An unusual power the rise and influence of medical doctors part 1 by stanley wilkin

An Unusual Power: the rise and influence of medical doctors.

Stanley Wilkin

Contents: Chapter 1: The Slow, Imperturbable Rise Chapter 2: Choice, Change, Conservatism in 17th Century European Medicine Chapter 3: Scientific Revolution 21/7/17

1: The Slow, Imperturbable Rise.

Introduction Throughout most of the modern era, identified as the past 200 years, professionals have been despised, and amateurism, associated with aristocratic sensibilities, seen as the desired state. Within my lifetime amateurs in sport were considered higher minded than professionals who earned their living playing, for example, cricket or tennis. In Britain, Fred Perry a tennis champion of the 1930s from a Northern background, was notoriously treated in a disrespectful manner by the prevailing tennis establishment and ostracised when he turned professional. Although it was a professionalâ&#x20AC;&#x2122;s way of paying for home and family they were suspected of venality. In fact this position lasted only a hundred years and was a consequence of the British upper middle class colonising sport and forcing out the lower classes, in particularly the working classes. Foot racing by working class men was common in the early part of the 19th century with a number of records broken, bets made, and money accrued, but this area was colonised by upper middle class elements, the group with money and status who performed the majority of the countryâ&#x20AC;&#x2122;s organisational tasks, with professionalism becoming taboo. This change occurred at approximately the same time that attitudes, fashioned by the demands of ruling vast swathes of the world as the Empire grew, and new notions of character, involving duty and sacrifice, were developed to efficiently run it. Concepts of personality are always contingent on the social and political priorities of the time. In the end, only football remained as a way of earning money through sporting acumen. Football provides another example of colonisation in that it has generally been assumed that the sport gained its modern rules and shape from the English public schools, such as Eton, the focus of the above traits, but recent research has shown that the rules came from northern English working menâ&#x20AC;&#x2122;s clubs, which effectively civilised the 1878 rules created by public schools. 1 While this will be a sociological examination of professionalism, connecting the phenomenon to transmitted aristocratic traits, it will primarily concern the rise of medical professionals, examining how they acquired the enormous influence and power within present day society, which I describe as a colonising process. The imperatives of Empire were imitated within 1 Sanders, Richard. How Football was Born. History Today. Vol.63, issue 10

society. In this research I will make claims that although the renaissance changed and shaped European attitudes the discovery of the Americas was fundamental to other later changes, and it was upon that event that Europe obtained its later prominence. Professionalism, particularly as exampled by physicians, developed as an organising arm of central government, a role it continues to play inhabiting selected ideas and behaviour. Usually it expresses similar values to residing governments and worldviews that ensued and ensure conventional behaviour and stasis.

Physicians became closely related to the

aristocratic elite that for centuries ran this country. This work will consider the medical profession, a multifaceted group, as inhabiting a peculiarly autonomous position within society, demonstrating controls that function outside of state parameters. The latter will be examined primarily through the anomaly of psychiatry that operates within a largely subjective, group-centred dynamic. In doing so, it will consider examples from Britain, France and the USA. This work will also argue that aristocratic mores have been assimilated by the profession, a strong belief in group and individual superiority and control of others. It will scrutinise the historical process. As this is an historical survey, until the 1880s, according to David E. Allen (Amateurs and Professionals, The Cambridge History of Science Vol. 6. The Modern Biological and Earth Sciences) the upper middle class followed only four occupations: armed forces, church, the respectable branches of law and medicine. These processes, whereby aristocratic attitudes were further transformed into professionalism, caused the absorption of many different methods of treating people, labelling others as frauds and criminals. This is not a Whig history of the medical profession and institutions, a story of natural progression, but will attempt to analyse the development of professional medicine in intellectual, social and ontological terms in which the quack for example is viewed as an outsider, the outlawed, and in which the physician, often with a fixed view of the world, has colonised both the past, present and future.

