MEROVINGIAN MEDICINE BETWEEN PRACTICAL ART AND PHILOSOPHY

Abstract

This essay offers a new examination of medical knowledge in Merovingian Gaul (c. 500–c.750), the ways that it became part of non-specialized learning, and its continuities with Carolingian medicine. In most histories of medicine, the Merovingian world is portrayed as providing a hostile environment for medicine due to the Christianization of knowledge. A significant problem, however, is that there has been no study of what medicine was known or how it was treated since 1937, and even that study can now be seen to be built on false premises. The first part of the present paper offers a new conspectus of Merovingian medical knowledge based on the earliest manuscripts and argues that this new overview changes where we can see continuities in content and practice with Carolingian medicine. The second part builds on this to explore the intersections between religious and secular study, and how medicine fitted within a generalist rather than specialist education. The final section looks at how this learning complemented understandings of the miraculous and nature and in the process helped to deal with challenges from folk practice and the failures of medicine to offer effective aid during pandemics. It is concluded that medicine was in good health in the Merovingian period as it contributed useful ways to see natural order in Creation.

Medicine in the Merovingian world could be a contested business. Once, in the region of Paris in the mid-sixth century, a man named Daningus sought respite from dropsy, a swelling of the body from the accumulation of fluids.¹ It was a condition well discussed in medicine since the days of Hippocrates, but there was no agreement on either the cause or the best cure. Daningus turned to local physicians (medici), but found their efforts wanting. In despair, he appealed to Bishop Germanus of Paris (d. 576), who had begun to gain a reputation for his powers of healing. The holy man duly anointed the supplicant with oil and the condition was relieved. Yet it was not exactly the miraculous cure one might expect from a work of hagiography. The narrator of our tale, the learned writer and bishop Venantius Fortunatus (d. 610), proclaimed that the oil infusion Germanus used was capable of absorbing liquid and drying it out, rebalancing the humours, as one might expect if one knew the warming properties of oil in Hippocratic medicine and its descendants.² Germanus's impressive skill was that he knew an effective remedy from among the many recipes one found in medical books. For effective care of the body, a physician might not be enough: what one needed was someone learned and well-read enough to know what worked. Germanus joined a long list of exemplars stretching back to the Bible who were not only healers of souls, but also healers of bodies.

The nature of Germanus's medical wisdom can appear obscure. The closest sustained early medieval exposition of how medicine might intersect with Christian learning is in the encyclopedic Etymologiae of Isidore of Seville (d. 636). There, Isidore offered an impressively compressed digest of Hippocratic-Galenic ideas before he waxed lyrical about how medicine was a “second philosophy,” a counterpart to spiritual learning that gained vibrancy from the way it demanded people draw on insights from all seven liberal arts.³ This kind of talk has impressed few modern commentators, many of whom would prefer to see medicine as a science rather than as a philosophy. It has been seen as typical of early medieval Mönchsmedizin or “monkish medicine” that diluted medical learning with concerns for practicality and piety over theory and specialization.⁴ Gundolf Keil, in 1991, went further and bluntly stated that people in the Merovingian kingdoms simply rejected their Roman medical heritage because it was incompatible with their religious sentiment.⁵ Yet Germanus and Fortunatus suggest something quite different, with concern for effective medicine in pastoral contexts emerging from non-specialists who were still engaged critically with medical learning. As we shall see below, so much is now evident even in Gregory of Tours’s famously cool comments on doctors.⁶ Moreover, there remains an almost untapped treasure trove of medical texts in Merovingian manuscripts that could allow us to delve deeper into that early medieval learning. The only previous study, by Loren MacKinney in 1937, unfortunately rested on manuscripts no longer considered “Merovingian” and was pursued in unfortunate ignorance of those that more certainly were.⁷ As Charles Daremberg asserted in 1870, until we have actually studied the texts and manuscripts of the period, we cannot assess it.⁸

To understand medicine as a philosophy requires a shift in focus from traditional histories of medicine. There is little to be gained by trying to argue that there was profound progress in the period because, by any absolute standard, there was none. There is, however, much value in looking at the cultural contexts and resonances of medicine, as Peregrine Horden has argued.⁹ To study early medieval culture in general, as Julia Smith put it, is to study “the expression of meanings, perceptions, and values by means of which people construct their understanding of reality, organize their experiences, and determine their actions.”¹⁰ Such an approach stresses human agency and language as well as, by implication, the resources with which people could work. It demands seeing idea and action as situational and as part of interconnected webs of practices. Tight focus on subject-specific technicalities will not do. Medical knowledge, as we shall see, can often be hard to separate from attitudes towards belief, power, and process that are not about medicine itself, but which still affect how it developed and was understood. Meg Leja has productively shown exactly that with her recent explorations of Carolingian medicine, exposing how medical knowledge intersected with debates about body and soul.¹¹ There have been good studies of attitudes towards medicine and physicians in the Merovingian period by Edward James, Valerie Flint, and Allen Jones, all inspired by more anthropological-textual approaches to Merovingian history.¹² Matters can be pushed further. In recent years, the complexity of a Merovingian culture once thought resolutely “barbarous” has been brought into focus on almost every possible front, including its historiography, law, liturgy, and art.¹³ Merovingian medicine needs to be reassessed within this revised context.

