The Herbalist: Nicholas Culpeper and the Fight for Medical Freedom

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These arrangements laid the foundations for a medical system overrun with anomalies and riven with rivalries. It was a mess that got messier with every successive attempt to rationalize it. In the 1540s, an act was passed ‘for the enlarging of their [the College’s] privileges, with the addition of many new ones’, as the College’s first official history put it. Among the privileges so enlarged was the control the College exercised over the apothecaries. Henceforth, its officials were to have ‘full authority and power, as often as they shall think meet and convenient, to enter into the house or houses of all and every Apothecary … to search, view and see such Apothecary wares, drugs and stuffs as the Apothecaries or any of them have’. Any stuffs found ‘defective, corrupted and not meet nor convenient’ the doctors could order to be immediately destroyed on the offender’s doorstep.

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The same year, another act amalgamated the Company of Barbers and the Guild of Surgeons, perversely in order to separate the two crafts. Surgery – or ‘chirurgery’, as it was then known, derived from the Greek for handiwork – was a manual occupation, learned like any other craft through apprenticeship. Its role in healing was to deal with external operations: amputating limbs, cauterizing wounds, resetting dislocations, removing tumours, letting blood, extracting teeth, and – the area that produced the most common demarcation disputes with the physicians – treating skin conditions, including diseases such as plague and pox. Since many members of the Barbers’ Company also offered such services, the aim of bringing them together with the surgeons was to ensure that they did so according to common standards. Surgeons who ‘oftentimes meddle and take into their cure and houses such sick and diseased persons as [have] been infected with the Pestilence, great Pox, and such other contagious infirmities’ were forbidden to ‘use or exercise Barbery, as washing or shaving, and other feats thereunto belonging’, and barbers were likewise forbidden from performing ‘any Surgery, letting of blood, or any other thing belonging to Surgery (drawing of teeth only excepted)’. To encourage the development of surgical skills, the act pledged an annual entitlement of four fresh corpses from the gallows, for use in anatomical lectures.

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Having established surgery as a separate craft, another act was passed in 1543, just two years later, which threatened to destroy it. Dubbed the ‘Quacks’ Charter’, its preamble launched a blistering attack on the surgeons for their ‘small cunning’. ‘They will take great sums of money and do little therefore, and by reason thereof they do oftentimes impair and hurt their patients,’ it objected. Because of this, the act ruled that ‘every person being the King’s subject, having knowledge and experience of the nature of herbs, roots and waters or of the operation of the same’ should be allowed ‘to practise, use and minister in and to any outward sore, uncome [attack of disease], wound, apostemations [abcess], outward swelling or disease, any herb or herbs, ointment, baths, poultices and plasters, according to their cunning, experience and knowledge’.

(#litres_trial_promo) This effectively allowed more or less anyone to perform any surgical operation that did not require a scalpel.

The identity of those who initiated the Quacks’ Charter is unclear, but the physicians must be among the suspects. They were concerned that the Barber Surgeons Act had given the surgeons too much power and were eager to undermine their privileges. The act may also have been a response to Henry VIII’s religious reforms. In the late 1530s, the process had begun of closing the Catholic monasteries, which until then had run the hospitals. This created a crisis in public healthcare that the act could help alleviate. Whatever prompted it, the effect was chaos, as it did not specify who was to determine the ‘knowledge and experience’ of those that it allowed to practise.

The College lobbied both monarch and Parliament for further acts and charters reinforcing its own position. It also produced its own ‘statutes’, setting out in meticulous detail its rules and procedures. The earliest that survive date from 1555. They were written by Dr John Caius, one of the College’s most influential sixteenth-century presidents. His name was originally ‘Keys’, but, following a practice popular among intellectuals wanting to add gravitas to their names, he Latinized it to ‘Caius’, but kept the original pronunciation.

