Jamie McKinstry
Durham University, United Kingdom

Metaphors have been used extensively in medicine to describe patients, illustrate diseases, and educate students.¹ By comparing unlike things that have something in common, they enhance communication in education, science, and clinical medicine.² Not restricted to the twentieth and twenty-first centuries, their use dates back to areas such as rhetoric and the “age of medical humanism.”³ Yet their didactic and emotive effectiveness can also be identified in the Middle Ages, particularly in the writings of John of Salisbury (c. 1120–c. 1180), who was influenced by earlier philosophers such as Plato, Aristotle, Hippocrates, Galen and Avicenna.⁴ The use of metaphor in teaching and explaining medicine and its challenges has therefore a well-established history.

A metaphor is effective when it establishes a credible connection with the person for whom it was created. Such connection was often notably absent in the Middle Ages, when the role of the individual patients was often minimized, despite their obvious importance in the development of a diagnostic medical theory. A case in point is the scale of pain developed by Pietro d’Abano at the University of Padua in the late thirteenth and early fourteenth centuries.⁵ This presumably was developed with the aid of patients, with the purpose of forming an accurate guide to the severity and quality of the pain suffered so that a diagnosis could be made, followed by treatment. Pain was graded in a manner equivalent to the modern ranges of “zero to ten”, and the metaphors chosen ranged from “stabbing” (pungitivus) to “piercing” (perforativus) and the dramatic “crushing” (contritivus). But as Fernando Salmón has observed, once the theory was developed, the voices of subsequent patients seem to fade.⁶ The scale, a product of medicine’s negotiation with the academia at Padua, offered no latitude for including symptoms absent from it (there is no term for a burning pain, for example), requiring instead choosing the most appropriate word or metaphor from the scale despite it being only approximate. Can it be, therefore, that metaphor could also distance both physicians and patients from symptoms in the Middle Ages?

The absence of a patient’s voice is particularly apparent in Geoffrey Chaucer’s description of the physician in the “General Prologue” to the Canterbury Tales, along with the curious, almost disconnected use of metaphor. There is no doubting the physician’s training. We are informed that “In al this world ne was the noon hym lik, / To speke of phisik and of surgerye” and that “He knew the cause of everich maladye” which he diagnosed with reference to the medieval system of the four humors.⁷ These are explained to us along with the use of astrology in order to add a universal voice to the diagnosis. Beyond the theory, however, we can perhaps see how easily medical explanations of symptoms could become metaphorical abstractions rather than statements of reliable fact. Both of these systems of diagnostics, astrology and the humors, are attempts to offer medical explanations to the public—but in a terminology that is fixed.

In the brief tutorial offered by Chaucer we become aware that the patient, specifically his voice or experience, is strangely absent. Clearly he must be initially present, but the main focus is on the physician. The reasons for his excellence are almost too perfect and too clipped as we are informed that “He was a verray, parfit praktisour: / The cause yknowe, and of his harm the roote, / Anon he yaf the sike man his boote” (422-4).⁸ His apparent “perfection” as a practitioner of medicine is based on his ability to swiftly find the “roote” (a metaphor, of course, in itself) and dispense the appropriate remedy (the “boote”). The speed with which this happens is exaggerated by Chaucer in the appearance of the apothecary who is standing “Ful redy” nearby, a social comment on the financial arrangements that existed between physicians and apothecaries but one which also makes the doctor and his colleague dominate the scene. The patient, rendered invisible, is obscured by the two authoritative medical figures, and is bombarded with pre-meditated assessments of his condition, metaphors that have become technicalities, the essential “boote.” Chaucer has shown us the importance of a dialogue between physicians and patients which medieval medicine, at least in Pietro d’Abano’s example, seemed keen to dissolve once it had served its useful purpose.

Yet even in the Middle Ages there must have existed doctors who were more sympathetic or more engaged with their patient’s feelings and sufferings. Two texts from that era illustrate this in the context of headache, a condition remaining to this day difficult to express in terms of severity, longevity, or even location. A metaphor is often the solution.