Such a study also requires us to rethink how to understand what an early medieval medical text is. Many foundational historians of medicine such as Karl Sudhoff (d. 1938) were involved in medical practice too and so they sought coherent treatises with recognizable purpose and theorization that fitted their ideals.¹⁴ From this perspective, the many inconsistences of content and language in the material they encountered seemed chaotic. This was no less true in a second stream of foundational scholarship from classical philologists such as Valentin Rose (d. 1916). Rose labored to establish the authoritative versions of texts in critical editions for the Bibliotheca Teubneriana, much as scholars did for any ancient texts.¹⁵ The idiosyncrasies in many medical manuscripts frequently worked against such a task, however, notably when the so-called Gynaecia attributed to the fourth-century physician Vindicianus forced him to print five different versions in parallel columns.¹⁶ The aims of the project strained against the evidence itself, which seemed more organic in form than modern editors liked. In both streams of scholarship, the medical and philological, we are presented with the same problem: the scholars who established the field processed evidence in line with transhistorical standards that meant their judgments were frequently shaped by what their sources seemed to lack. In such a context, manuscripts were treated as incidental and often degenerate witnesses to lost perfection, rather than as the creative cultural products of their scribes and communities that they were. This is a situation familiar in many areas of Merovingian and Carolingian studies, where it has slowly forced a “return to the manuscripts” to reassess raw textual data and its many different uses across time and space.¹⁷ To understand Merovingian medicine, we need to follow suit: return to the manuscripts and work outwards to establish what it meant to the people who used such knowledge as they moved between the creation and reception of ideas to find order and wisdom.¹⁸

In Search of Merovingian Medical Books

We begin with the problem of establishing what medicine was known and what shape it took in Merovingian books. Latin medicine before the Merovingian period was already something of a curate's egg, dominated by variable translations of key Greek works — particularly those attributed to Hippocrates and Galen — and large-scale assemblages of pharmaceutical material. There was a strong interest in lay digests of practical medicine (euporista), most readily represented by the Medicina Plinii, which provided a collection of cures organized by ailment, so that a traveler could avoid being defrauded by unscrupulous physicians (and also, no doubt, find alternative cures if specific ingredients were not available).¹⁹ In Gaul, a particularly full digest was Marcellus of Bordeaux's De medicamentis liber, produced in retirement by a figure who had once worked in Constantinople for Emperor Theodosius.²⁰ The region offered little more to the pre-Merovingian history of medicine. Merovingian Gaul itself could boast only one named medical writer: Anthimus, a Greek legate who offered King Theuderic I (d. 533/34) dietary advice to assist the king to avoid the need for physicians, partly based on general medical knowledge and partly based on what the legate had seen at court.²¹ We do not, however, know anything about Anthimus or his training. When the Carolingian “revival” took off in the late eighth century, it was dominated by old handbooks and treatises, but these were frequently excerpted or adapted to create new ones.²² This revival is sometimes even considered to have relied on the importing of resources from Italy rather than from books already in circulation north of the Alps on the assumption that the cultural situation had become so bleak.²³ Merovingian medicine seems at best to have been in a holding pattern and at worst to have ceased almost altogether.

Yet the evidence of Merovingian medical manuscripts suggests that there was at least more medical knowledge in circulation than just Marcellus and Anthimus. The richest example is a general educational miscellany, likely produced at the cathedral school of Bourges in the 720s, which contains the short Galenic treatise De febribus, a medical lunar prognostic, and a substantial but hardly comprehensive composite text entitled De arte medica, comprised mostly of short recipes.²⁴ De arte medica, moreover, contains identifiable borrowings from a “Hippocratic” Dynamidia on the properties of nuts and fruits, part of a theoretical preface to the Old Commentary on the Hippocratic Aphorisms, and a rich collection of short recipes from a Teraupetica, Pseudo-Apuleius's popular Herbarius (hitherto unnoticed), and more from as-yet unidentified sources.²⁵ It was, in short, a well-resourced assemblage that hints of a multitude of exemplars now lost to us. To this could be added another short collection of recipes appended to a Latin-Greek glossary from around the same time, now in London (and hereafter the Harley Antidotarium).²⁶ A small fragment of a text, possibly from Lyon but now in Paris, concerns the use of purgatives for treating conditions and balancing the humours, something altogether more explicitly in the Hippocratic-Galenic mould than the two recipe books.²⁷ Finally, there is a partial capitula and few words from a lost medical book rescued from the bindings of a manuscript now in Sélestat.²⁸ It is a poor tally compared to the seventy or so medieval manuscripts for the Carolingian period noted by Augusto Beccaria.²⁹ There are, however, many structural differences between the two periods that make true comparison difficult, such as a shift away from using fragile papyrus and the importance of monastic centers with little-to-no Merovingian history for the new Carolingian commitment to the written word.³⁰ Even as a fragment of what there once was, however, the Merovingian manuscripts start to reveal something of a distinctive and surprisingly rich profile for medical knowledge in the region.

Comparison with early evidence from elsewhere highlights the distinctiveness. None of the material is obviously close to the much-cited list of recommended readings for monks provided by Cassiodorus (d. c. 585) in Italy nor does it seem to have derived from the translation efforts of the school of late-antique Ravenna.³¹ Of the contents of the seven or so extant pre-750 medical manuscripts from Italy, the only major text shared with Frankish manuscripts is Pseudo-Apuleius's Herbarius.³² In Spain, Isidore must have had a few books available to judge by the Etymologiae, although the only obvious text shared with the northern manuscripts is the Old Commentary on the Hippocratic Aphorisms.³³ Nothing from the Merovingian manuscripts immediately connects to the North African cluster of late-antique texts from Augustine's friend Vindicianus, his pupil Theodore Priscianus, and Cassius Felix, which collectively marked a strength of medical learning there, although, as we shall see, some indirect connections might be discernible on other evidence.³⁴ Medical knowledge in the English kingdoms seems different again to judge by citations associated with Theodore of Canterbury, Aldhelm, and Bede, much of which seems related to the North African writers or Isidore.³⁵ One cannot, of course, rule out the possibility of many more points of connection, given the demonstrable loss of so many early manuscripts. It does, however, highlight how problematic it can be to generalize about the vitality of early medieval medicine, given that the resources and evidence we do have varied from place to place.