Dr Caius’ statutes specified that there should be quarterly meetings, ‘Comitia’, attended by all the Fellows. At the Michaelmas Comitia (held on 30 September), the College selected from among its number a president and eight seniors or ‘Elects’. The Elects would then choose the ‘censores literarum, morum et medicinarum’, censors of letters, morality, and medicine – effectively the custodians of the physicians’ monopoly. They were to exercise these roles, not with the ‘rod of iron’ of olden times, Caius declared, but with a caduceus, the mythical wand entwined with two serpents carried by the Greek god Hermes, representing gentleness, clemency, and prudence, which has since become a symbol of medical practice. Caius personally donated a silver caduceus to remind the Censors of this responsibility. It was one they would often forget.

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Their first role as censors of ‘letters’, or medical literature, was aspirational. They may have wanted to control the licensing of medical books, but this responsibility belonged to another livery company, the Stationers’, working under the supervision of the Church. As censors of morals they were primarily concerned with enhancing the physicians’ professional image. The Fellows were touchy about their social status. Since antiquity, physicians had aroused mixed feelings in society. ‘The physician is more dangerous than the disease,’ went the proverb.

(#litres_trial_promo) In the prologue of the Canterbury Tales, Chaucer introduced a ‘Doctor of Physic’ as a figure of learning, knowledgeable in ‘magic natural’ and well read in the medical classics, but ‘His study was but little on the Bible’. This was a reference to the old saying ubi tres medici, duo athei: ‘where there are three physicians, there are two atheists’, the suspicion of atheism arising from their devotion to classical (i.e. pagan) knowledge. The slur rankled – the ‘general scandal of my profession’, the physician, essayist, and Honorary Fellow of the College Sir Thomas Browne called it in his masterwork Religio Medici (1642). Chaucer had also alluded to another accusation, that doctors were greedy, making money out of the misery of others by prescribing expensive medicines and charging exorbitant fees: ‘For gold in physic is a cordial;/Therefore he loved gold in special’.

(#litres_trial_promo) The sentiment was echoed by Christopher Marlowe in his play Dr Faustus (published 1604), when the eponymous hero contemplates his prospects:

Bid Economy farewell, and Galen come:

Be a physician, Faustus; heap up gold.

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But, as every physician knew, in a medical emergency, attitudes were different. When a child sickens, when boils erupt, when fever grips, when plague knocks on the door, then the physician is ‘God’s second’, as the playwright and satirist Thomas Dekker put it, lampooning the public response to plague. ‘Love thy physician,’ he advised, adding that ‘a good physician comes to thee in the shape of an Angel’, unable to resist the common play on a word that then referred both to a divine messenger and a gold coin.

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The Censors’ moral role was aimed at counteracting this image by imposing a strict code of conduct. This code was not concerned with issues such as behaviour towards patients, the level of fees, or charitable obligations. It was about insisting that Fellows dressed in scarlet and silk caps on public occasions and addressed the College President always as ‘your excellency’. It was about prohibiting College members from accusing one another of ignorance or malpractice, intervening in a colleague’s case unless invited, questioning a colleague’s diagnosis, employing apothecaries who practised medicine, or disclosing the recipes of medicines.

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The College’s Annals show that most Fellows observed these ‘moral’ strictures to the letter. When it came to internal discipline, the only matter the President and Censors had to concern themselves with on a regular basis was absenteeism, which was rife. The primary concern was external discipline, the policing not of colleagues, but competitors.

As censors of medicine, the College was entitled to control the practice of medicine in London or within a seven-mile radius of its walls. Anyone reported to be practising without a licence faced a summons from the College beadle and the threat of a fine or imprisonment. And what an apparently motley bunch the beadle brought in, with names, as the medical historian Margaret Pelling has noted, worthy of a Jacobean comedy: Gyle, Welmet, Wisdom, Blackcoller, Lumkin, Doleberry, Sleep, Buggs, Hogfish, Mrs Pock, Mrs Paine and Mother Cat Flap.

