The Greatest Benefit to Mankind: A Medical History of Humanity

Paré gave a conventional account of the ‘five duties’ of his art: ‘to remove what is superfluous, to restore what has been dislocated, to separate what has grown together, to reunite what has been divided and to redress the defects of nature’. His prime innovation lay in rejection of the standard treatments for gunshot wounds: the use of cautery (the burning iron) or scalding oil (‘potential cautery’) to destroy poison and forestall putrefaction before beginning restorative therapy. In his La methode de traicter leys playes faictes par hacquebutes et aultres bastonsàfeu (1545) [Treatise on Gunshot Wounds], he described how, as a greenhorn on campaign in Italy in 1537, he had been forced to innovate. Initially, as taught, he had used boiling oil on what were considered to be poisonous gunpowder wounds:

But my oil ran out and I had to apply a healing salve made of egg-white, rose-oil and turpentine. The next night I slept badly, plagued by the thought that I would find the men dead whose wounds I had failed to burn, so I got up early to visit them. To my great surprise, those treated with salve felt little pain, showed no inflammation or swelling, and had passed the night rather calmly – while the ones on which seething oil had been used lay in high fever with aches, swelling and inflammation around the wound.

At this, I resolved never again cruelly to burn poor people who had suffered shot wounds.

Thenceforth he relied on restorative methods, using a digestive (wound-dressing) made of egg, oil of roses and turpentine, justifying this on the supposition that the gunpowder and shot were not, after all, poisonous. Piously, he always said that he had dressed the wound but God had healed the patient: Je le pansay; Dieu le guarit.

Another innovation mentioned in his Dix livres de la chirurgie (1564) [Ten Books of Surgery] was the use of ligatures in conducting amputations. Other writers had recommended tying off the veins and arteries so as to stop the blood, but Paré worked out the practical details. This made successful thigh amputations possible – William Clowes reported performing one in 1588, as did Fabricius a little later. There was, however, one drawback. No fewer than fifty-three ligatures were necessary in a thigh amputation, and this required trained assistance. Consequently, ligatures could come into general use only after a method had been found to control blood flow until the surgeon could tie the blood vessels, something accomplished in eighteenth-century France when J. L. Petit invented the first effective tourniquet.

Paré’s Cinq livres de chirurgie (1572) [Five Books of Surgery] dealt at length with fractures and dislocations, while in the Deux livres de chirurgie (1572) [Two Books of Surgery] he addressed the study of obstetrics, showing the art of podalic version (turning a baby in the womb, to facilitate feet-first delivery, as earlier described by Soranus) – and also seeking to explain monstrous births. His successes, however, did not go unchallenged. In 1575, the Paris faculty condemned him for publishing on ‘medical’ topics – an affront reflecting the tetchiness of physicians towards surgeons’ encroachments on their turf.

The practice of early modern surgeons challenges the myth that before anaesthesia and antisepsis their craft was crude and often lethal. The case notes of the London surgeon Joseph Binns (d. 1664) present a different picture. In a career stretching from 1633 to 1663 he recorded 616 cases. Of these no fewer than 196 related to gonorrhoea or syphilis; 77 were of swellings and 61 were more properly medical – including ague, stomach-ache, headache, insomnia, diarrhoea and epilepsy. Fifteen individuals suffered battle wounds, 14 were hurt at work, 19 suffered from falls from horses and 41 were injured in fights. Of the 402 outcomes recorded, 265 were cured and 62 improved; 22 showed no improvement and 53 died.

As Binns’s cases show, surgeons’ work remained mainly routine, small-scale and fairly safe – if often agonizing. Next to dressing wounds, drawing teeth, dealing with venereal sores and chancres, treating skin abrasions and so forth, the most common surgical procedure (indeed the profession’s badge) was blood-letting, often performed at the patient’s request. Galenic medicine had warned about the dangers posed by a ‘plethora’, believing that fevers, apoplexy and headache followed from excessive build-up of blood. Venesection was the obvious corrective. The normal method for phlebotomy was to tie a bandage around the arm to make the forearm veins swell up, and then open the exposed vein with a lancet: this was popularly called ‘breathing a vein’. Cupping with scarification was another procedure for drawing blood.