The Bourges miscellany provides several possible leads for identifying where Carolingian manuscripts built on Merovingian foundations or at least a shared heritage. There are, for instance, important connections with the contents of two Carolingian manuscripts from the Paris region. In one, from Saint-Germain-des-Prés, dated c. 800, there is a full copy of the Dynamidia which shows a closer textual affinity with the Bourges extracts than with other early versions.³⁶ That it happened to be copied alongside Anthimus's De observatione ciborum might hint further at the Merovingian provenance of an underlying exemplar. Meanwhile, Arsenio Ferraces Rodríguez has recently shown that the compiler of De arte medica had access to a rare Teraupetica, known in two full but slightly different versions in two northern Carolingian manuscripts.³⁷ The Teraupetica may itself have originated in the Frankish kingdoms to judge by some linguistic quirks and an associated dietic calendar that mentions the consumption of mead and beer.³⁸ In one of the two, from Saint-Denis, it is juxtaposed with a compilation known as the Tereoperica (or Practica Petrocelli), the preface of which seems to have been a model for the preface to the Teraupetica.³⁹ The work's most recent editor, Laura López Figueroa, has speculated that that work too might be from Merovingian Gaul, given its limited and exclusively northern European early circulation plus the fact that it cites nothing later than the sixth-century Trallianus.⁴⁰ The last sentence of the preface, meanwhile, connects to a letter contained within a medical Liber epistolarum which surely not coincidentally is also included in the Saint-Denis manuscript.⁴¹ Given the Teraupetica's compilatory nature, it seems most likely that it borrows from the letter rather than the other way around. Whatever the precise relationship between the three texts, that they should intersect textually and be included together suggests that Saint-Denis had access to traditions that had been entwined in Gaul for a long time already.

A further set of affinities points to connections between Bourges and the Narbonne region. The strength of cultural continuities in the south has long been hypothesized because of distance from the Frankish heartlands and developments there such as the “monasticization” of Frankish ideals.⁴² It is from this area that we find one of the earliest “Carolingian” medical books: the wide-ranging two-book De arte medicina omne.⁴³ Like the Bourges De arte medica, its information on herbs is built around extracts from the Dynamidia (fols. 27v–34r), Pseudo-Apuleius (fols. 40r–47v), and Teraupetica (fols. 116r–132r + 177r–v). Its most “theoretical” inclusion, as with De arte medica, is a long extract from the preface to the Old Commentary on the Hippocratic Aphorisms (fols. 98v–102v). The compiler was interested in prognostic material too and included a medical lunary (fol. 18r), although different from the one copied in Bourges. A small manuscript related to the same center, dominated by a mislabeled copy of (Pseudo-)Vindicianus's Gynaecia, also offers another sliver of a connection by sharing a treatment for scabies with De arte medica.⁴⁴ The same recipe can be found alongside Anthimus's work in the famous Lorsch Arzneibuch (c. 795), which illustrates how Carolingian medicine drew on traditions already established in Gaul in the Merovingian period.⁴⁵ In none of these cases are we confronted by a direct relationship between the Bourges miscellany and the early Carolingian medical books. That they were all able to draw on the same or similar compilations, however, proves that the relevant medical traditions were in wide circulation since at least the early eighth century, if not before.

The Harley Antidotarium suggests further continuities of networks of medical knowledge stretching through the Frankish world from the south. Its first text is a long medical recipe called the acharistum, which claimed to be useful for an array of things from stomach ache via asthma to neutralizing spider venom.⁴⁶ The same text, give or take corruptions, was copied into two of the earliest Carolingian medical manuscripts: the Lorsch Arzneibuch and a compendium from Dijon.⁴⁷ The Dijon manuscript is notable for having various connections with the web of texts illuminated by the Bourges miscellany, including a variation of De febribus and an Epistula Flebotomie known from the Saint-Denis Liber epistolarum (as well as from elsewhere).⁴⁸ It also contains an extract from Cassius Felix on dysentery not far removed from the rare recension known to Bede (d. 735), who cited it paired with a story from Gregory of Tours on an outbreak of disease in 580.⁴⁹ Again, if we analyze the evidence in terms of networks and associations of texts, rather than individual canonical compositions, it is clear that the Carolingian “revival” of medicine drew on learning that had already circulated widely in different ways throughout the Latin-reading West. As some of those early networks seem to have included readers in or connected to the Merovingian kingdoms, we may want to be cautious about assuming medical knowledge was radically lost or rejected in Gaul between the Roman and Carolingian periods.

