The Middle Ages have left us spectacular representations of human pain. The medieval iconography of saints' tortures, with their sharp contrast between the painful nature of the torture and the ecstatic faces of the sufferers, is a powerful one to the modern viewer. Indeed, celebration or resigned acceptance of pain seem to be common attitudes of the period. Bernard of Gordon (c.1258-c.1320), a devoted Christian and master of the medical school at Montpellier, summarized this feeling. In 1308, he wrote a treatise on how to preserve human life, although it is not clear which life Bernard thought the physician should be preserving - the one in this world or the one in the next:

In order to somehow prolong the life of our insignificant human body, I begin, with God's help, a regimen of health which will follow the three ages of man from the day of birth to the final hour of death. As a result, after departing, we shall, with God's help, come rejoicing before the tribunal of the Judge.

According to Bernard, childhood was characterized by the pursuit of pleasure and old age by reflection as the last step before death. Between the two stages was an age of hard work, affliction and pain. And the origin of this state of suffering was the fall of our first parents, as written in Genesis.

There is no doubt that religion permeated all spheres of Western medieval life. Sufferers and healers alike would express and experience pain in a cultural fashion defined by the pervading image of a suffering Christ. This religious imagery was also taken into account when elaborating a theoretical analysis of the reality of pain.

However, the celebration of suffering was not the only Christian approach to pain during the Middle Ages. For example, the relation between pain and knowledge was understood very differently by the Franciscans and the Dominicans, two religious orders that were highly influential in medieval thought. Self-inflicted pain and the glorification of suffering were at the centre of the mystical way to knowledge of some Franciscan groups. By contrast, the Dominicans, who stressed learning as the pathway to God, were openly averse to pain, since it distracted from study.

Pain and medical learning
The centrality of pain in the Christian definition of what it meant to be human - notably Adam's gaining the ability to suffer after the Fall and Christ's humanity as defined by his physical suffering - was also accepted by the universities of the thirteenth century. The newly translated Latin works of Greek and Arabic authors, such as Aristotle's books on nature, were used to teach the students of the arts that pain was at the very core of the definition of humankind as a living animal. Works from a medical tradition, such as the Hippocratic On the Nature of Man, were also used to show that pain was a defining human characteristic.

But pain, then as now, also presented practical issues.
It was a common complaint brought to healers by their patients, and the university-trained physicians from the newly established schools of medicine needed to provide a theoretical and practical response to those demands. By 1300, medicine had become one of the four branches of institutional knowledge taught and learnt at the European universities - and, furthermore, a successful one. University medicine's main representatives became rich and famous, and they developed various strategies to secure for themselves the control over a particular way of understanding health and disease.

University medicine had a well-defined technical
literature and shared with the arts a grounding in Aristotelian logic and natural philosophy. By the late thirteenth century in Paris, Montpellier and Bologna alike, the university medical masters had already adopted several new works by the main medical authority of antiquity, Galen, in Latin translation to enlarge the set of works that had previously defined medical education. Among these works were Galen's main treatises on pathology, and pain was an important topic in these works.

How were medical students taught to translate the experience of pain into a specifically medical reality? Because medicine was a scholastic business, the pattern would follow the twin pillars that sustained scholastic knowledge - the authority of the ancients and a logical apparatus based on Aristotelian principles. To these was added, to a variable degree, the practitioner's own experience.

The nature of pain
In the schools of arts and medicine, academic discussions about pain gave prominence to its causes. It was agreed that pain could be caused by an imbalance of the normal complexion of the individual - that is, in an imbalance in the proper mixture of the four bodily fluids, the humours, that constituted the human body. In a medical system built upon a complexional anatomy, the humours (blood, phlegm, bile and black bile) were the material carriers of the four qualities - heat, cold, dryness and humidity - that characterized the basic elements that made up the human body: earth, water, air and fire.

The balance of humours was held responsible for the wellbeing, physical and psychological, of the individual and of each of his or her parts. Far from being an abstract scheme, this humoral model informed diagnostic, prognostic and therapeutic interventions. Pain might appear when the mixture of the humours was altered in a single part or in the whole body.

