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Medicine in Portugal in the Medieval Ages: A contribution to the history of science

Paulo Nuno Martins *
Interuniversity Center for
History of Science and Technology,
New University of Lisbon
Campus of Caparica, Building VII, Floor 2,
2829-516 Caparica, Portugal
*e-mail: paulonuno2003@iol.pt

Acknowledgements - the author wishes to record the help and suggestions of Dra. Cristina Moisão in this paper.

Keywords:

Medieval hospital, Santa Cruz Monastery, Estudo Geral, Hospital of Todos-os-Santos, brotherhood of Nossa Senhora da Mesericórdia, University of Coimbra.

Abstract

In the 8th century, in Al-Andalus (denomination of the Iberian Peninsula, under the Arab domain) there were hospitals, denominated by bimaristan or simply maristan, that promoted the treatment of the most varied diseases. With the beginning of the Christian conquest at the end of the 9th century, the functions of the hospitals had several nomenclatures in relation to the functions.

This article also describes the most significant events in the history of medical education in Portugal, since the formation of Condado Portucalense (1095-1139) until the end of the 15th century. The teaching of Medicine in Portugal began in the Monastery of Santa Cruz in Coimbra (1131), in the 12th century, with the placing of clergy members to study medicine in foreign universities. In 1290, medical studies were carried out at the Lisbon General Study, until the beginning of hospital medicine in Portugal, with the construction of the Hospital of Todos-os-Santos in 1492. Along with the creation of this emblematic Lisbon Hospital, it appeared, in 1498, the brotherhood of Nossa Senhora da Mesericórdia. In the end of the fifteenth century, there was bipolarization in medical education, between the University of Coimbra, more theoretical (medicine), and another in the Hospital of Todos-os-Santos , with a more practical training (surgery).

I-Introduction

The period of Portuguese Medieval Medicine has been little studied (e.g. Marques (2010)) probably due to a shortage of documents, but the truth is that modern Portuguese hospital medicine would not exist as it is today, without the contribution of the knowledge acquired during eight centuries of our hospital history. Sometimes the beginning of the medieval Portuguese hospital system, is compared to the lodging, where medicine and surgery were little studied. This article aims to contribute to the clarification of this theme, from the time of Al-Andalus (denomination of the Iberian Peninsula in the 8th century), through the beginning of the Christian conquest in the late 9th century, initiated by D. Afonso Henriques, until the construction of the Hospital de Todos-os Santos at the end of the 15th century, which aggregated 43 of the medieval hospitals of Lisbon (such as D. Maria de Aboim, S. Jorge, S. Pedro Mártir, among many others).

Moreover, from ancient times training and medical practice have not been independent from the contexts in which they take place over time. As far as possible and the circumstances of each epoch, one seeks to preserve the foundations of the Hippocratic message, invoked by the graduates in Medicine. During the Middle Ages, in Portugal, the classical teachings of Greek-Roman medicine prevailed, complemented by Arab medicine. However, some more innovative practices, namely the anatomical observations and the surgical indications mentioned by Galen, were ignored in the teaching of Medicine in Portugal. Pedro Hispano was the most important Portuguese physician of the Middle Ages.

Progressively, from the end of the fifteenth century, European medicine inherited from antiquity, in particular by the Galenian texts, the Hippocratic aphorisms and the Islamic school (Avizena and Razi), which founded the clinical practice of the Medieval period, gave rise to new medical theories with the substitution of empirical knowledge for the scientific basis. At this point, the contribution of some Portuguese physicians who accompanied the foreign scientific movement, namely, Garcia de Orta, Amato Lusitano, Rodrigo de Castro, António Luís and Henrique Jorge Henriques, is noteworthy. However, these contributions were not felt decisively in Portuguese medicine until the eighteenth century, due to the proliferation of people practicing medicine without qualifications (which contributed to the discredit of the profession), the expulsion of the influential Jewish medical community (1496) (e.g. Rasteiro (2000)), the establishment of the Inquisition in Portugal by papal bull, as well as, the temporary loss of national independence.