Continuity did not mean fossilization. The Teraupetica and Tereoperica both show engaged and considered efforts to generate new euporista through a process of mining multiple texts to generate lists of potential cures organized by condition. De arte medica frequently offered the same feature, if less steadily, with its groupings of recipes on jaundice, gout, ergotism, and then renal and stomach complaints taken from different sources.⁵⁰ The author-compiler also put effort into rearranging borrowings from Pseudo-Apuleius's Herbarius, in the process refashioning entries so that they were organized by condition rather than, as had originally been the case, by herb.⁵¹ In both De arte medica and the Harley antiodotarium, scribes made considerable use of texts for which we have no known authoritative original text. This reinforces how, even before the Carolingian period, writers compiled medical texts from a much richer and less stable set of textual traditions than any standard checklist of canonical texts would suggest. Where MacKinney, Riddle, and others have envisaged continuities that revolved around passive copying, we can perhaps see something a little more restless and intermittently creative.⁵²

What drove that creativity may have come from both practical and intellectual trends. A feature of De arte medica is that the ingredients are generally not exotic apart from frequent use of black pepper and a single call for cinnamon in a long general-purpose recipe.⁵³ This could speak of the poor availability of spices and herbs in the wake of disruption to trade patterns in the seventh century. A practical approach to the imperfect availability of ingredients, however, had always been part of late-antique euporista, in the way that they had offered multiple potential recipes to address the same conditions. It remains unclear, therefore, what might have been affected and why, especially as few people now accept that the Arab conquests of the seventh century led to quite the harsh break in trade continuities once proposed by Pirenne.⁵⁴ One cannot rule out the influence of taste on the spice trade as old Roman habits gave way to new ones.⁵⁵ An aversion to spices is, however, not a feature of the Harley Antidotarium's collection, which has a richer selection of ingredients such as cinnamon (mostly from Sri Lanka), spikenard (mostly from the Himalayas), and saffron (mostly from Greece to Persia); nor is it apparent in the very many early Carolingian recipe miscellanies which demanded a broad range of exotic ingredients.⁵⁶ One Merovingian document that has survived in exemplar form even demanded provision for royal missi with options for the supply of cumin, pepper, costum, cloves, nard, and cinnamon.⁵⁷ Supply may have been inconsistent, but demand remained.

The compilation of multiple recipes in euporista fitted the tendency of early medieval scribes to excerpt and refashion even notionally authoritative Christian texts. The Bourges miscellany alone bore witness to disembodied, deauthorized extracts from Jerome, Gregory the Great, and Isidore of Seville on various aspects of history, sin, penance, and (in the case of Isidore) measurement.⁵⁸ Extracts from secular and canon law were treated similarly, as scribes purposefully appropriated useful material for the classroom.⁵⁹ There are telling parallels with computistical materials, too, which were typically compiled from multiple sources with more concern for content than authorial authority.⁶⁰ In the Bourges miscellany, this is represented by two separate sets of notes supporting the fifth-century reckoning of Victorius of Aquitaine without direct copying of his work or naming the supplementary works used.⁶¹ Medicine was not a special case and it does not seem to have been deliberately “deauthorized” by the way it was treated as is sometimes claimed.⁶² Medicine, in short, was constantly being reshaped and reimagined according to need and taste just like other subjects, but not out of some putative “monkish” indifference to the texts.

Between Professional and Monkish Medicine

The basic creativity of Merovingian medicine invites further consideration of how medical knowledge was used and what its social environment was. A key feature of the euporista was that while they were not necessarily all for professional use, because they often drew on books that were, many were likely utilized by physicians in practice. Theodore Priscianus imagined precisely such a situation, in fact, with his extant Latin euporiston explicitly intended as the accessible recapitulation of a longer (now-lost) Greek work.⁶³ The earliest example of a vade mecum thought to have been owned by a physician is slightly later than the Merovingian period, dating to c. 800, but it too is predominantly a reference book of recipes plus the ubiquitous Epistula Flebotomie.⁶⁴ In the context of any supposed monastic hostility towards medicine, matters become more definitionally imprecise still. All extant early medieval medicine survives because the success of efforts by cathedral and monastic libraries to preserve knowledge developed significantly outside an enclosed religious environment and involving non-Christian authority. This means that we should expect fundamental continuities between the medicine learned in professional, lay, and religious contexts.⁶⁵ If there were such a thing as “monkish medicine,” it was defined more by its context than by its content, even if such a conclusion would offend the secularized sensibilities of most historians of medicine since the nineteenth century.

A difficult issue here is the extent to which one imagines there were alternative contexts for any specialized medical training in Merovingian Gaul. Gerhard Baader, in a 1972 article, argued that there was no evidence of medical training in Gaul after the sixth century at all.⁶⁶ In part this is simply because there is no explicit evidence stating that there was, beyond the growing evidence for it becoming part of education in clerical or monastic settings.⁶⁷ There were, however, still medici mentioned in narrative sources and, as we have seen, there were still medical books, so we should perhaps not get carried away with any skepticism. Baader's most suggestive piece of evidence was that Reoval of Poitiers, a friend of St. Radegund, received some surgical training in Constantinople in the late sixth century.⁶⁸ This could suggest that such training was unavailable in Gaul, but, before we exaggerate this too, we know from other sources that Reoval travelled east primarily to obtain relics and, more importantly, what he observed was a castration operation, which were rarely performed in the west.⁶⁹ One would anyway expect to find people of means attracted to the best medical education of major Greek-speaking cities rather than relying on Latin training that was only ever considered second best. But assuming that most physicians did not travel to the east, they must have received training from somewhere.

Sadly, we do not know enough about these physicians. Away from religious institutions, education surely looked different in many respects and must have changed over time. Some physicians may still have had recourse to the Greek books there must once have been in the Latin world even just to have supported basic translation efforts there. Only one palimpsested partial copy of Galen survives.⁷⁰ MacKinney provides a couple of examples from Gregory of Tours in which Jews offered medical advice of a sort, one in Bourges and one in Bordeaux (who in fact is only reported to have been disparaging about the healing properties of relics).⁷¹ The basis of their professed expertise and any books they might have used, however, must remain a matter of speculation. We also assume that training involved significant oral transmission of material and probably not a little hands-on instruction. At no point, however, was there an institutional continuity of something like a medical school with a library that allowed for the long-term preservation of materials.