A few surgeons came up with ambitious new operations. In Italy Gaspare Tagliacozzi (1545–99) described in his De curtorum chirurgia per insitionem (1597) [On the Surgery of the Mutilated by Grafting] the procedure of rhinoplasty or nose reconstruction, which was obviously attractive in the era of syphilis. Rhinoplasty had been known in India since ancient times; in southern Italy the operation was apparently practised by empirics. Tagliacozzi was thus far from the technique’s inventor, but he published and claimed to have perfected it. In his rhinoplastic procedure, a skin flap was partially detached from the flesh of the upper arm, and allowed to establish itself as a viable tissue. Then the flap, still attached to the arm, was shaped and sewn to the remains of the nose. The patient remained with his arm thus attached to his nose for fourteen days, before the flap was severed from its original site. After a further period, the process began of reshaping the flap to form the new nose. The whole business took from three to five months.

Overall, however, with its deep-seated craft basis, surgery remained rather traditional. Paré concluded:

A Chirurgion must have a strong, stable and intrepide hand, and a minde resolute and mercilesse, so that to heale him he taketh in hand, he be not moved to make more haste than the thing requires; or to cut lesse than is needfull; but which doth all things as if he were nothing affected with their cries; not giving heed to the judgement of the common people, who speake ill of Chirurgions because of their ignorance.

Whether surgeons were ignorant or not, there remained severe limits upon what they could achieve.

PHARMACY

Pharmacy underwent significant change as the range of remedies was extended, thanks to the retrieval of classical drugs, the discovery of new vegetable products from America and the Indies, and the increasing use of chemical substances. Herbs – understood in the widest sense as the leaves, seeds or fruits, bark and roots of plants, shrubs and trees – had always been the prime ingredients of medical remedies. If used individually, apothecaries called them ‘simples’; combined into a compound drug, perhaps with animal and mineral ingredients, they would be called ‘Galenicals’. Herb gathering (simpling) and preparation of remedies were domestic skills practised in the family, but there was also a commercial side to herbal medicine.

With the Greek revival, physicians became concerned that the remedies then in use were inferior, and sought to recover the original materia medica used by the ancients. This required the reform of botany, since there was no uniform nomenclature, leaving plant identification chancy. Botany enjoyed its own humanist renaissance: medieval authors were denounced for their barbaric language and for corrupting ancient texts, and there was a call for pure editions of classical botanical works. The great scourge of the pharmacists was the Paris humanist Symphorien Champier. About 1513 he issued his Myroel des Apothecaires, whose subtitle reveals his position: The Mirror of the Apothecaries and Druggists in Which is Demonstrated How the Apothecaries Commonly Make Mistakes in Several Medicines Contrary to the Intention of the Greeks … on the Basis of the Wicked and Faulty Teachings of the Arabs.

Around the mid fifteenth century manuscripts of Theophrastus’ Historia plantarum [The History of Plants] and De causis plantarum [On the Causes of Plants] were brought from Constantinople and translated into Latin by Theodore Gaza. Galen’s De simplicium medicamentorum facultatibus [On the Powers of Simple Remedies] had been used in the medieval universities, but in 1530 a new Latin translation was published, corrected by reference to ‘old manuscripts’. More important, however, as a vehicle for medical botany was the De materia medica of Dioscorides (fl. AD 50–70), which galvanized the botanical revival. The work had been known in Latin to the Middle Ages, but humanists collected Greek manuscripts, and the Aldine Press published a Greek edition in 1499.

With the Dioscorides revival, herbals themselves changed. The earliest printed ones were compiled from medieval sources, but later works by William Turner (c. 1510–68), Leonhart Fuchs (1501–66) and others became more naturalistic, both verbally and pictorially, mirroring the Renaissance anatomy atlases. The first to abandon the old stylized pictures was the Herbarum vivae eicones (1530) [Living Images of Plants] of Otto Brunfels (d. 1534), town physician of Bern. The artist Hans Weiditz (d. c. 1536) (school of Durer) gave this herbal its innovative look. When his plants did not tally with Dioscorides’, Brunfels tried to force identifications.

He described 258 different plants; ninety-seven years later, Caspar Bauhin’s (1560–1624) Pinax theatri botanici (1627) [A Catalogue of Botanical Theatre] included around 6,000 specimens. This stupendous increase was achieved through individual and collaborative efforts. The first chair in botany was established in Padua in 1533; botanical gardens were created in Pisa and Padua in 1544–5, with other universities following: Bologna, Leiden, Leipzig, Basel and Montpellier. Plants, however, were not always available and altered with the seasons; this made the artificial or dry garden (hortus siccus) an invaluable invention, allowing rare plants to be preserved or exchanged, and providing teaching material and draughtsmen’s models.