(#litres_trial_promo) Those who voluntarily presented themselves to the Censors, seeking a licence, tended to appear under more respectable names, usually Latinized, like that of the College luminary Dr Caius: Angelinus, Balsamus, Fluctibus. They had to prove to the Censors that they had a firm grasp of medical theory. To establish whether or not this was the case, they were examined, not on their knowledge of the latest anatomical theories or diagnostic techniques, the revolutionary findings of the great Renaissance medics and anatomists such as Jean Fernel of Paris or Gabriele Falloppia of Padua, but on their understanding of the works of a physician and philosopher who had lived a millennium and a half earlier.

No other field of knowledge has been dominated by a single thinker as medicine was by Galen. Born in AD 129 in Pergamon (modern Turkey) to wealthy parents, Galen was, in many respects, a model physician: studious, clever, and arrogant. In his youth, he studied at the Library of Alexandria, the great repository of classical knowledge, and travelled to India and Africa, learning about the drugs used there. He became a skilful anatomist who could expertly cut up an animal living or dead, and, though the dissection of humans was taboo, he had attained a grasp of human physiology thanks to a spell as physician to the gladiators. He also had an astute understanding of patient psychology and was very good at attracting prestigious clients, including the Roman Emperor Marcus Aurelius, an endorsement he never lost an opportunity to advertise.

As well as being a brilliant practitioner, Galen gave medicine academic respectability. Basing his ideas on those of Hippocrates, the semi-mythical Greek physician immortalized as the author of the Hippocratic Oath, he created a comprehensive theoretical system that seemed to provide a sound basis for understanding and treating disease. Underlying this system was a view of the body as a system of fluids in a state of constant flux. There were four such fluids or ‘humours’: blood, phlegm, choler (yellow bile), and melancholy (black bile). The relative proportions of these humours in different parts of the body determined its temperament, and an imbalance produced illness. A runny nose was a result of excess phlegm, diarrhoea of choler, a nosebleed or menstruation of blood, particles of black material in vomit or stools of melancholy (the most elusive of the humours). The identification of these four humours provided a convenient way of tying the workings of the body in with the prevailing view of how the universe worked. Everything in the cosmos was understood to have a character defined by its place in a quadrilateral scheme: the four seasons, the four ages of man (infancy, youth, middle age, old age), the four points of the compass, the four ‘elements’ that make up all matter (fire, air, water, and earth), the four ‘qualities’ that determine their character (hot, dry, moist, cold). Each humour had its place in this scheme: phlegm was cold and moist, combining the character of winter, frozen by northerly winds, and the wet weather of the westerlies that blew in spring, which explained why so many people suffered runny noses during those seasons; choler was hot and dry, excessive during summer and autumn, the seasons of stomach disorders, when it would flow most copiously.

The treatment of disease involved trying to rebalance the humours, achieved through diet or eliminating the surplus humour. A fever, for example, might be caused by an excess of blood in a particular part of the body, which, unable to escape, putrefies, producing heat (just as organic material in a compost heap becomes warm as it rots). The solution, therefore, was to drain off the superfluity by such methods as blood-letting or, in the case of other humours, prescribing ‘purgatives’, medicines that provoke the evacuation of bile through vomiting or diarrhoea, or herbs that produce a runny nose.

Galen’s understanding of disease was supplemented by an equally systematic understanding of the body, derived from his own dissection and vivisection experiments, as well as prevailing philosophical ideas. He saw the body as a system for extracting from the environment the life force or pneuma, an ‘airy substance, very subtle and quick’, and modifying it into three spirits or ‘virtues’: vital, which vivified the body; natural, which fed it; and animal, which produced sensation and movement. According to this view, ‘chyle’, a milky substance derived from the digestion of food in the intestine, is carried to the liver via the portal vein, where it is manufactured into blood imbued with natural spirit. This dark nutritive blood passes through the veins into the body, where it is consumed, feeding the muscles and creating tissue. Some of this blood also reaches the right chamber or ‘ventricle’ of the heart, from where it either passes into the lungs, which filter and cool it, or seeps into the left ventricle via invisible pores in the septum, the membrane separating the heart’s two chambers. Thus the heart ‘snatches and, as it were, drinks up the inflowing material, receiving it rapidly in the hollows of its chambers. For [think if you will] of a smith’s bellows drawing in the air when they are expanded [and you will find] that this action is above all characteristic of the heart; or if you think of the flame of a lamp drawing up the oil, then the heart does not lack this facility either, being, as it is, the source of the innate heat, or if you think of the Herculean stone [a loadstone or magnet] attracting iron by the affinity of its quality, then what would have a stronger affinity for the heart than air for its refrigeration? Or what would be more useful than blood to nourish it?’