For the Latin-speaking West, the best evidence of specialized training is likely texts geared towards outlining technical matters that transferred into ecclesiastical and monastic libraries. The Liber epistolarum in the Saint-Denis manuscript, if the contents do reflect earlier compilations, perhaps offers the best case from those encountered so far, as it contains classroom dialogues, an isogoge (introductory overview) that covers serious conditions, and practical advice on surgical matters, much of which goes beyond everyday basics. This is the kind of anonymous short-form material that Baader considered central to the early medieval degradation of medicine because of the ways it minimized philosophical discussion and authority.⁷² How deliberately hostile the production of such texts was may be doubted given the extent to which most subjects could be treated in such a manner, as we have seen above. Moreover, it is not clear that there ever was an extensive array of more sophisticated Latin training texts or that access to longer-form works became more restricted. Only some Ravenna lecture notes on Galen's On the Sects suggest extended philosophical reflection in a Latin-speaking context, perhaps alongside the Old Commentary on the Aphorisms, but these seem exceptional rather than typical.⁷³ Even access to such texts did not necessarily count for much. The scribe of De arte medica either abandoned copying from the Old Commentary mid-sentence after only six-and-a-half lines or else his exemplar was faulty.⁷⁴ What people valued was practical medicine.

Hospices (xenodochia) may have presented one point of contact between practical medicine and any intellectual appropriations of it in a more strictly religious setting. There remains much doubt whether hospices would have been fully dedicated to medical practice, because of the way that they were generally established as charitable institutions with liturgical functions to provide support for the weak and sick.⁷⁵ Moreover, there were likely very few to be found, with the earliest perhaps only established in Arles early in the sixth century and the idea spreading only slowly up the Rhône thereafter.⁷⁶ Even the most pessimistic estimate of a few tens of institutions still provides some potential crossover points. The author of the Passio Praejecti, for example, considered those employed at a xenodochium founded in Clermont to be physicians (medici).⁷⁷ He may just have meant “healers” in a more generic, if not spiritual sense. Such an interpretation seems forced, however, especially given wider interest in healing. There is no reason to doubt that physicians were working alongside people in religious institutions who were interested in healthcare. It would also be an obvious institutional setting in which relevant books could be copied and circulated.

The interconnectedness of knowledge in its many forms was a common aspect of Christianized education in the period more generally. This is well recognized, but has frequently been a cause for despair by those who would want to see evidence of more specialization in the pursuit of medicine.⁷⁸ Not, of course, that many of the beneficiaries of a general education were seeking to become physicians. In Cassiodorus's Institutiones and Isidore of Seville's Etymologiae, the traditional seven liberal disciplines together established a foundation of logic and reason which could then be applied to the successful investigation of other subjects, including history and scripture. Medicine had an ambiguous position in such models, to be sure. It had at times been considered one of nine disciplines — with architecture being the ninth — but it was commonly left out of the smaller scheme because it pertained more to earthly than celestial matters. In Martianus Capella's The Marriage of Philology and Mercury, a work mentioned by Gregory of Tours as a touchstone of good learning, the personification of medicine had to remain silent in a debate before the senate of the gods.⁷⁹ Many historians have considered this to be representative of a denigration of the art and it may have been seen as such by some at the time as it positioned medicine as a trade rather than a science.⁸⁰ Medicine, however, was still envisaged to be part of a wider course of study both for the benefit of the soul and for anyone with ambition. As we saw at the outset, Isidore considered medicine a “second philosophy,” but he also considered it one of the seven disciplines of physica, the natural “sciences.”⁸¹ This was affirmed in studies of the liberal arts by two grammars produced in the period.⁸² One of the letters of the Liber epistolarum expressed such a sentiment too, which reinforces the early circulation of the idea in specifically medical contexts if we accept a Merovingian provenance for material in that compilation.⁸³ We also find it in an interpolated version of the Old Latin Commentary on Aphorisms, in which an additional passage encouraged medical students to pay attention to “philosophy, geometry, and arithmetic,” and to “grammar, rhetoric, music, and mathematics,” although the principal witnesses to the interpolation are Carolingian and Italian, so it is difficult to know how early or widely that version circulated.⁸⁴ Collectively, anyway, these threads seem to hint at a continuity of late Roman educational ideals through to the Carolingian period in which Christian religious and physicians could be expected to share an appreciation of the fundamental building blocks of knowledge including medicine, even if we might expect emphases to be different according to school or vocation.

The Merovingian Bourges miscellany illustrates one local variation of such an interconnected knowledge. It is important that this was a product of a cathedral school rather than a medical school because this helps us to understand the perceived logic of medical texts. In practice, the miscellany was once six units, with the Galenic Epistula de febribus in Part III and De arte medica taking up all of Part VI. In its isolated position De febribus may seem an underwhelming choice of text to copy.⁸⁵ It outlines the nature, causes, and cures for different kinds of fever: quotidian, tertian, quartan, and the more persistent sunacus. In terms of theory, it uses ideas about the influence of the humors in the body and the effects of lifestyle, so quotidian fever could be caused by overwork or tertian fever by the warmth of red bile. The letter offers a rule of thumb for identifying cures, such as using warms foods if the cause is a cold climate or an overabundance of cool melancholy. This is basic Galenism. But it is not included in the manuscript to represent the heights of medicine or to contribute to a deep medical education. It was numbered as the twenty-first and last item in a book that included (among other things) Asper's Ars grammatica, extracts from Isidore on measurement, some exemplar legal documents, and a collection of riddles.⁸⁶ To these, other scribes added a table of lunar epacts (the age of the moon on the first day of the calendar month across the nineteen-year lunar cycle), computistical notes, and the medical lunary. In such a context, De febribus represented part of a general education which emphasized ordered structures in language and nature, structures that might be useful for the students at Bourges in many different walks of life, from theological study to administrative work. The Harley Antidotarium, following grammatical texts as it does, may have been copied in a similar context. The structures of medical knowledge were fully in keeping with how knowledge generally was envisaged in the period.