A great boost was provided by Pier Andrea Mattioli (1500–77), who in 1542 became physician to the province of Gorizia, where he worked on a commentary of Dioscorides. Published in 1544, his edition of De materia medica became the spur for botanical and pharmacological research, earning its author European celebrity. Like Linnaeus later, Mattioli had a gift for inspiring collaborators to travel, collect and send him specimens. Expanding with each edition, the work culminated in the version of 1565, a lavishly illustrated Latin folio running to nearly 1500 pages, bejewelled with full-page illustrations.

As the entrepôt of the Mediterranean, enjoying close links with the Middle East and the overland spice trade from the Indies, Venice was the natural centre for the humanist goal of recovering classical medicaments. Not least, the Venetian Republic controlled Crete and Cyprus, the herb gardens of the ancients. Drugs unknown to the latin West – balsam and myrrh for instance – were rediscovered. Famous for its purging powers, rhubarb had entered Europe through the overland trade routes from the East; by the early seventeenth century, seeds from Bulgaria allowed one medically valuable type of rhubarb (Rhaponticum, from the Pontus or Black Sea) to be grown in Europe, while search continued for the ‘true’ rhubarb which Marco Polo had reported in 1295 as deriving from China. Theriac, that panacea of the ancients, composed of up to a hundred herbal, animal and mineral ingredients, seemed in the 1540s quite impossible to compound; many of its ingredients were unknown and more than twenty substitutes were needed. But by 1566 the Veronese botanist-pharmacist Francesco Calzolari (1522–1609) was using only three proxies. Physicians grew confident that the remedies of the ancients had been recovered.

Thanks to Iberian voyages of discovery, new drugs filtered in, together with foodstuffs like potatoes. Cocoa came back with Cortés in 1529, becoming a favourite drink, a specific for ‘wasting diseases’, a stimulant, and even the basis of cocoa-butter suppositories. Meanwhile the Portuguese had rounded the Cape of Good Hope in 1487–8 and reached India in 1499. By 1512–13 they landed in the legendary Spice Islands, the Moluccas, whose spices had traditionally arrived in Europe via the overland route.

Remedies from distant parts entered into scholarship, particularly through the writings of Nicolas Monardes (c. 1493–1588) and Garcia d’Orta (1501–68). Educated at Seville, Monardes commented that New World drugs were inferior to those of Spain (pharmaceutical chauvinism was strong), but he later changed his mind, enthusiastically praising their powers in his Dos Libros (1565–74). The book followed a standard format, giving for each plant its place of origin, appearance, colour, properties and uses. New World plants posed problems, for their virtues were uncertain. This led him to concentrate on the distinguishing marks of the new plants and to describe how they were processed by the American Indians. Together with coca, jalap, sarsaparilla and sassafras (these latter famed for blood-cleansing), one of his best-known descriptions was that of tobacco, which he praised for curing head pains, toothaches, bad breath, chilblains, worms, joint pains, swellings, poisoned wounds, kidney stones, carbuncles and fatigue. Its efficacy derived from its heating and drying qualities. Despite King James I’s strictures against ‘this filthy custom’, tobacco enjoyed a high medicinal reputation in the seventeenth century.

In the face of the terrifying syphilis epidemic, imported plant remedies might appear godsends, for treatment with mercury was almost worse than the disease. In the Caribbean the Spaniards saw syphilis (more probably yaws) treated by decoctions made from guaiac wood (Guaiacum officinalis); by 1508 this was being imported into Spain and its use became widespread. Also known as ‘holy wood’, guaiac was obtained from evergreens indigenous to the West Indies and South America. The folk belief that God planted cures where diseases arose reinforced the conjectural New World origin for syphilis. Shiploads of guaiac were imported into Europe, organized by the Fuggers of Augsburg, the mercantile and banking family who monopolized the trade and profited mightily. The German humanist and soldier Ulrich von Hutten (1488–1523) experienced the horrors of the mercury treatment; he went through eleven mercury cures in nine years, then he heard of guaiac, and after repeated infusions believed he was cured. Von Hutten’s De guaiaci medicina et morbo gallico (1519) [On the Guaiac Remedy and the French Disease] was translated into German and French, but by the time Monardes wrote in 1565 guaiac was losing support.