Historical Process: From Tudor times physicians were the aristocrats of the medical world, a position acquired through their close association with the crown and the new learning that had emerged since the 12th century. Surgeons and Barbers formed a company in 1540, but apothecaries, who for several centuries made up the different medical experts, were incorporated in the Grocerâ&#x20AC;&#x2122;s Guild in 1605. Both remained much lower down the social and managerial scale and, of course, even today surgeons are known by the normal, everyday appellation and not Doctor. This reflected the social conflict of medieval times from which the western idea of the doctor emerged: an authoritative, managerial figure possessed of social status and power rather than inhabiting a laissez faire role based upon equal status with those they treat. 2 In Europe, the physicianâ&#x20AC;&#x2122;s social status was of the highest in the fledgling academia based upon, within a hierarchy, logic, natural philosophy and medicine. 3 In The Medical Renaissance of the Sixteenth Century, Schmitt (1985) notes the unwillingness still of 16th century physicians to descend from theory to practise even though the original university medical instruction at Salerno had been more practical than theoretical. The philosophical elements of medical instruction bestowed upon physicians their humanist and high status credentials. As I will demonstrate, their position in society was not based upon effectiveness but from an evolving role that had roots in early Renaissance within the universities and, without changing knowledge-foundation, accumulated greater prestige as respect for ancient learning grew. In addition was the blood-taboo that relegated anyone who caused blood to flow to the level of craftsman (Gottfried, 1986). In the final conclusion, physicians were perhaps more intent on social status than cures, unless whatever cures they discovered advanced their social status. While present-day doctors are commonly revered, viewed preposterously as selfsacrificing demi-gods, physicians from medieval times until the Late Renaissance in England, were sometimes viewed disparagingly. The general accusation was that doctors, as distinguished from lay healers, were little more than murderers out for gain (Gottried, 1986, pages 58-59). The difference between that approach and the idealised one of present is often clarified through the idea of scientific progress, knowledge of human biology and of viruses, but that immediately begs the question of why laud the messenger and not or not exclusively 2 Gottfried, Doctors and Medicine in Medieval Europe. 1340-1530. Princeton University. 1986 3Schmitt. Ed. Wear, French, Lonie. The medical renaissance of the sixteenth century. Cambridge University Press, 1985.

the discoverer. We do not after all laud teachers because of the subject matter they teach, that is we do not say the teacher of Socratesâ&#x20AC;&#x2122;s philosophy deserves the plaudits owed to Socrates for his apparently innovative ideas. As will be seen (see above), the social status of physicians had nothing to do with the efficacy of their methods. The approach to illness, in particular plagues, owed much to the ancient Greek natural philosophers who preceded Plato, as well as to Aristotle. It too was based on observation of phenomena, with the same tendency to note one substantial event and extrapolate all observable consequences upon its effects. Where air or water as driving forces were observed in the ancient world, odour, always present with disease and corruption, was considered equally a driving force of other contingent consequences. Another philosophy and societal change were needed to turn theory into practice. Although it is I feel necessary to record and analyse the history of physicians, this work does not take the usual position4that by focusing on these individuals and groups it is possible to trace a unilinear scientific, medical approach. Although many medical historians no longer view scientific medicine as the only right kind, the general public still retains that belief, viewing medical doctors as icons and modern medicine as sacrosanct.

Even though medical doctors became more closely defined through licensing by the College of Physicians London, bishops and Oxford and Cambridge universities, the process towards this development lay in the medieval world. I have provided other social and political reasons: the growing commercial 5aspects of society, knowledge becoming a source of income, played its part. Academic medical practitioners can be found in the universities as well as within the clergy, exhibiting limited learning in the field. Prior to the 16 th century, there were physicians throughout Europe quoting Galen, perceiving sickness in terms of odour (see above), corruption of the air, in a dangerous dynamic with humours. Again, in the medieval world astrology played a significant role as seen in John of Burgundyâ&#x20AC;&#x2122;s Treatise on the Epidemic.6 Those calling themselves physicians studied at the universities and attached themselves to members of the elite. Many of the ideas about sickness and medical treatment 4 English Almanacs, Astrology and Popular Medicine: 1550-1700. Hill Curth. Manchester University Press. 1988. 5 Ed. Faith Wallis. Medieval Medicine. A Reader. University of Toronto Press. 2010. 6 Ed. Faith Wallis. Medieval Medicine. A Reader. University of Toronto Press. 2010.Page 423

