The history of osteoarthritis - Episode 3

Osteoarthritis in the middle ages

Osteoarthritis in the Middle Ages was not yet at the centre of medicine which was gradually reuniting its knowledge, creating its schools and beginning to differentiate itself from the other sciences.

We will see in our next special feature, osteoarthritis in the Renaissance, how, with the progress of surgery, the development of schools and attitudes changed the way of thinking, what the common rheumatic diseases were and how they could be treated.
Some incipient forms of a still little known illness.

osteoarthritis an middle age

It has often been stressed that herbal medicine and mediaeval medical treatises contain more cures for eye diseases than all other diseases combined. That will surprise those who think that rheumatic diseases, particularly osteoarthritis, should be common in the Middle Ages when arduous labour was not lacking.
In reality, this "neglect" of doctors of the Middle Ages could have the same explanation as that of "the strange silence of Greek physicians." Anthropologists tell us that the incipient form of osteoarthritis existed in the Middle Ages, but the extremely short life span of our ancestors did not allow the disease to evolve towards severe forms.

Ancestors who were at risk of having remedies applied that were worse than the disease and being prescribed bloodletting at every opportunity. Indeed, despite some progress achieved, in particular, by Arab physicians, medical knowledge progressed very little in the Middle Ages. On both sides of the Mediterranean, we ardently copied the works of Hippocrates and Galen. More precisely, the Arabic translators were the first heirs of ancient knowledge; it is often Latin translations of Arabic texts that enable Western scholars to discover classical authors!

Yet, let us not forget, that in the Middle Ages the first Faculties of Medicine appeared, including the very first one, the School of Medicine of Montpellier, where the first dissections were performed. This work prefigured the growth of anatomy which took place during the Renaissance.

  • Lessons of anthropology
  • Theory of the humours and mediaeval treatments
  • Medicine and the Arab schools
  • The first Faculty of Medicine in the world was created in Montpellier

Lessons from anthropology

Osteoarthritis existed in the Middle Ages, but severe cases must have been rare

This is, for example, what the study suggests of the skeletons of 252 individuals who lived in the area of Brandenburg (Germany) between the 13th and 16th centuries. All belonged to the town of Bernau. Their main activities, agriculture and crafts, provided them with relatively good living conditions for the time. However, 52% of the individuals studied had died before the age of 20 years and life expectancy was only 25 years. It is therefore hardly surprising that, while most of the skeletons of the 85 adults of this population had evidence of osteoarthritis, it was only incipient forms of mild to moderate severity.

A team of Swiss researchers gives us more specific information. The study of 273 adult skeletons that lived in the Neolithic and the Middle Ages shows the absence of osteoarthritis of large joints such as the hip. Two other rheumatic diseases, rheumatoid arthritis and ankylosing spondylitis, are also absent. However, these distant ancestors could have been suffering from osteoarthritis of the spine (cervical, dorsal and lumbar). Curiously, this condition appears to have been more common in the Middle Ages than the Neolithic Age. An effect of longer life?

By studying a much larger series of skeletons (695 Saxon or those of the English Middle Ages), British researchers effectively found signs of osteoarthritis (hip OA) in 29 of them. Knee osteoarthritis is also present but mainly affects the patella (14 cases) and very little the knee joint (4 cases). The authors conclude that the latter type of osteoarthritis may be of recent onset.

- Kramar C, Lagier R, Baud CA Rheumatic diseases in Neolithic and Medieval populations of western Switzerland. Z Rheumatol. 1990 Nov-Dec;49(6):338-45. 
- Faber A, Hornig H, Jungklaus B, Niemitz C. Age structure and selected pathological aspects of a series of skeletons of late medieval Bernau (Brandenburg, Germany). Anthropol Anz. 2003 ; 61 :1 89-202.
- Rogers J, Dieppe P.Is tibiofemoral osteoarthritis in the knee joint a new disease? Ann Rheum Dis. 1994 Sep;53(9):612-3.

Theory of the humours and mediaeval treatments

osteoarthritis mediaeval treatments

In the Middle Ages in the West, sickness was often a result of Heavenly intervention and prayer was essential for healing. The doctors, however, were inspired by theories of the ancient Greeks (approved by the Church) that four "humours" in humans reflect the four basic elements of the World:

  • yellow bile (corresponding to fire) makes a person violent and choleric;
  • phlegm (corresponding to water) is responsible for pallor, fatigue, lack of courage;
  • atrabile or black bile (corresponding to the earth) gives gluttony, laziness, melancholy;
  • blood (corresponding to the air) makes the person joyous, generous and loving.

These four humours must be balanced for an individual to remain healthy. The diagnostic task of the physician was thus to determine, by observing the patient, what humour had taken over. Fever indicated that it was yellow bile, while coolness and perspiration pointed to phlegm. In any event, bleeding, by opening a vein or applying leeches, was a method widely used to balance the humours. Some preferred administering hellebore: the humour in excess was then removed by the violent diarrhoea and vomiting provoked by this treatment.


osteoarthritis mediaeval treatments

A precursor of aspirin was among the medications of the Middle Ages.