One key remedy from the East was opium, largely imported from Turkey. It had been in use in Egypt in the second millennium BC, and Avicenna called it ‘the most powerful of stupefacients’. Ever the queen of drugs, it was profusely used in western medicine from the sixteenth century, and Thomas Sydenham (1624–89) later proclaimed that ‘among the remedies which it has pleased the Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.’ It seemed the wonder drug; not just a pain-deadener, it also stopped dysentery and relieved respiratory disorders.

India supplied new remedies. In 1563 Garcia D’Orta published Coloquios dos simples, e drogas he cousas mediçinais da India [Dialogues on Simples and Drugs and Medical Matters from India] which described such eastern products as aloes, camphor, sandalwood, ginger, asafoetida and betel, and new fruits such as mangoes. Like the Italian humanist botanists, he had to confront identification problems. (Was modern cinnamon the ‘canella’, ‘cinnamon’ or ‘cassia’ of the ancients?) Other eastern drugs filtered to the West later, including Chinese rhubarb and ginseng, introduced in the eighteenth century by the Jesuits.

Thanks in part to the labours of the botanists and the importation of new drugs, the apothecary’s trade boomed, though for many (witness Romeo’s remarks) the apothecary remained a wretch vending poisons:

I do remember an apothecary

And hereabouts he dwells – whom late I noted

In tatter’d weeds, with overwhelming brows,

Culling of simples; meagre were his looks,

Sharp misery had worn him to the bones;

And in his needy shop a tortoise hung,

An alligator stuff’d and other skins,

Of ill-shap’d fishes …

Like other branches of medicine, apothecaries organized themselves. In England, James I recognized them as a special body in the Grocers’ Company in 1607, and ten years later they gained their independence, organizing as the Masters, Wardens, and Society of the Art and Mystery of the Apothecaries of the City of London.

THE MIND

Renaissance humanism, mysticism, hermeticism and astrology fostered interest in the human soul, the spiritual fulcrum in a cosmos governed by supernatural forces – good and evil. It is not surprising, therefore, that one field in which Renaissance philosophy made a contribution to medicine was mental disorder. Theories remained complex, however. The neo-Platonist Ficino related melancholia to the sway of Saturn, but also to the action of black bile, the humour of genius and of depression.

Humanist moralists explored the mind, notably the French essayist, Michel de Montaigne (1533–92), twice mayor of Bordeaux. Suffering agony from a bladder stone

(#ulink_37074bda-95cb-55f4-9431-d221513632a5) and sickened by religious and dynastic bloodshed, he retired from the world to compose his mind in tranquillity, only to find himself haunted by ‘monsters’ and ‘chimeras’. Solitude sparked ‘melancholy adust’, a sick humour disposing his melancholic temperament towards madness. Composing his Essais (1580) was an antidote, a writing cure aimed at restoring balance through anatomizing his mind in quest of self-knowledge.

Montaigne kept his soul ‘at home’ in the body, studying both, hoping to grasp how man should live wisely and face death well. Yet in response to the old Socratic injunction of self-knowledge (‘nosce te ipsum’), he was sceptical: Quesçay-je? (What do I know?), he asked. Such themes were relentlessly pursued, not least by Shakespeare, whose contemporary, Robert Burton (1557–1640), described himself as ‘fatally driven’ upon the rock of melancholy and mixed philosophy and medicine. His Anatomy of Melancholy (1621) was a satirical flagellation of folly but also a serious medical inquiry which included the following causes of depression: ‘idleness, solitariness, overmuch study, passions, perturbations, discontents, cares, miseries, vehement desires, ambitions’, and hundreds more.

Philosophical medicine explored sickness of the mind and its synergy with the body. Mingling suspicion with sympathy, paintings and plays made much of fools, melancholies and madmen. ‘Bedlam’ acquired its notoriety, and Tom o’ Bedlam became a well-known figure, wandering the lanes, singing and begging. The period also brought the wave of mass hysteria and persecution known as the witch-craze. Despite the biblical injunction, ‘thou shalt not suffer a witch to live’ (Exodus 22:18), the medieval Church had long remained little concerned about witchcraft, but by the late fifteenth century this had changed, and a Papal Bull of 1484 condemned its spread and authorized a crackdown on its practitioners. Two years later, the Malleus maleficarum [Hammer of the Witches] of the Dominicans, Institoris and Sprenger, created a witchfinders’ handbook that passed through more than twenty editions and translations. Accusations spread, especially where religious conflict and social tension were rife, and trials and executions mounted till around 1650. As late as 1692 the Salem, Massachusetts, trials resulted in thirty executions, and witches were still occasionally being executed in parts of Europe on the eve of the French Revolution.