remained connected to ideas in the medieval world, and continued so until the 19

century,

drawn from the ancient Greeks via the Arab world. In fact, a case can be made that many medieval concepts remain with us but their names have simply been altered. In John of Burgundyâ&#x20AC;&#x2122;s treatise, above, plagues are observed as being caused by the will of God, odours or miasma, noxious vapours emitted from the earth, and the susceptibility of individuals understood through the concept of humours. Personality therefore played a significant part in the catching of diseases or of becoming ill. Odours were a conduit for disease not necessarily the only device. Sickness occurred for three reasons: sin, trial of faith and intemperance of passions, requiring mediation between the physician and priest. This cooperation, 16 th century physicians did away with in their own practises. 7Treatments were taken from many sources, including the bible, and then as now becoming a doctor required feats of memory. But medicine was multileveled and included demons and witches as sources of sickness, with appropriate practitioners to treat each source. Community based healers, named Folk Healers, 8

formed the largest group of healers, religious leaders formed another group and book-based

university trained healers, or doctors, the third. In fact throughout the 16 th and 17th centuries there were all manner of medical practitioners offering a choice of treatments, often working in other professions at the same time. Universities emerged in the 12 th century, with medicine taught at first informally, but by the 15th century Padua University had emerged as the most respected of the medical schools. Women had acted as physicians until the emergence of universities when, as these facilities were only for men, their involvement in academic medicine largely ceased although many remained as barbers, leeches, and apothecaries.9 Although women still played a significant part in medicine in an informal capacity up to the beginning of Victorian times, by the Late Medieval period they were increasingly marginalised from formal practise as a possible consequence of monopolising and colonial tendencies. Earlier, women, such as Margery Kempe (1993-ca.after 1438) and Hildegard of Bingen (1098-1179), had written respected books on medicine. In Europe, by the end of the 15 th century women were actively hounded out of the profession. Two Dominican friars wrote Malleus maleficarum, connecting women healers with witchcraft. 10The treatments offered by academic physicians were largely fixed 7 Ed. Faith Wallis. Medieval Medicine. A Reader. University of Toronto Press. 2010. Page 86. 8 Kate Kelly. History of Medicine: The Middle Ages 500-450. 2009 9 Doctors and Medicine in Medieval England 1340-1530. 1986. Page 263 10 Kate Kelly. The History of Medicine. The Middle Ages. 500-1450. 2009. Facts On File, Inc.

on the writings Avicenna (980-1037), or Ibn Sina (full name Abū ʿAlī al-Ḥusayn ibn ʿAbd Allāh ibn Sīnā ) based on Aristotle and Galen. Apothecaries and surgeons more often learnt their trade through formal apprenticeships11usually of seven years followed by an assessment by an expert panel. Whatever form of learning was undertaken, medicine was clearly seen as a lucrative trade or additional employment.