II- History of hospitals and medical education in medieval times in Portugal

During the early Middle Ages, there were some doctors residing in Al-Andalus, such as Avenzoar Averroes, Albucasis (considered, in Arab culture, the "father of surgery”) (e.g. Tschanz (2011a)), Maimonides. It is known that the Arab world had hospitals, called bimaristan or simply maristan, that were open to all, collecting patients to promote the treatment or recovery of the most varied diseases and injuries. The largest institutions were associated with medical schools and libraries, where prospective physicians were taught, examined, and licensed. This town was also the forerunner of ambulatory hospitals, well known in the 11th century, tents that moved between the various settlements with the aim of bringing medical care to people who were too distant or sick to address the bimaristans (e.g. Tschanz (1997)). The territory that now corresponds to Portugal was no exception in these customs during the 8th century. At that time, the teaching of medicine, in the territory that today corresponds to Portugal, was not organized, being habitual the oral transmission of the knowledge to the generations to come. We know that by the Visigothic Code, the doctor could teach a disciple his art, and the student must pay 12 visigothic salaries (e.g. Vasconcellos (2008)). Arab medicine was able to take advantage of the scientific knowledge of the peoples who surrounded the Mediterranean Sea, including the concepts of medicine of Greeks and Romans. The Arab doctors included their knowledge in manuscripts, constituting true encyclopedias of medical matter. For example, Dr. Albucassis wrote a work of 30 volumes dealing with medicine, surgery (including topics on obstetrics, gynecology, orthopedics, cataract and kidney stones extraction, dental realignment), pharmacy, the fruit of his 50-year professional career experience (e.g. Tschanz (2011b)). Also, Avenzoar wrote several books dealing with food and diets, psychology and neurology, anesthesia (with cannabis, opium, henbane), as well as a training course in surgery (e.g. Tschanz (2011c)). For his part, the doctor Maimonides, interested in Philosophy and Medicine, could bring together the concepts of the Greek-Roman, Arabic, Hebrew and European cultures, stating that a doctor would have to treat the patient as a whole and not the isolated disease, that is, heal the body and soul. He wrote 10 medical works, dealing with several topics such as asthma, hepatitis, and the importance of physical exercise (e.g. Tschanz 2011d)).

With the beginning of the Christian conquest by D. Afonso Henriques at the end of the 9th century, with demographic growth and the increase of contagious diseases (which contributed to high mortality), it became necessary to provide institutions to support the sick people, the elderly and orphaned children. Being Lisbon a wealthy city, with diverse religious communities of different faiths, it was inevitable the emergence of numerous hospitals.

The first of them was as old as the nation itself, since D. Afonso Henriques ordered that a provisional infirmary should be set up in his camp, at the siege of Lisbon, and thus the first military hospital of our history (e.g. Correia (1941)). The Christian hospital of the Middle Ages in Portugal was a small, economically independent institution at the expense of rents of properties donated by benefactors, namely the king, with operating regulations Which generally guaranteed the rights of the sick and the poor as a matter of priority and which required the employees to perform rigorous duties. It is also known that many monasteries had infirmaries (some of the hospitals in the Middle Ages were dependent of the clergy), just as hospitality was given to the sick in many noble houses in Portugal.

The functions of these hospitals were somewhat different from the current view. At the time, these houses had several nomenclatures in relation to functions: Hospitals treated patients, the “Albergarias” sheltered people passaging by, the “Gafarias”(leprosarium) received lepers and the “Mercearias” housed elderly and unprotected children. There were also Bath hospitals, where thermal treatments were practiced, such as the “Judiaria Grande” in Lisbon and the hospitals for "incurable", such as the one located in the Fangas da Farinha, with 25 beds. In Portugal, in medieval times, there were 209 Hospitals, 186 “Albergarias”, 75 “Gafarias” and 35 “Mercearias” (e.g. Correia (1943)). As an example of Medieval Hospitals in Portugal we have the “Hospital dos Meninos”, the “Hospital de Rocamador” ”Hospital de Santa Elisabeth”. Already as an example of mediaeval “Albergarias “ we have the “Albergaria de São Salvador”, “Albergaria de Santa Clara”, “Albergaria de São Nicolau”.