Nineteenth-century psychiatrists retrospectively diagnosed witches as mentally disturbed, their confessions of compacts with the Devil being the progeny of delusions and hysterical personalities. More recently, such charges have been levelled primarily at the witch-hunters, for whipping up mass hysteria. Though most early-modern doctors supported the prosecution of witches, a few were sceptical, and doubts were particularly expressed in the De praestigiis daemonum (1563) [On the Conjuring Tricks of Demons] of Johannes Weyer (1515 – 88). Weyer was the town medical officer of Arnhem in the Netherlands, and he warned against mistaking sickness for Satan. The Devil had no power over the body; so-called witches imagined the enormities they confessed, perhaps in the throes of fever. He insisted that the deeds of which they were accused – causing sudden death, impotence or crop failure – were natural occurrences. Witches were to be pitied and healed rather than harried and punished.

Felix Platter (1536–1614), dean of the medical faculty at the University of Basel, left extensive accounts of psychiatric disorders in his Praxis medica (1602) [The Practice of Medicine] and Observationum (1614) [Observations]. From a medical viewpoint he downplayed diabolical agency, though advising the use of amulets in cases of madness. He discussed hysteria and sexual disorders, described cretinism (then common in Switzerland), and advocated a basket of psychological, pharmacological and physical therapies. Occasionally at witch trials, medical and theological interpretations of insanity clashed. Yet it was not until the triumph of the mechanical philosophy that a naturalistic theory of mind gained ground, ruling out the supernatural element in mental illness.

A window is offered onto the deranged by the case notes of the Revd Richard Napier (1559–1634), a contemporary of Shakespeare’s who specialized in healing those afflicted in mind and spirit. A high proportion of the afflicted visiting him suffered family troubles, financial insecurities and religious torments, and many believed they were bewitched. Of the 134 cases of deep depression this Anglican clergyman handled, fifty-eight were attributed to deep grief following children’s deaths (‘Much grief for the death of two children’, one parent related). Of Agnys Morton, who had murdered her illegitimate baby, evidently suffering from puerperal fever, Napier recorded,

This woman is distracted of her wits … went to make herself away, being tempted as she sayeth thereunto by the Tempter. Will not in any case say her prayers … Very ravenous and greedy, and will say the foul Fiend lyeth at her heart, that she cannot feed him fast enough.

Napier cast horoscopes in forming his diagnoses, and healed with a mixture of herbal remedies, prayer and counsel, often giving patients sigils and talismans. He may be regarded as one of the last Renaissance magi.

MEDICINE IN SOCIETY

Renaissance humanism benefited the doctor more than the patient. The new learning hardly helped physicians to cure diseases. But it gave the medical profession an elevated sense of its proper dignity, and though playwrights loved poking fun at the pedantic pomposities of costly and useless physicians, medicine grew more status-conscious, and more dismissive of its rivals. ‘All that falsely usurp this Title of Physitian’, declared Richard Whitlock, ‘take off their Visards, and underneath appeare Wicked Jewes, Murtherers of Christians, Monks, abdicant of their orders, &c. Unlearned Chymists, conceited Paedagogues, dull Mechanicks, Pragmaticall Barbers, wandring Mountebancks, Cashiered Souldiers … Toothlesse-women, fudling Gossips, and Chare-women, talkative Midwives, &c. In summe … the scum of Mankind.’

This heightened sense of dignity was marked in public recognition. Earlier tendencies towards the public employment of physicians continued. The code of criminal procedure promulgated for the Habsburg empire by Charles V in 1532, known as the Carolina, required judges to consult surgeons in cases of suspected homicide, and midwives in infanticide. A landmark in forensic medicine, the Code was adopted in much of continental Europe. Medical authors were keen to display their expertise in the courtroom. Paré explained how to recognize the signs of virginity in women – important because under ecclesiastical law non-consummation was one of the very few grounds for annulment of marriage – and the indications of death by lightning, smothering, drowning, apoplexy, poison and infanticide; he also showed how to distinguish between wounds given to a body when dead and alive.

Medical institutions continued to develop under royal and municipal patronage. In 1518 Henry VIII chartered the College of Physicians, granting it examining, licensing and policing powers over medical practice in London. (It became ‘Royal’ from the time of Charles II.) Unlike some European counterparts, however, the college did not succeed in extending its jurisdiction to a wider region, nor did it have control over the licensing of surgeons and apothecaries.