Although this chapter will demonstrate that it was the Classic or Academic physicians that provided the status doctors largely enjoy today, after the worst of the plagues had subsided their star had apparently significantly declined. In England the Black Death had killed many physicians, medical teachers and authors, ensconced in the theories of the ancient Greeks and Arabs, which were at least 500 years old. Those that survived did so with shattered reputations. Physicians had no solution to the plague. According to Robert Gottfried12it was at this point that surgeons came to the fore and partially restored the reputation of medicine. Their practical focus engendered respect, as success, in a limited fashion, as were their failures, was clear to the observer. Henry V recruited many surgeons for the wars in France, increasing both numbers and reputation. These individuals, returning from France, established in1423 the College of Medicine, and composed the ranks of the Fellowship of Surgeons. This represented the high point for surgeons for the following centuries as new ideas from Italy ensured physicians’ renewal of power and influence. The emergence of hospitals during the plaques aided physicians as they often found employment there, another means of evolving professionalism, gradually ousting clerics. Another reason for the growing dissatisfaction with physicians was that by 1500 printers were publishing medical books, a third of all the books printed (Gottfried, 1986), in English rather than Latin, thus exposing the nonsense of many medical ideas which were largely unchanged from the 12th century. When their manuals and treatises were printed solely in Latin they could overawe the general population. Also, the lack of Christian ethics ( here understood as altruism, freedom from greed and largesse towards the poor) in physicians’ writings, and contracts between physician and patient or municipality and physician based 11 Alan Withey, A National Health Service. History Today. Vol.63 issue 10. 12 Doctors and Medicine in Medieval England 1340-1530. Princeton University Press. 1986.

upon remuneration, too created hostility, especially when compared to the behaviour of community healers who were soon to be dismissed as quacks. 13 Shakespeare provides an overview of medical experiences, describing kind doctors in Macbeth and King Lear, fakes such as Dr Pinch in The Comedy of Errors, and Cerimon, a magician, in Pericles.

Medical Competition: Before considering how academic medical practitioners began the long process of controlling or colonising the healing of sickness, I will look at their competitors and contrast the varied positions. The healer was anyone in the community who could â&#x20AC;&#x2DC;expedite recovery from illnessâ&#x20AC;&#x2122;.

This was implicit in English Common Law, although failure to bring about recovery could result in prosecution for felony. As medical licensing grew those without qualifications who based their practices on experience were labelled disparagingly empirics. The huge demand for medical services during the 16th and 17th centuries meant that licensed physicians had to compete with many different kinds of practitioners. Lay healers were accessible for most people. Most active physicians would not have had qualifications. Alongside those healers who employed recognisably modern techniques there were a number who employed magic. By and large, this resulted, especially in the countryside, in communal healing practices, very different from the organised, centralised form that developed incrementally from the 16 th century onwards, consisting of empirics, unqualified people who treated by experience not learning. Although Alan Withey (History Today, Vol.63.issue 10) writes of practitioners travelling long distances throughout the countryside to treat patients, in fact this was probably only for invasive treatments or I suggest in advisory capacities. The medical choices open to people were not just from those licensed in one fashion or another but by many within the community. Practitioners appear to have come in many forms, from altruistic clergymen practitioners to upwardly mobile practitioners concerned mainly with remuneration. There was not the homogeneous quality to doctors there is today reading from the same manuals and reciting the same codes. Change to this market place free-for-all came about through 13 Ed. Wear, Geyer-Kordesch, French. Doctors and Ethics: the Earlier Historical Setting of Professional Ethics. Rodopi. 1993.pages 110-111. 14 English Almanacs, Astrology and Popular Medicine: 1550-1700. Hill Curth. Manchester University Press. 1988. Page 15.

parishes and councils contracting licenced practitioners when the need arose. Although it created less autonomy within the profession, it imposed external standards that functioned through market forces. Recent research (History Today: Vol.63 issue 10) has shown 14,000 medical practitioners in England by the 17th century, although many may have been supplementing incomes from other sources. Medical Colonisation: The disappearance of different forms of healing is the main concern of this chapter, reflecting on the centralisation of medicine and the eradication of all other forms of healing practitioners through the processes of illegitimisation. Gottfried (1986) identifies the corporate nature of medieval society as determining the development of medical institutions by the Tudor period, its effects evident today. The physicians he asserts required the corporate structure to protect their livelihoods, many of which operated locally. Such institutions were based on towns, and when fully established in London began to acquire their present corporate, monolithic nature. In order to fully comprehend this process termed colonisation, which I believe has continued without sufficient acknowledgement to the present day, this book will trace the political growth of doctors. The concept of colonisation considers doctors to have emerged from a medieval corporate structure that slowly swallowed up or dispelled other organised or laissez faire medical practitioners.