(#litres_trial_promo) Like nutritive blood in the veins, the bright red blood vitalized by the heart ebbs and flows through the pulsing arteries, like tidal water through rivers and streams, irrigating the body. The brain produces the animal virtue, which is distributed through the body via the nerves, producing feeling and movement. In addition to these three virtues, the male body also produces procreative spirit in the testicles that is distributed as sperm through the ‘spermatic vessels’ to the woman’s womb (whether the ovaries produced procreative material in a similar manner was to remain a matter of controversy for centuries to come).

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Galen was very pleased with this theory, and considered it definitive. ‘I have done as much for medicine as Trajan did for the Roman Empire, when he built bridges and roads through Italy,’ he wrote. ‘It is I, and I alone, who have revealed the true path of medicine. It must be admitted that Hippocrates already staked out this path … he prepared the way, but I have made it passable.’

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Galen underestimated his influence. His ideas survived not only Trajan’s Rome, but the sacking of the great Library of Alexandria, the birth and spread of Christianity and Islam, the Black Death, the invention of printing, and the Reformation – a millennium and a half of history – with barely any adjustment. As late as 1665, one medical reformer was complaining that ‘an Extreme Affection to Antiquity [has] kept Physic, till of late years as well as other Sciences, low, at a stay and very heartless, without any notable Growth or Advancement’. Galenism held sway over the College of Physicians from the day it was founded. Everyone who wanted to practise medicine in London had to conform to its principles. This was still the case on 4 May 1603 when the twenty-five-year-old William Harvey presented himself to the Censors of the College of Physicians to apply for a licence to practise.

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Little did the Censors appreciate what the young man who sat before them would do for their profession. William Harvey went on to become a colossus of the medical world, hailed as one of the world’s greatest anatomists and England’s first true scientist. Sir Geoffrey Keynes, author of the definitive 1967 biography of Harvey, was so overcome with admiration for his subject, he concluded that ‘even if we wished to do so, it would be difficult, from the evidence in our possession, to find any serious flaw in Harvey’s character’. One contemporary wrote that his ‘Sharpness of Wit and brightness of mind, as a light darted from Heaven, has illuminated the whole learned world’.

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Harvey was born on 1 April 1578 to Joan, ‘a Godly harmless Woman … a careful tender-hearted Mother’, and Thomas Harvey, mayor of Folkestone in Kent, a rich landowner with properties not far from Isfield.

(#litres_trial_promo) After attending King’s School in Canterbury, he was sent to Gonville and Caius College Cambridge, where its benefactor Dr Caius was Master. Caius had made medicine a core part of his college’s curriculum, securing a royal charter allowing two bodies of criminals executed in Cambridge to be used for anatomical demonstrations. Harvey’s own education benefited from this arrangement as he later recalled seeing ‘a frightened person hanged on a ladder’ at Cambridge, and presumably witnessed the subsequent dissection.

(#litres_trial_promo) The variety of medicine taught was, of course, devoutly Galenic. Caius had studied at Padua with Andreas Vesalius, the father of modern anatomy, whose discoveries based on human dissections had challenged many of Galen’s, which had relied upon animals. Despite this, when Vesalius later suggested to Caius that an obsolete passage should be dropped from a collection of Galen’s writings Caius was editing, Caius refused on the grounds it would be too dangerous to tamper with such an ancient work.