The Portuguese medieval clinic was performed at home, so none of the hospitals had a private doctor, and he was called when necessary. Medical practice was not confined to treating the rich to obtain the fees, but on the contrary, it was the practice that contributed to the physician's fame, making him well known in order to facilitate its hiring by the wealthy classes. The medical hierarchy, in the Middle Ages, in Portugal, was constituted by the Physician or Doctor (some being specialists in certain diseases), the surgeon, the bleeder (who made bleedings), and finally the healers and midwives.
During the Middle Ages, in Portugal, medical treatments involved mastery over the science of the stars (such as those practiced by Mestre José Vizinho, physician and astrologer of D. João II (e.g. Costa (1983)), religious acts (obstetrics was strongly linked to the cult of “Senhora do Ó”), bleeding, and surgical procedures. Surgery has developed itself since antiquity in parallel with war, treating fractures and wounds, referenced in papyri in ancient Egypt, the extraction of spears and arrows, as well as wound washing and cauterization to control bleeding, referenced by the Greeks.

The most common contagious diseases of medieval times in Portugal were leprosy and plague, although caries, diarrhea and fevers were also common. As for the plague, we witnessed an epidemic in the national territory, in 1348, described in a conventual chronicle and later by Fernão Lopes, related to the siege of Lisbon imposed by D. João de Castela in 1384 (e.g. Lopes (1922)). The chronicler describes that, despite the mortality among the Castilians, no Portuguese perished, inside or at the end of the city, stating that for such a wonder he could not discover the cause. Leprosy, "dor de gafem"(pain of gafem) or disease of S. Lázaro, in Portugal did not obey the spread observed in the rest of Europe, probably due to the lack of Portuguese participation in the Crusades in the Holy Land. In our country, many of the patients with leprosy were not isolated, and since they were authorized, they were not hospitalized in any institution (e.g. Nóvoa (2010)) and could maintain social life.

In Portugal, in the Middle Ages, drugs for the treatment of diseases were passed by pharmacies, which were subject to supervision by physicists. Drugs were based on treaties, most of which were of Arab origin (e.g. Marques (2010a)). Lisbon's pharmacies were mainly located in the parishes of Madalena and São Julião (corresponding to the current “Baixa” of Lisboa).

We must add that the true development of medicine in Portugal, during the medieval period, which preceded the construction of the Real Hospital de Todos-os-Santos, was due mainly to D. Sancho I, D. Dinis, D. Afonso IV, D. João I, D. Duarte and D. Afonso V.

In fact, at the time of the foundation of the “Condado Portucalense” (1095-1139), the teaching and practice of Medicine in Portugal (e.g. Lemos (1991)) were under the direct and exclusive responsibility of the religious orders. It was understood as a solidary and charitable practice, based on knowledge that priests and monks went to seek in distant lands and transmitted to each other, without the need to create specific schools of medicine. Monasteries, convents and lodges were the ideal place for learning and practical fulfillment of what was considered to be a religious design.

At the end of the 12th century, under the reign of King Sancho I, the prior of the Monastery of Santa Cruz, with the support of the king and the bishop of Coimbra, sent one of the canons to the University of Paris to learn theology and Medicine. On his return, the canon D. Mendo Dias began medical education in the way (and until the eighteenth century) it was usual to do so, that is, by reading to the novices classical texts of Greek-Roman and Arabic Medicine. Therefore, D. Mendo Dias was the first lens of Medicine in Portugal, and the Monastery of Santa Cruz was the cradle of the teaching and practice of Medicine in Portugal (e.g. Carvalho (1929)). During the 12th and 13th centuries, medical education in Portugal focused on the observation of urine for the identification of diseases, astrological implications and the use of the supernatural (prayer, invocations), the teaching of pharmaceutical substances with practical application, bleeding (for hygienic and therapeutic purposes).