In order to succeed, medieval

corporates (guilds) embraced strategies of power. 15 Their livelihood and status depended on physicians convincing both the powerful and commoners of their greater medical knowledge, the superior exclusive nature of that knowledge and also of the inferiority of other forms of medical knowledge. While physicians propagated theirs through the idea that they were concerned for and protecting the kingâ&#x20AC;&#x2122;s/queenâ&#x20AC;&#x2122;s subjects from unqualified medical practitioners, the lay practitioner, one not belonging to an organised body, claimed they were fighting against the learned physicians monopolisation of medical treatment. Andrew Wear in Medical Ethics in Early Modern England (1993, page 121) asserts that there were two approaches to medicine according to the power elite within early modern society. On one side were those who accepted physicianâ&#x20AC;&#x2122;s claims and encouraged the law to be employed against quacks, and on the other those who were against monopolisation of medical treatment, and who could also see that 15 Gottfried, Robert S. Doctors and Medicine in Medieval England 1340-1530. Princeton University Press. 1986.

some people had a talent for healing but could not, because of the expense, acquire qualifications.

Thomas Linacre: The foundation of the modern English physician can reasonably be traced to Thomas Linacre who, after studying medicine in Padua, incorporated his degree at Oxford and Cambridge, and settled down to teach Greek and practise medicine. He made an improved translation of Galen from Greek to Latin, the language of scholars. After practising privately, and perhaps even attending Henry V11 he, upon the Tudor king’s death, became Henry V111’s personal physician. He had by then many influential patients. Physician’s social and financial success depended upon who they treated and therefore access to the King or the aristocracy was the pinnacle for an ambitious physician. Nevertheless, physicians were prosperous and bourgeois, in the sense of individuals or groups concerned with profit and city-life. Did physicians, through association with the bourgeoisie, also constitute important members of an emerging middle-class, as they most certainly do now, providing a framework for the group’s beliefs and values? I would suggest not, as the middle-class traditionally bestow cultural benefits on society, and therefore constitute a later development. This paper takes the view that physicians were an urban phenomenon, by definition the bourgeoisie who defined success through money and status not solely through intellectual or artistic achievement. By the early 16 th century the prosperity of doctors was considerable and spread widely throughout the profession (Gottfried, 1986, page 266-267). Although the concept of the medical market place in early modern Britain is now contested, nevertheless as medical colonisation grew, so the market-place expanded as often during the 15th- 17th century’s medicine remained part of the common good.16Pills provide evidence of early consumerism, subject to the ease they could be bought and taken. What evidence we have of his medical expertise shows that, probably alongside many early physicians, he was cautious and reluctant to prescribe (O’Malley, 1965). Erasmus describes being treated successfully by Linacre who instructed that a compound be prepared, made by an apothecary, and given to the great man. He was thereby relieved of a stone ‘the 16Jenner, Wallis. The Medical Marketplace. Ed. Jenner, Wallis. Medicine and the Market in England and its Colonies, c. 1450-c.1850

size of a walnut’. Physician’s compounds were made up of spices from the Far East, so probably had the constitutional effect that modern spices do in cleansing or appearing to cleanse the system. It is possible that the compound was obtained from those who were not licensed physicians, old women, housewives, knowledgeable neighbours or based upon their knowledge, because, as with many instances of medical triumph, it is anecdotal. I will consider this matter later. In 1511 he and his circle may have had a hand in persuading parliament to pass the Medical Act of 1511, limiting the practise of medicine in England to medical graduates of Oxford and Cambridge and those licensed by bishops. With five other prominent physicians, he urged Henry to found a college of physicians. The founding of the College of Physicians of London in 1518 placed the granting of licences and control of medicine within the hands of learned physicians who knew Latin and Greek. Those with a Batchelor’s Degree, gained after studying for four years, became a Licentiate but only a Doctor of Medicine, gained after fourteen years, could become a Fellow, or Candidate as there were few available posts.