In 1600, Harvey himself went to Padua and studied anatomy under one of Vesalius’ successors, Hieronymus Fabricius. Fabricius had designed the first modern anatomy theatre, a wooden structure set up in the university’s precincts, which featured a stone pit surrounded by five concentric oval terraces. Harvey gazed from those terraces and into that blood-spattered pit on many anatomical, and in particular venereal, marvels that he would later memorably recall in his lectures, including syphilitic ulcers that had gnawed into the stomach of a prostitute, a boy whose genitals had been bitten off by a dog, and a man without a penis who was apparently still capable of sex.

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Harvey may also have witnessed Fabricius’ work on one small but important area of anatomical controversy: valves in the veins. These were shown by dissection to block the passage of blood through the veins into parts of the body such as the legs. Though working in the shadow of Vesalius, Fabricius was a Galenist such as Caius would have been proud of and was concerned that the valves conflicted with Galen’s view that the veins carried blood from the liver into the body. His ingenious solution was to argue that the valves were there to act like sluice gates, preventing the legs becoming engorged with blood, and ensuring an even distribution of nutritive spirit to other parts.

Harvey received his Doctorate in Medicine (MD) in Padua after just two years and was back in London by 1603, living in a modest house near Ludgate, under the shadow of St Paul’s Cathedral. Eager to start work, he approached the College of Physicians, perhaps with an introduction from Caius, seeking the all-important licence he needed to practise. He arrived at the College for his first examination at a nervous time. The previous week, Queen Elizabeth had been buried at Westminster Abbey after forty-four years on the throne. Her legacy to her Scottish cousin and successor James was not the settled stability of patriotic memory but seismic tensions produced by her refusal in her final years to deal with pressing issues of political and religious reform. London also faced the onset of plague, one of the worst epidemics for a generation. ‘He that durst … have been so valiant, as to have walked through the still and melancholy streets, what think you should have been his music?’ wrote Thomas Dekker in his review of the year. ‘Surely the loud groans of raving sick men, the struggling pangs of souls departing, in every house grief striking up an alarum, servants crying out for masters, wives for husbands, parents for children, children for mothers; here he should have met some frantically running to knock up Sextons; there, others fearfully sweating with coffins, to steal forth bodies, least the fatal handwriting of death should seal up their doors.’

(#litres_trial_promo) It was through such streets that Harvey walked as he made his way to the small stone house in Knightrider Street then occupied by the College.

Harvey’s credentials assured him a sympathetic reception. For his first examination he faced an interview board of four rather than the usual five Fellows, the absentee presumably being one of the many physicians who had fled the capital during the epidemic. The young man the assembled doctors beheld was short, with raven-black hair and small dark eyes ‘full of spirit’. He was, as a contemporary put it, ‘choleric’, referring to the Galenic tradition that associated an individual’s character with his or her ‘complexion’, the natural balance of their humours – choleric, melancholic, sanguine, phlegmatic. Choleric people had an excess of choler, which made them, as Nicholas Culpeper later put it in his guide to Galen’s medicine, ‘quick witted, bold, no way shame-fac’d, furious, hasty, quarrelsome, fraudulent, eloquent, courageous, stout-hearted Creatures’.

(#litres_trial_promo) In some respects at least, this appears to be an accurate portrait of Harvey, who was certainly quick-tempered. According to one gossip, as a youth he carried a dagger with him, and was apt to draw it ‘upon every slight occasion’.

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Knightrider Street, South of St Paul’s Cathedral (‘Poles church’), as shown on late 16th century ‘Agas’ map of London.

He presumably turned up at the College unarmed, and, being a stickler for decorum, dressed respectfully (but not fashionably – he disliked fashion, considering it a ‘redundant covering, a fantastic arrangement’).

(#litres_trial_promo) He was the only candidate to be interviewed that day, leaving plenty of time for a rigorous examination. There were four parts, usually conducted over three or four separate sessions, all based on the works of Galen. They covered physiology, pathology (the symptoms, ‘signs’ and causes of disease), methods of treatment, and ‘materia medica’ (pharmacy). Examinees were then given three questions chosen at random by the President, and asked to cite passages in the works of Galen that answered them. The entire proceedings were conducted orally in Latin.