The status of medicine-as-wisdom offers a useful context for understanding Anthimus's letter to King Theuderic. Taken purely in terms of its contents, Anthimus offered the king little more than some dietary advice that encouraged him to find health through moderate living, extending even to thoughts on how the Franks should boil rather than fry bacon — the most distinctive part of a Frankish diet according to Anthimus — to ensure that it maintained moisture.⁸⁷ The advice was framed by anxiety about balancing the humours in keeping with Hippocratic thought, although with adjustments and the medical theory pushed just below the surface and with no stress on learned medical writers, Latin or Greek.⁸⁸ Such dietary advice to kings had a pedigree within medicine, as exemplified by the popular pseudo-Hippocratic Epistula ad Antiochum.⁸⁹ Epistolary gifts of knowledge, meanwhile, were a staple of post-Roman political culture to reinforce diplomacy through culture.⁹⁰ Our evidence for Merovingian kingship more-or-less begins with Bishop Remigius of Rheims offering character advice to the young new king Clovis, much as philosophers and prophets had often done to the powerful.⁹¹ His contemporary, Theoderic the Great, employed Cassiodorus to write sophisticated letters which often spilled over into philosophical musings.⁹² As Yitzhak Hen has shown, royal patronage of culture was big business in the early Middle Ages, and this culture could be very eclectic indeed.⁹³ In an environment that valued knowledge, medicine was in no imminent danger of being suppressed, because people recognized its power and usefulness.

Authority and Acceptable Medicine

The theoretical and practical framings for medicine draw us further into medicine's early medieval religious-cultural environment. It is this environment, of course, which generated the derogatory label Mönchsmedizin (“monkish medicine”) and the common assumption that somehow religious sensibilities undermined serious pursuit of the medical art. Yet explicit evidence that Christians were actively suppressing medicine is thin, to say the least. The most common point of reference is the preface to the Lorsch Arzneibuch (c. 795), in which the author defended his labors against those who accused him of writing “foolishly” (inaniter).⁹⁴ In his defense, the author cited medicine's well-recognized place in learning and praise for it in both biblical and patristic texts, including Cassiodorus and Isidore. The preface stands as ambiguous evidence for hostility: a defense was clearly necessary against critics, but it was also not difficult to make a case that drew on considerable, established authority (and before then producing a sizeable and well-resourced medical book that included at least some texts known in Merovingian Gaul). The example is, of course, too late and too isolated to reflect Merovingian attitudes. As we shall see, however, such defenses of medicine were hardly new.

The most common forum in which one finds any Merovingian anxiety about medicine is in tales of the miraculous. Healing at tombs and through relics were a staple part of the Merovingian hagiographical repertoire as they helped to express the on-going spiritual power of the saint to heal the community at large. In Bourges, the tomb of Bishop Austrigisil (d. 624) was said to have drawn people from as far as Brittany seeking bodily restoration.⁹⁵ The tomb of his successor St. Sulpicius (d. 644) quickly became a place where people were cured of withered limbs, blindness, and impaired hearing, too.⁹⁶ In neither hagiographical account were physicians themselves disparaged, perhaps fittingly given the evidence of medical teaching at the cathedral school, but nor were they actually mentioned. It was not like that everywhere. Fortunatus's account of Germanus of Paris, for instance, included three healing miracles in which the saint was explicitly said to have succeeded where physicians had failed miserably, including the story of Daningus.⁹⁷ The Passio Praeiecti pointedly recounted how a man named Ursio broke his arm and other parts and, after doctors had failed him, he received his health back at Praejectus's tomb.⁹⁸ In Laon, a nun's wound was healed by sitting on the chair of St. Anstrude after doctors had declared there was nothing they could do.⁹⁹ As Valerie Flint observed, the very fact of these stories proves not that medicine was rejected, but that a physician was a high-status professional with whom it was worth religious figures competing.¹⁰⁰ Medicine was good; faith could be better.

The famous case of Gregory of Tours challenging his own archiater (‘master physician’) Armentarius suggests that the problem was often a matter of who was presiding over the healing rather than a matter of medical practice per se.¹⁰¹ Gregory related how he had suffered with dysentery shortly after becoming bishop in 573 and how, despite Armentarius's best efforts, his suffering had led him to question the efficacy of earthly medicine. Eventually he sent for dust from the tomb of St. Martin and mixed it with water, so that he could show Armentarius a more effective remedy (and, with that sense of demonstration, suggesting that Armentarius himself was curious to hear about alternative cures). Having drunk the potion, Gregory claimed, he was able to eat a full meal shortly afterwards, and he hailed the dust as more effective than all the physician's “ingenious artifices” (ingenia artificia). In the process, as Raymond Van Dam observed, the healing had validated the authority of the new bishop.¹⁰² Indeed, Gregory then took the dust and its healing power on a journey, so that others could share in that healing with him, and he proclaimed again that it “overwhelmed the sophistry of physicians” (medicorum vincit argutias).¹⁰³ His friend Venantius Fortunatus celebrated this by calling him Gregorius Medicus in a poem.¹⁰⁴ Gregory saw association with healing as a way to strengthen his reputation as a community leader in an environment which was highly contested on many fronts.¹⁰⁵