"Drugs" were also prescribed, including some, such as precious stones, which were used for their magical properties. More seriously, willow bark concoctions were recommended, from the time of Hippocrates to treat fever and certain types of pain, perhaps including rheumatic and notably osteoarthritic. This empirical treatment has found its way into the era of scientific medicine, since it is from willow bark that modern chemists extracted the first molecules of aspirin.







Medicine and the Arab schools

After the fall of the Western Roman Empire, the ancient knowledge was first collected by the Byzantines. From the 9th century, the works of ancient Greece or the Byzantine Empire, including medical treatises, were translated and studied throughout the Muslim world. Thus, what can be called the Arab schools came into being, with a strong influence and in which a few people stood out primarily by their philosophical and theological works, but also by their medical or surgical works.

osteoarthritis medicine arab school

Among the most famous :

  • Rhazes (Abu Bakr Muhammad ibn Zakaria ar Rasi), who worked in Baghdad in the ninth century. He described smallpox and measles.
  • AbulCassis or Albucasis or (936 - 1013) whose reputation as a surgeon extended well beyond Cordoba. He wrote a famous treatise where he argues that medicine and surgery make up the same discipline.
  • Avicenna (Abu Ali Ibn Abdullah Ibn Sina, 980-1037), author of the "Canon of medicine" to be widely distributed in the West after being translated into Latin by Gerard of Cremona.
  • The Jewish doctor Maimonides (Moses ben Maimon, 1135-1204), born in Spain and in exile in Cairo, where he became a famous philosopher and physician attached to the court of the Sultan.
  • Avenzoar (Abu Marwan Abd al-Malik ibn Zuhr 1091-1162), from Seville, who was particularly interested in brain diseases, but best known for being the master of Averroes.
  • Averroes (Ibn Rushd, 1126-1198), a great admirer of Aristotle and nicknamed in Europe for this reason as "the Translator" or "the Commentator." Author of a famous medical treatise known as the "Colliget," which would be translated several times into Latin and Hebrew. After holding the highest offices, Averroes fell from grace for defending the philosophers against the theologians.

Abulcassis had great influence in the West where some of his students and patients came from. This innovative surgeon already carried out his sutures with catgut (resorbable catgut is still used today in surgery). He performed surgery, in particular, bone surgery, and was probably the first to ablate the patella. In patients with patellofemoral osteoarthritis?

The first Faculty of Medicine in the world was created in Montpellier

The world's first Faculty of Medicine

osteoarthitis history Faculty of Medicine

Hospitals, usually created by monks, soon appeared in the Christian West (Paris, St-Julien-le-Pauvre was founded in 577 and the Hotel Dieu in 650). But it was in 1220, in Montpellier, then under the suzerainty of the King of Aragon, that the world's first Faculty of Medicine was created.

The geographical location of Montpellier, the historical context of the 12th and 13th centuries and the policy pursued by Guilhem VIII, Lord of Montpellier, appear to be the source of this remarkable event.

A city at the crossroads between Italy and Spain, close to the Mediterranean and the road to Saint Jacques de Compostela, Montpellier hosted many pilgrims, some of whom were sometimes tired and sick hence hospitals had to be created for them. Saracens and Jews participated in the development of knowledge and were not uncommon in this well-located market town.

In 1181, Guilhem VIII granted permission for "physics" (medicine) to be taught in Montpellier, to all those who wished to attend, irrespective of where they were from. Arab and Jewish doctors, expelled from Spain by the Catholic Monarchs after the Reconquista, facilitated the birth, 40 years later, of the first School of Medicine. They brought with them the traditions of Greek physicians, but also of Razès, Averroes, Avicenna, Maimonides and AbulCassis.

Up until the 14th century, the courses of the School of Medicine of Montpellier were given at the teachers' homes.

Two outstanding features of this school are worth mentioning. Anatomical dissections were performed in Montpellier from the 12th and 13th centuries. In addition, surgery, a discipline usually scorned by mediaeval physicians and reserved for barber-surgeons and other bone setters, was taught there. These include, Guy de Chauliac, attached to the papal court in Avignon and whose treatise Chirurgia Magna was in annex to a Latin version of a book by AlbuCassis. This treatise would be a reference work for centuries.

osteoarthitis history Faculty of Medicine

History does not say whether these surgeons used opium and hashish as anaesthetics, as was sometimes done in the Middle Ages.

Petrus Hispanus taught at the Faculty of Medicine of Montpellier before he became pope under the name John XXI. And it was in Montpellier that François Rabelais, writer, defrocked monk and then reinstated and physician, received his degree of Doctor of Medicine.

Dr Francois Rabelais (1494-1553)