In 1599 these amounted to thirty Fellows and six

Candidates. Wear (2000) provides a higher figure of 50 registered only in London. As the target of licenced physicians was the rich, the small numbers were of little consequence. Physicians, being highly learned, were taught Hippocrates and Galen, studied the classics in detail, and, at Oxford, dissected executed criminals. For their medieval forbears it had been one of the seven disciplines.18In part, at this stage and later, it was important that physicians knew how to talk with the elite. John Caius was born in Norwich in 1510 from a similarly privileged background to Linacre, who became even more adept in Greek and Latin, an equally convinced disciple of Galen and an opponent of Andreas Vesalius under whom he studied in Padua. Vesalius introduced anatomy into the student curriculum and successfully undermined the ‘selfsufficiency of classical medicine.’19 Although Caius further supported the College of Physicians, understanding perhaps its role in identifying what a physician was, that is learned in Greek and Latin and following certain mainly fixed treatments, he lived to see the belief in Galenic medicine eroded by new outlooks.

17 A.W. Sloan. English Medicine in the Seventeenth Century. Durham Academic Press. 1996.page 2. 18 Ed. Faith Wallis. Medieval Medicine: A Reader. 2010, page 86. 19 Margaret Pelling. The Common Lot. Longman 1998. Page 33.

What a physician was then: Our present hallowed conception of medical practitioners comes from this early period when important physicians were allied to the renaissance, still in its infancy in England. We call them humanist to distinguish these scholars from the medieval age, although it is difficult to see how they differed except in not ascribing sickness to supernatural sources. Like their medieval forbears successful treatment was based upon trial and error, with effective forms of treatment passing into the ownership of a particular physician. Although later the position of academic physicians, based upon Galen,20 would be attacked by others eager to explore alternative methods based upon independent observation of natural phenomena and of independent judgement not conditioned by long-dead Greek medical practitioners, which actually had its roots in medieval medicine21. Medieval medicine was seen as dependent upon superstition and folklore and needed desperately to be superseded. Recent research 22 has indicated the efficacy of medieval medicine, and the work done in hospitals run by religious establishments.

Even then, many historians of medicine concentrate on its academic

practitioners as that is where information can be found. There is no justification in seeing the medicine of Linacre as an improvement. The only change was in the process of defining physicians as an exclusive body, who could control what and was not considered healing. With this came standard and agreed forms of treatment. In this changing world, commercial interests were paramount. A major difference between physicians and others providing a service, such as artists and craftsmen, was that physicians escaped being considered merely tradesmen through involvement with seats of learning. There is no clear justification for believing that professionalism at this stage was the natural response to the influence of greater empirical knowledge, as Linacreâ&#x20AC;&#x2122;s knowledge was no different from physicians of an earlier period. In addition, the influence of classical thinking and scholarship, urbanisation, Protestantism, the end of feudalism, with the assumption by professionals of the aristocratic traits of courtesy and gentlemanly conduct (Gottfried, 1986) and emergence of middle-class, were the forces behind the growth of individualism. Society as a whole became less concerned with martial skills and right of birth, but now included those with the intellectual 20C.D. Oâ&#x20AC;&#x2122;Malley. English Medical Humanists University of Kansas Press. 1965 21 Ed. Faith Wallis. Medieval Medicine. A Reader. University of Toronto Press. 2010. 22 Vivian Nutton. Medieval medicine. Metascience 2010. 19: 83-85.

skills to deal with the complexities of government. Central government required able bureaucrats. These humanist physicians tended to travel to Italy, Padua and Bologna, where the best medical schools were, for their medical training.