The characteristics of the pain depended on the affected part and of the mixture that resulted from the excess or defect of one or more humours. A pain that was felt as, for example, weighty was always due to alterations in an internal organ. A gnawing pain referred to an unbalanced complexion with an abundance of a 'biting' substance which created the gnawing sensation. Within this medical model, pain could also be caused by a break in the continuity of the body, internal or external.

Academic circles also, however, indulged in a great deal of higher theoretical speculation of dubious value. Was pain a kind of alteration of the action of the sensitive soul? How was pain perceived? Did pleasure come before pain or vice versa? Was pain an object of the senses? Was it possible to differentiate between the cause of pain and pain itself? Was it only the sense of touch that could feel pain? Such questions were common themes open to lengthy exposition and discussion in public lectures.

It is not just the content but also the methods of scholastic medicine that are completely alien to modern Western sensitivities. Particularly striking is the recourse to authority, that is, to the written sayings of the ancients, which were more important in establishing a diagnosis, prognosis and therapeutic advice than the actual experience of the practitioner.

But the voices of patients were also granted authority and absorbed into the academic arena. Live or drawn from written sources, patients' narratives were used by the medical masters to build up a medical discourse about pain. Taddeo Alderotti (1223-c.1295), medical master at Bologna, studied written medical testimonies to ask why mentally ill people did not always perceive pain and whether a large pain could conceal a smaller one.

Patients' experiences of pain melded with theoretical speculation in the classification of different kinds of pains elaborated by Bartholomew of Varignana (c.1260-p.1321), also associated with the medical school at Bologna. Dino del Garbo (d.1327), who practised and taught medicine at various northern Italian schools, set greater store by women's experiences of pain in childbirth as proof of the reality of pain than the authority of the biblical curse.

And patients' narratives about pain were also to be taken into account in practice. Arnald of Vilanova (d.1311) who taught at Montpellier, advised in his Mirror of Medicine that the patient's account of pain was relevant in making a good diagnosis. In fact, for most medical authors, the main reason to study pain was to develop a tool for a better diagnosis of internal diseases. This was, for example, the aim of the complex classification of pain into 15 different types developed by the master Pietro d'Abano (c.1250-c.1316) from the University of Padua. According to Pietro, a pain could be throbbing, dull, stabbing, distending, pressing, vibrating or shaking, piercing, gnawing, nailing, crushing, grappling, freezing, itching, harsh or loose.

Pain relief
In daily practice the university-trained physician faced the challenge of alleviating the pain suffered by his clients. Opiates were well known among university-trained and other healers in the Middle Ages, and physicians and apothecaries fought to control the market of narcotics. The use of ice as a local painkiller was also advocated, and was thought to work in the same way as opiates. However, they were not considered first-choice painkillers on theoretical grounds because they did not attempt to eliminate the cause of pain: they only masked its perception.

The extent of narcotics use is difficult to establish. Common therapeutic devices that aimed to eliminate the cause of pain by restoring the humoral balance were more likely to have been used. In this respect, pain was just another ailment that would benefit from bloodletting, laxatives, purgatives and the monitoring of food, drink and sleep. Other remedies, such as astrological seals, were thought of as being useful as painkillers because they conveyed some specific properties explained by a magical rationality.

Despite working within a Christian cultural framework where suffering had a wider significance than it has now, pain was far from a neglected topic among university medical circles of the late medieval period. The duality of pain, as a theoretical and practical problem, proved more important to the university-trained physicians than the imagery of spiritual martyrdom. Pain was an important theme, not only as a diagnostic tool but also as a complaint to alleviate, in the emerging rhetoric that helped to elaborate and advertise the new medicine that the universities successfully disseminated from the thirteenth century onwards.

Fernando Salmón is Professor of the History of Medicine at the University of Cantabria, Spain.

A longer version of this essay is featured on the CD-ROM accompanying the 'Pain: Passion, compassion, sensibility' exhibition, priced £2.00.