The first example comes from some fifteenth-century banns, advertising the services of a physician who was appealing for work locally.⁹ After a list of the ailments and injuries he was able to treat (bruises, broken bones, canker, worms) a condition is given with which the local people may have been unfamiliar—migraine. The term is first recorded in Old French from the twelfth century, but clearly was still obscure. So, the advertisement gives additional color and explanation: “he wyl curyn ye mygreyn qwiche is a Maladyȝ yat takyth halff a man is hed & doth hym lesyn is syȝthe of his yie.”¹⁰ This is actually a startlingly accurate description, stating that the pain is so severe that it takes up half of a man’s head and causes him to lose the sight in one eye. Anyone who has suffered from this will immediately recognise the sensation, and such was the desired response from the fifteenth-century lay public. Whether currently suffering or having had their memory stirred by these emotive words they would hurry to see the physician to purchase the necessary “boote.” The metaphor was needed to bring in business, but beneath the financial prudence (the equivalent of Chaucer’s arrangement with the apothecary) lies an implicit understanding of the power of medicine and metaphor in the Middle Ages, here taken to a very local (and practical) level. In considering the expression of symptoms from a modern migraine sufferer, namely “My head is made of glass,” Laurence Kirmayer believes that we need to decide to whom the metaphor actually belongs—the physician or the patient.¹¹ On the surface, in the medieval example, we would say the physician; however, as with the pain scale of Pietro d’Abano, the metaphor must have some emotive and recognizable link with the patient in order for it to be medically (and in this respect, financially) successful.

Away from the world of advertising, in late medieval Scotland, the poet William Dunbar (c. 1459–c. 1517) also suffered from a similar condition, at least according to one particular poem. In a short verse seemingly directed to his patron, King James IV, Dunbar complains that “My heid did ȝak ȝester nicht, / This day to mak that I na micht. / So sair the magryme dois me menȝie.”¹² The term migraine appears again and, echoing the medical banns, is followed by a powerful, metaphorical explanation: “Perseing my brow as ony ganȝie, / That scant I luik may on the licht” (4–5).¹³ Strictly speaking this is a simile rather than a metaphor, but the sense remains that the pain is as piercing as an arrow which penetrates the centre of the forehead, the searing pain causing him to shun daylight. A few lines later we learn of the mental implications of this state which in turn become metaphorical abstractions in order to accurately locate the source of pain. Dunbar writes “The sentence lay full evill till find, / Unsleipit in my heid behind, / Dullit in dulnes and distres” (8–10).¹⁴ The “sentence” or “subject” (either his inability to write poetry or the reason for his headache) cannot be found, such is the strength of the pain, both of which are buried “in my head behind” and lie, like the poet, literally, “un-sleeping,” a wonderfully evocative term emphasizing the throbbing pain that never ceases to cause dullness and distress. From the suffering insomniac the metaphors have taken us, imaginatively, deep into the recesses of his head to attempt to discover the source of his pain whilst also communicating the severity of the condition. We now know exactly how he feels and can sympathise or, as physicians, we might be ready to decide how we would wish to treat him.

By using metaphor and possibly even exaggerating the severity of the pain, Dunbar may have been trying to attract the attention at the court, having been financially neglected by the king in favour of others, something that may have caused him no end of headaches, literally and metaphorically.¹⁵ Indeed, Dunbar is not averse to using quite extreme bodily imagery and metaphor in attempts to advance at court: in other works his body is variously crushed, relegated to the ceiling, or transformed into an old horse.¹⁶ But we might also be hearing a voice of the archetypal struggling poet in the way the description is framed Despite the immediacy of the pain, the poem begins “My heid did ȝak ȝester nicht, / This day to mak that I na micht” (1–2).¹⁷ This is therefore an account from the past, telling of the pain of last night which continues to affect him to this day and prevents him from writing.

Inherently subjective by their very nature, metaphors may undermine accuracy in terms of the severity or duration of symptoms. Nevertheless, Chaucer’s physician recorded what he saw, though describing it in terms of a system of predetermined metaphors posing as medicine. In contrast, Dunbar (and to some extent the author of the banns) revealed the processes behind metaphor itself and who exactly should be involved—the subject themselves. And whereas Pietro d’Abano and medieval medical scholastics discarded the important knowledge first obtained from their patients, elsewhere the metaphors, though full of emotive power, more accurately described the condition of an emotive condition affecting a particular time or person. Thus in the medieval depiction of wounds, the visible breaking of the skin was an important sign of an immediate reality, but was also emblematic of a past experience specific to that individual.¹⁸ In this respect, these two medieval headaches are highly effective as tools to understand the essence of a condition, represented as emotive and imaginative expressions of strikingly accurate insights, valuable not only in education but also in the treatment of a particular patient at a specific time in the history of medicine.