Paracelsus

The setting up of a College of Physicians can arguably be seen as an assertion of exclusivity and scholarship, but certainly not of ensuring high level medical treatment. At this point, there is no reason to believe that they were more effective than their unlicensed and thereby unqualified practitioners. English medicine remained conservative compared to many areas of Europe. Although unlicensed practitioners have a poor reputation in the present, the division between the groups was of the learned and unlearned. Although the Medical Act of 1511 declared that only medical graduates from Oxford and Cambridge could practise medicine legally, licensed by Bishops, this was to prevent practice of medicine by the ignorant and superstitious, who posed a danger to the health and well-being of the nation. As licenced doctors then and later were very small in number and limited to large cities this legalisation of medical activity was perhaps more to do with changing understanding of scholarship, from theology to Renaissance concerns, of the rise of a class defined by scholarship, including Thomas More and Erasmus, and central control of knowledge and its practitioners. It certainly concerned class dynamics. If as O’Malley (1965, page 15) asserts it was about ‘weeding out the unqualified’ and ‘lead to an improvement in medicine practised legally’ it is extremely difficult to see how this benefited prospective patients. Far more rational is to see this as the attempt by an emerging middle class to obtain status and power siphoned from that of the crown. The limitations of medical instruction at the time suggest that a licensed physician knew Greek and Latin, used blood-letting, examining the pulse, and other authorised treatment, which often amounted to beneficial or equally possible injurious concoction of natural curatives. Those who engaged in similar activities, but knew neither Latin nor Greek, were likely to be accused of quackery. It was not medical efficacy that distinguished the many practitioners. The traditional Whig position is to point out the positive value for future scientific medicine, but this was a long way in the future, ignoring the absolutist tendencies already obvious within the profession. If we are to equate the above benevolence, then that trait was probably more evident in the unlicensed who also probably obtained better results. The idea of qualified and unqualified is not as certain as many might suppose. Qualified here means those attached to the two new universities and that traditional power bases of the age and the kind of knowledge, based upon class and authority, they asserted. To become qualified an individual required money, a suitably middle-class background, and connections. This has not substantially changed. Knowledge thereby becomes authenticated by wealth, status and power-as it still I suggest remains.

As we will see, medicine at this point consisted of many different competitive strands and it was this dynamism that the College of Physicians threatened in a successful attempt (although modern medicine is equally made up of various strands) to squash and in the process create a medical monolith of extraordinary power. Many competing forms of medicine were denounced as quackery, and the colonisation of sickness had begun by a group distinguished by their attachment to traditional authority and status within society. Although not used in such a way, and eventually to also be discredited, learning from mothers, grandparents or neighbours about curative natural ingredients is also to be qualified; learning and employing proven remedies equally is to be qualified. Apart from all the other issues tackled here, we also have a form of modern knowledge, one obtained through examination and certification. Only in London did the physicians sue unlicensed practitioners for illegal practice. In 1663 physicians attempted to extend their remit throughout the country but the rights granted by Charles 11 were never confirmed by Parliament. The close connection of the college to the Crown caused it to wan as royal authority diminished towards the end of the seventeenth century. Verbally and via the written word physicians attacked unlicensed others who deigned to practice their craft for money, but as so many people during this period practised some kind of medicine physicianâ&#x20AC;&#x2122;s attacks seem to be to do with preserving social status in the market place. The licensed physician was extremely expensive. As Roy Porter 23points out, there seems little difference during these earlier centuries in the effectiveness of licensed and unlicensed physicians. What difference there was appears to have consisted of learning, a knowledge of ancient Greek, Latin, Homer and Virgil. Of greater consequence to my later arguments is the invention of pills, which I suggest was and remains for marketable

23 Quacks. Tempus publishing, 2000, page 127.

purposes.