However, in Portugal, the strong dependence on foreign doctors, coupled with the poor qualification of the few who existed, led King D. Dinis, by the initiative and request of the clergy, to favor the creation, in 1288, of the Estudo Geral of Lisbon, the first Portuguese university confirmed by Pope Nicholas IV, by the bull of August 9, 1290, and whose subjects included Medicine (then with the name of Physics) (e.g. Carvalho (1996)). Between the date of its foundation and until 1537 the University changed five times of location, between Lisbon and Coimbra. Thus, after having established it in Lisbon, D. Dinis transferred it in 1306 (or 1307) to Coimbra, returning in 1338, by order of D. Afonso IV, to Lisbon. In 1354, it returns to Coimbra until 1377, date in which, by determination of D. Fernando, it is relocated again in Lisbon.

Moreover, D. Dinis disciplined the teaching of Medicine in 1309, in which the Master of Medicine determined the duration of the course of one chair (e.g. Silva (2002)). It was not enough, however, to attend the teaching of medicine to be authorized to exercise it. In the reign of D. Afonso IV, the medical finalist had to be submitted to an interrogation, before Mestre Afonso and Mestre Gonçalo, physicians of the king.

In the time of D. João I, despite the existence of the University, the study of medicine and surgery was unruly and of inadequate quality, and so the king demanded the provision of evidence before the” Físico-Mor”(Chief physician) of the kingdom, Mestre Martinho, for the practice of medicine (e.g. Reis (1991)). In addition, the policy of teaching and medical practice covered the culture of Arabs and Jews, clearly coming from the ranks of the clergy.

The Estudo Geral initially operated in the Alfama neighborhood and then near the Sé, in precarious spaces and financially supported by the royal family. Only in 1431 did the University have its own facilities in Lisbon (in the parish of S. Tomé), in facilities donated and remodeled by Infante D. Henrique (1394-1460). In fact, Infante D. Henrique, a man of enormous culture and vast vision, lover of letters and sciences, reinforces the political position of the king his father donating some of his houses to the Estudo Geral (e.g. Walter (1964)). In 1431, the term Medicine appears by the hand of the Infante, replacing that of Physician, and the first individualization of this science in a store of its own, with the figure of Galen.

In the reign of D. Manuel I the conditions of the Estudos Gerais improved substantially with the transfer of the institution to properties which had been of the infant D. Henrique.

Like other universities in medieval Europe (e.g. Mattoso (1997)), the "Estudo Geral” conferred the degree level of Doctor of Medicine to students whom the masters and doctors understood to be fit to practice medicine. However, there are no concrete references about the organization, duration and training program that enabled the degree of licensee. In 1431, D. João I (1357-1433) determined concrete changes in the teaching of Medicine in Portugal. A bachelor's degree was awarded at the end of three years of the course, while the graduation course required another four years of study. Graduates wishing to ascend to the doctorate degree had to provide scientific proof. In 1494, during the reign of King D. João II, it is determined that the teaching of Medicine, which until then was based on a chair (the "Prima"), included the "Cadeira de Véspera”.
Already during the reign of D. Manuel I (1469-1521), the access to the medical course now requires that candidates have a bachelor’s degree in Arts, which included the attendance of three courses of one year each.

However, the teaching of medicine in Portugal until the end of the fifteenth century (e.g. Sousa (1996)) was based on listening to texts of ancient science (Greek-Roman and Arabic), and the University graduates had no competence in medical practice. This meant that, for example, surgery was learned outside the University, often abroad. In this regard, D. João I in 1392 and then D. João II in 1448 determined that all medical professionals would have to be examined by the chief physicist / surgeon regarding the competence for the surgical practice, surgical skills were approved by the presentation of a certificate with a real seal.

The teaching and practice of ophthalmology is for the first time referenced in the reign of D. Duarte (1391-1438), who in 1434 issued a letter of privilege to the Jew Master Nacim, giving him the power to deny or grant a license to practice clinics for all ophthalmologists from the country.

D. Afonso V (1432-1481) was responsible for promulgating the “Regimentos do Cirurgião-Mor e do Físico-Mor”, (Regiments of the Chief Surgeon and the Chief Physicist) also disciplining the practice of Pharmacy, as a precursor of a path that would be followed for more than 5 centuries.

