the plague with cumulative sins of those living within the city, which had slowly begun to corrupt the entire society thus resulting in disease and plague (Agresta, 2020). Moral corruption was believed to be greatest in those who participated in activities such as prostitution, blasphemy, and gambling. In an effort to minimize the number of people partaking in these activities the city council of Valencia enacted restrictions on both gambling and prostitution within the city as prostitutes were systematically banned from parts of the city, yet the practice of sex work was never outright banned (Agresta, 2020). Between the 1450s and the 1470s the plague continued its onslaught on Valencia’s inhabitants; the city council began to heed the advice of its physicians and view the plague as an illness passed between individuals. City council initiated a ban on persons entering the city if sick themselves or if they had travelled from another city where the plague was known to be active. This would be the precursor to a city wide quarantine which was established in 1476 in an effort to prevent the sickness from entering the city; the efforts were only marginally successful however as rats carrying the disease found passage on food shipments and made their way into the city (Agresta, 2020).
Many of the practices implemented in Valencia during this time can be traced back to methods and theories established over a century prior to the appearance of the Black Death by distinguished physicians Jacme d’Agramont and Alfonso de Cordoba; despite their outdated writings it was many of these methods which provided relief and prevented the worsening of the sickness within the city. The first of these teachings is to ensure one has fresh water as stagnant water harbours infection (Alfonso de Cordoba, 1348, as cited in Aberth, 2005). The city council translated this understanding and banned throwing garbage and animal carcasses into the city canals to prevent blockages which would lead to pooling of water (Agresta, 2020). A second lesson discusses the importance of clean air and the prevention of accumulation of filth as miasma was thought to cause sickness; this is applied as the council implemented rulings concerning the bodies of those who had perished from the Black Death and insisted they must be buried outside the city lest they pollute the air within (Jacme d’Agramont, 1348, as cited in Aberth, 2005; Agresta, 2020). Finally, a third word of caution discusses the importance of avoiding contact with sources of infection and this too was demonstrated the city of Valencia as they prohibited entry of the sick, along with the quarantine of the entire city as a protective measure; it was noted that some of richer birth seized the opportunity to leave the city before this was implemented and temporarily lived in villas they owned outside the city to minimize their risk of infection. While not all of the policies from these noteworthy physicians were implemented, those that were had profound effects in slowing the spread of sickness throughout the city.
Culmination of Medieval Iberian Medicine
Medicine and medical care in Medieval Iberia has a long and rich history, marked by continuous progress and an ever increasing concern for public welfare. Through the five centuries spanned in this period of time it becomes apparent that while growing pains did occur, the increased legislation and rulings concerning the administration of healthcare services would ultimately benefit the people of Iberia. The periodic testing and standardization of medicines would allow for more appropriate and effective treatments for all those who received such services; no longer would each physician have to create their own remedies. Licensure and formal instruction of physicians and surgeons alike would work to protect the public from fraudulent and dangerous individuals masquerading as doctors. It is important not to forget licensure came at the cost of many Jewish livelihoods as they were punished most severely for non-compliance. Lastly the Black Death appeared at the height of these advancements in medical regulation, for without these checks and balances in place the plague would have cost many more lives as unfit medical practitioners would have doubtless recommended medicines ill-suited to remedy the sufferings of those afflicted with the sickness. The city of Valencia, whose excellent record keeping, has shown their many efforts to combine historical medicinal teachings with those of modern practicalities; the city council felt strongly concerning the moral corruption and physical filth in the city and made efforts to correct both of these concerns in their efforts to fight the sickness spreading through the city. Medicine, practitioner regulation, and the provision medical care made equally large strides throughout the centuries and would continue to do so as the lessons learned throughout this period would not soon be forgotten.
References
Aberth, J. (2005). The Black Death: The great mortality of 1348-1350: a brief history with documents. New York: Palgrave Macmillan.
Agresta, A. (2020). From purification to protection: Plague response in late medieval Valencia. Speculum, 95(2), 371-395. Doi: 10.1086/707682
Cabre, M. (2008). Women or healers? Household practices and the categories of health care in late medieval Iberia. Bulletin of the History of Medicine, 82(1), 18-51.
Kadaan, A. N, & Angrini, M. (2013). To what extent was Montpellier, the oldest surviving medical school in Europe, inspired by Islamic medicine?, Journal of the International Society for the History of Islamic Medicine, 12-13.
McCleery, I. (2014). Medical licensing in late medieval Portugal. In Medicine and the Law in the Middle Ages (196-219). Brill.
McVaugh, M. (2017). Determining a drug’s properties: Medieval experimental protocols. Bulletin of the history of medicine, 91(2), 183–209. https://doi.org/10.1353/bhm.2017.0024
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