Gregory's assault on the authority of medicine appears to have been no matter of rude ignorance or distaste for earthly wisdom. He had, after all, still submitted his care to Armentarius in the first place until he felt moved to try a different approach with the physician's assistance. Moreover, he gave away something of his own medical knowledge in the course of his stories. Faith Wallis has detailed how many of his descriptions of illness coincided with prevailing ideas in medical books.¹⁰⁶ He hints at pharmaceutical knowledge too in his story about St. Martin's dust when he claims that the dust rivalled agridium (= scammony) as a laxative, hyssop for soothing pulmonary issues, and pyrethrum for clearing the head.¹⁰⁷ These were relatively exotic medical ingredients and ones that suggest he knew a good herbal, likely Dioscorides’ De materia medica or a derivative.¹⁰⁸ The dust of St. Martin did not replace medicine, but rather functioned exactly in accordance with how medicine should work.¹⁰⁹ Gregory was, after all, a “careful observer of the natural world” and rarely prone to simple credulity.¹¹⁰ He did, however, seek advantage in his own narratives where he could.¹¹¹

Beyond the critical polemics of Gregory and the hagiographers, medicine crept into Merovingian imaginations in positive ways. St. Columbanus, the famous Irish wandering saint, compared the struggles of learning wisdom to the “fatigues and sorrows” endured by medical students to show that worthy knowledge never came easily.¹¹² Defensor of Ligugé, around 700, assembled a number of positive quotations about medicine for his Liber scintillarum, as part of his rich collection of thoughts to assist with navigating issues of virtue and vice.¹¹³ These included several from Ecclesiasticus chosen specifically to emphasize how one should welcome physicians as workers for God. This hints at how the good ethics of physicians were supposed to be a decisive factor in their favor. More than one letter in the Liber epistolarum we encountered earlier commented on how physicians were to be moderate, trustworthy, sober, and well-read, loosely expanding on ideas descended from Hippocratic ideals.¹¹⁴ Such praise was not new and could be found, for instance, in the works of Jerome and Augustine.¹¹⁵ Ethics, discipline, and learning had long provided a shared playing field for people pursing medicine and the Christian faith.

There was little doubt that pharmacy was potentially good, too, because it depended on natural resources created by God for people to use. The preface to the Teraupetica, when it quoted the letter in the Liber epistolarum, declared that “the remedies of God are to be applied through all cures, because divine power deigns to revive dying bodies.”¹¹⁶ The full letter continued to explain that God had created the world precisely for human uses, including herbs for medicine and trees for unguents. Such thinking chimed well with the prevailing attitudes towards cosmology and science in the seventh and eighth centuries. As is plentifully evident from Isidore, Hiberno-Augustine, or Bede, there was a strong belief in the orderliness and rationality of nature stretching throughout Creation.¹¹⁷ Medical knowledge supported this way of seeing the world and was cited accordingly. Indeed, scribes readily Christianized it.¹¹⁸ The ascetic rejection of earthly things, seen through a specifically moral prism, did not necessarily involve the rejection of natural things, because God's Creation was accepted as good and rational.

Acceptance of medicine as natural can be contrasted with attitudes towards amulets in Merovingian Gaul. Use of such items, often for healing and protection, are modestly well-attested in the material evidence for the period, as recently highlighted by Genevra Kornbluth.¹¹⁹ In our written sources, we generally only have the words of critics, eager to persuade people from using amulets because those people saw them as acceptable within a Christian worldview and the critics disagreed, although how close we can get to actual popular belief from such sources remains doubtful.¹²⁰ Caesarius of Arles complained in a sermon about the sick placing more faith in phylacteries than in the healing power of Christ.¹²¹ Eligius of Noyon condemned phylacteries too alongside pendants using amber or herbs, all as part of anxiety about the encroachment of polytheistic practice into Christian culture.¹²² The anxiety was still evident in a reference to phylacteries and ligatures in the Indiculus superstitionum, likely drawn up in the circle of St. Boniface for discussion at Les Éstinnes in 742.¹²³ In each case, hardliners feared that belief in the efficacy of amulets threatened the normalization of demonic influences among otherwise Christian communities. Healing was not a natural function of the objects, but rather an assumed one that invited agencies external to a Christian cosmology. Most medicine in the Hippocratic-Galenic mode had a very different ontological status.

Anxieties here were closely related to concerns over prediction and prognosis. Prognostics had always been controversial in medicine. Galen himself had faced sharp criticism over interest in the field and had had to conceptualize it as something that worked in parallel to proper medicine.¹²⁴ Predicting the outcome of any human condition ran the risk of seeming to claim divine foresight. In Gaul, Gregory had dismissed the value of astrology for predicting the future in his De cursu stellarum, preferring instead to use astronomy rationally (rationabiliter) for the purpose of calculating the timing of the night offices.¹²⁵ Sufficiently well-evidenced cycles and well-known examples of cause and effect were not divinatory because they did not make a mockery of chance. This is where the inclusion of a medical lunary in the Bourges miscellany is striking for showing that people were open at least to the possibility that it might be worthy of scrutiny. That text itself simply listed the days of the lunar month and the likely outcome of falling ill on one of those days (for example, “luna I, a long infirmity . . . luna x, without peril . . . luna xxvi, they will die swiftly”).¹²⁶ In the miscellany, it had not only a medical context, but also computistical and eschatological resonances. It followed lunar and paschal tables, which meant that its own lunar framing fitted within an accepted astronomical mathematical model for the organization of liturgical time and history. In a space after the lunary, a scribe added a note on how leap years were caused by the discrepancy between the calculated and astronomical solar cycle rather than by Joshua ordering the sun to stand still (Josh.1.10), further emphasizing the dominance of a rational, natural, and predictable framework.¹²⁷ Certainty about the future, in one sense at least, was also provided by the inclusion of the poem Cantemus Domino in the middle of the lunar materials, a poem which celebrated God's creation of the natural world and the promise of the world's inevitable future destruction after Judgment Day.¹²⁸ Speculation about the earthly future may have been discouraged, but one could be certain about the suffering to come for many people and the structures of time and salvation in which that would occur. A good Christian could engage with prognostics if they took time to understand these matters properly and in a broad, learned context.¹²⁹ In the meantime, medicine at least offered some respite and a field of knowledge for contemplating Creation's patterns.