All physicians, Portuguese or foreign, were obliged to undergo the examination to be authorized to practice in national territory. Those who were caught using the art of healing without royal charter were arrested and subject to fines. It should be noted that there existed extra-university examinations, which consisted of an interrogation about reading and other medical subjects, as well as a practical test. The “carta de Física of Mestre Cofrem”( The Physics card of Mestre Cofrem), of 1459, describes an extract from the Canon of Avicenna on anatomy and physiology, followed by an interrogation about fevers and general pathology.

The teaching and practice of medicine in Portugal was radically changed with the foundation by D. João II (1455-1495), in 1492, of the Hospital of "Todos-os-Santos" (which was located in the old "Praça da Figueira"), in Lisbon (e.g. Sacadura et al (1965)). Some years later, D. Manuel I (1469-1521), in a pioneering and visionary measure, determined that the surgery was part of the medical training at the University, and its teaching was carried out at that Hospital (e.g. Carmona (1954)). This was to replace the old lodges and other substandard hospital facilities, with three wards on the upper floor where patients were required for surgical treatment, and on a lower floor were there were ample spaces for the stay of alienated patients and incurable patients. This building suffered two fires (1610 and 1750) and was destroyed by the earthquake of 1755.

Along with the creation of this emblematic Hospital of Lisbon, another hospital was founded in 1498, called the confraternity of “Nossa Senhora da Misericórdia” (e.g. Alves (2014)). The first establishment of the "Misericórdias" of Lisbon was installed next to the Lisbon Cathedral and originated in the recommendations of Queen D. Leonor to her husband. The main purpose of this establishment was the practice of charity (caring for abandoned, poor children), while the Hospital of “Todos-os-Santos” aimed at treating the wounded and seriously ill.

In the end of the 15th century, the Portuguese kings decided to reform the teaching of Medicine in Portugal with a view to its dignification. So, it was the transferred from the University of Lisbon to Coimbra (e.g. Arnaut (1997)). The strategy also involved training and hiring of teachers abroad. The number of disciplines increased as teachers were contracted with the desired merit. The medical teaching of the University of Coimbra at this time makes reference to a list of six disciplines, three majors ("prima", "véspera" and anatomy) and three minor ones (that included the theoretical teaching of the surgery).

Meanwhile, there was the idea of creating a regular course of surgery at the Hospital of "Todos-os-Santos", in Lisbon, while medicine would be taught at the University of Coimbra (e.g. Silva (2002)). The bipolarization of clinical medical training began to be sketched, a result of the University of Coimbra, of scholastic root and fundamentally theoretical that granted the degree of doctor, whereas in the Hospital of "Todos-os-Santos" it was given a more practical formation that enabled for the performance of surgical performances. This dichotomy in Portuguese medicine, in separating medicine from surgery, remained unchanged until the nineteenth century.

III-Conclusions

At the beginning of the 8th century, in Al-Andalus (denomination of the Iberian Peninsula, under Arab rule) medical care was made in the Maristan, while medical education was not organized, being transmitted orally from generation to generation until to the beginning of the Christian conquest at the end of the 9th century. After the foundation of the "Condado Portucalense", medieval Portuguese medicine was performed at home, with the most severe cases being treated at the hospital.
In fact, since the formation of the "Condado Portucalense", with population growth and the increase of contagious epidemic diseases that contributed to high mortality, it became necessary to create institutions that support the sick, old and disabled, and the inevitable emergence of many hospitals in Portugal. The hospital of the Middle Ages was a small institution, economically independent at the expense of donations donated by benefactors. Others were founded by royal order, being kept at the king's expense.

In general, they had several nomenclatures in relation to the functions: the hospitals treated patients, the shelters welcomed people of passage, the gafarias sheltered lepers, the groceries housed elderly and invalids (e.g. Ferraz (2005)). The hospital administration depended on its founders, being able to be religious or lay. Most of the hospitals were dependent on the clergy, and only in the fourteenth century began lay fraternities of lay people who established small hospitals for the sick. These medieval confraternities were later extinguished and incorporated into the Royal Hospital of “Todos-os-Santos”.

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Acknowledgments

Paulo Martins acknowledges funding from Foundation for Science and Technology (FCT), Portugal.

First Publichsed 2017

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