Notes

1. James O. Woolliscroft and Robert Phillips, “Medicine as a Performing Art?: A Working Metaphor?,” Medical Education 37 (2003): 934-9.
2. Francis Peabody, “The Care of the Patient,” The Journal of the American Medical Association 88 (1927): 877-82.
3. Stephen Pender, “Between Medicine and Rhetoric,” Early Science and Medicine 10.1 (2005): 36-64; Stephen Pender, “Examples and Experience: On the Uncertainty of Medicine,” The British Journal for the History of Science 39.1 (2006): 1-28.
4. Takashi Shogimen and Cary J. Nederman, “The Best Medicine?: Medical Education, Practice, and Metaphor in John of Salisbury’s Policraticus and Metalogicon,” Viator42.1 (2011): 55-74.
5. Fernando Salmón, “From Patient to Text?: Narratives of Pain and Madness in Medieval Scholasticism,” in Between Text and Patient: The Medieval Enterprise in Medieval and Early Modern Europe, ed. Florence Eliza Glaze and Brian K. Nance, Micrologus’ Library 39 (Firenze: Sismel Edizioni Del Galluzzo, 2011), 373-95.
6. Salmón, 382.
7. Geoffrey Chaucer, The Canterbury Tales, in The Riverside Chaucer, ed. Larry D. Benson, 3rd edition (Oxford: Oxford University Press, 1987), 30, lines 412-13, 419. All references to Chaucer will be to this edition and cited by line number. “In all the world there was none like him, / To speak of medicine and of surgery /… / he knew the cause of every malady”. All translations from Middle English and Middle Scots are my own.
8. “He was a true, perfect practitioner / Knowing the cause, and of his harm the root, / At once he gave the sick man his remedy.”
9. Linda Ehrsam Voigts, “Fifteenth-Century English Banns Advertising the Services of an Itinerant Doctor,” in Between Text and Patient: The Medieval Enterprise in Medieval and Early Modern Europe, ed. Florence Eliza Glaze and Brian K. Nance, Micrologus’ Library 39 (Firenze: Sismel, Edizioni Del Galluzzo, 2011), 245-77.
10. “[H]e will cure the migraine which is a malady that takes half a man’s head and causes him to the lose the sight of his eye.” The text appears in London, British Library, MS Harley 2390, fols 105-106v.
11. Laurence J. Kirmayer, “The Body’s Insistence on Meaning: Metaphor as Presentation and Representation in Illness Experience,” Medical Anthropology Quarterly 6.4 (1992): 340.
12. William Dunbar, “My heid did ȝak ȝester nicht,” in The Poems of William Dunbar, ed. Priscilla Bawcutt, Association for Scottish Literary Studies 27 (Glasgow: Association for Scottish Literary Studies, 1998), 127, lines 1-3. All references to Dunbar will be to this edition and cited by line number. “My head did ache last night / So this day I could not write poetry / So painfully does the migraine afflict me.”
13. “Piercing my brow as any arrow / That scarcely can I look on the light.”
14. “The subject lay difficult to find / Not having slept, in my head behind / Dulled in gloominess and distress.”
15. Although little is known of Dunbar’s life, his probable financial pressures are discussed in J. W. Baxter, William Dunbar: A Biographical Study (Edinburgh: Oliver and Boyd, 1952), 181-99.
16. Jamie McKinstry, “‘Blait mouit bladȝeanes with bledder cheikis’: Dirty Politics and the Poetry of William Dunbar,” Peer English 6 (2011): 18-32.
17. “My head did ache last night / So this day I could not write poetry.”
18. Jamie McKinstry, “Perpetual Bodily Trauma: Wounding and Memory in the Middle English Romances,” Medical Humanities 39 (2013): 59-64.