The evidential precarity of prognosis brings us back once more to Gregory of Tours and Armentarius. The problem as expressed by Gregory was not that he did not believe in medicine, but that, after a long suffering, he could see and document its limitations. Armentarius had failed by putting his faith in ideas that did not bring about the promised future healing and at least in Gregory's telling seemed open to learning about alternatives. There were many other failures of medicine in Gregory's day. On several occasions, outbreaks of Yersinia pestis devastated towns such as Marseilles in different waves of the Justinianic pandemic.¹³⁰ Gregory also told a story of how in 580 an outbreak of what he claimed was dysentery had killed many people in Gaul. Some people had taken herbs to combat poison, but nothing could stop a high infant mortality. “We lost our little ones, so dear and sweet,” he lamented, “whom we had cherished in our bosoms and carried in our arms, whom we had fed by our own hand and nurtured with such care.”¹³¹ Such moments could provide genuine epistemological crises made more powerful by emotion. Gregory's near-contemporary Procopius of Caesarea, for example, gave a dramatic account of mass mortality and social crisis caused by plague in Constantinople in 542. He prefaced this with an attack on Hippocratic-Galenic ideas about disease being determined by personal and environmental factors because, in the face of the disease, such matters clearly explained little.¹³² Y. pestis was new to the late Roman world and medical knowledge was poorly set to make sense of it. Understanding did come eventually, although, in the first instance, it came from cosmological and grammatical thought rather than medicine, starting with Isidore of Seville's catalogues of nature and disease.¹³³ There it became part of understanding the grammars of the natural world alongside eclipses, earthquakes or bad weather, as people sought to combat superstition and read potential signs on the basis of certain knowledge.¹³⁴ Once more, the interconnectedness of early medieval knowledge provided the space in which challenges to medicine could be weathered and indeed a space in which people critically sought wisdom in all its forms.

To conclude, Gregory of Tours never wanted an end to medical knowledge when he criticized Armentarius. It was too useful, if nothing else, as a body of thought that helped people to understand Creation critically. Knowledge was a key weapon against superstition and credulity. The principal problem for him was physicians and their social charisma, which impinged upon how Gregory viewed his own social leadership as a healer of souls. The spiritual challenge was heightened by a difficult period in which the certainty of medicine had been repeatedly challenged by mass mortality events. It no doubt helped little that Latin cultures had increasingly infrequent contact with Greek learning, when Greek was the primary language of scholarly and efficacious medicine in Antiquity. Latin medicine had never had a Golden Age and the many crises of the fifth and sixth centuries did not make it easier for one to begin. Merovingian medicine was on a difficult footing. One can perhaps sympathize with historians of medicine who turned from the philosophical world of Galen, to the fragments of the post-Roman world, and then onto the more richly detailed world of the Salerno school of the eleventh century. To define medicine on the basis of what it lacked, however, misses the wider value of medicine as part of philosophy. Gregory, Germanus, and many others still believed that medicine could work within a Christian framework, even if it did not always bring relief alone and sometimes physicians could not help. Despite the crises, communities in the Merovingian world still saw the value in the art, still engaged with its learning, and still adapted it to make it useful. In the process, it became entangled with many other forms of knowledge. Gregory was a misleading guide to his times, as he is so often.

Merovingian medicine, caught between practice and philosophy, was far from sterile. There were richer and more distinctive resources available for the study of medicine than Keil and others supposed. These were not passively copied, but rearranged and reappropriated to form new handbooks of practical medicine, actively connecting late antique euporista and the eclectic productions more clearly in evidence in the more numerous manuscripts of the Carolingian “revival.” The content of these books may not have been radical or progressive, but the restless and creative use of what was available at least meant that Latin medicine grew and diversified. This fitted with how other areas of learning were treated as Christian schools embraced medicine as part of a broad syllabus, both for its practical healing aspects that could support charitable deeds, and for its evidence for the orderliness of nature and the good of Creation. It was an important cultural framing device for how people could understand the world and act within it. As such, it intersected with and complemented other areas of philosophy, with their concerns for critical epistemologies and authority. In both the volume and contexts of Merovingian medicine, there remains much direct evidence that is lost, which makes it hard to say much about dedicated professional training, the attitudes of physicians to bishops, and many other aspects of medicine. A limited volume of evidence, however, does not mean that not much was happening. In this particular case, the profile of the manuscript evidence and the comments about medicine only make sense as the tip of an iceberg. For all its defects, people engaged with Merovingian medicine as both philosophy and practice in ways that developed foundations for the new medical cultures that followed and flowered under Carolingian care. It represents yet another area in which the Merovingian world has been underestimated.