Physiciansâ&#x20AC;&#x2122; viewpoint: Although I have looked briefly at medical treatment by licensed physicians, here I will consider it in more depth. Although in a competitive environment a physician could still make his name and fortune through a particularly effective cure. Physicians believed, after Aristotle, in the four qualities, hot, cold, moist and dry. Examination would confirm one or the other.24 The imbalance of humours was still widely accepted in the 17 th century, although there were a greater variety of ailments recorded. In Late Medieval times there was also a considerable number of recorded ailments and greater knowledge of the human body. 25 Diagnosis depended upon astrology and uroscopy. In the latter, a 12 hour sample of urine was collected from the patient in a glass flask and taken to the physician, who did not often get too intimate with the patient, for inspection. Not until later were physical examinations 24 Sloan, English medicine, 25 Ed. Wallis, Faith. Medieval Medicine. A Reader. University of Toronto Press. 2010.

introduced. Treatment involved bloodletting and drugs, which were prescribed by a physician and dispensed by an apothecary. Drugs included theric, an antidote to poisons, galenicals, and animal products such as blood and bile. Medicine seems to have gained its success through therapeutic methods not necessarily those of intervention in a similar fashion to the preventive medicine of today. Exercise, diet, freedom from stress, the creation of internal and external balance. Both licensed and unlicensed healers worked to the same end. Where academic physicians were concerned, what killed, also cost. Already a physician was distinguished by power, esoteric learning, background and social status. The efficacy of prescribed invasive treatments were already irrelevant and by the 17th century physicians had acquired a reputation for killing as well as curing. â&#x20AC;&#x2DC;Trust not the physician; His antidotes are poison, and he slays More than you rob. â&#x20AC;&#x2DC; Timon of Athens: Act 4, Scene 3. Only in the last century did that situation change in favour of cure. Nevertheless, surgeons seem to have had success with the everyday damages of life and both surgeons and physicians were able to provide excellent advice on preventing illnesses. There have always been different approaches to medicine, but in Western societies these involved concerns of legitimacy, learning and authority. While medical historians tend to focus on licensed practitioners, they were just a small if powerful part of the overall picture. Most people may not have ever met a licensed practitioner but had regular contacts with other practitioners. Licensed physicians were concerned with the elite and usually had little concern with other elements in society. Also, effective remedies were done by those licensed practitioners, such as surgeons, further down the pecking order, not by physicians. Doctoring was different according to social status and habitation. Doctoring to the poor, to the rich, to urban patients and country patients was different as were the service deliverers. The growth of professionalism brought with it increasing degrees of homogenisation, as will be shown through the methods of colonialism. This section will look at this progression, connecting colonialist intentions with similar examples of power and superiority that occurred between

western and underdeveloped countries during the same period. Elizabethan Medicine: General perceptions of sickness remain important in understanding treatments. This concerns medicine In Elizabethan England as well as today. In the 16 th century the senses determined the nature of illness. The population as a whole was closer to the natural world than today thereby encouraging different viewpoints. For example, excrement was used in agriculture and medicines, with urine being used for bleach.26European societies were still rural in the 16th and 17th century and therefore expressed certain conditions. There was considerable mobility, largely seen as threatening by the elite, which in France was vigorously and firmly responded to. As Foucault has noted, this informed our present understanding of sickness. Cleanliness may have declined since the medieval period due, in part, to the prevailing view that washing took away certain necessary protectives from the body. This development has been connected to the rise of syphilis. Throughout the 17 th century there was a growth in street paving, with communal hygiene a matter for parish officials and individual homeowners (Pelling, page 23). The lack of organised public health was responsible for many illnesses. Dungheaps were located outside city walls and used for agriculture. The cities stank and as a consequence odour was still viewed as an important source of disease and a means of its cure. Anything that released foul odours (p 24) was seen as a source of disease. Nevertheless, these may have been only urban perceptions and not prevalent in the countryside. As will be seen throughout this period was as in the past an active and effective lay medicine which involved competition and collaboration. It was community based, although not entirely, without the demands, money and individualism, of the growing professionalism of the College of Physicians London. Successful practices were shared and mainly conducted openly. Although professional or academic physicians existed, there were not many, and most of these had other occupations. Clergy, merchants and landowners practised medicine professionally. Amongst the Academics, Galenism lost ground due to the practise of anatomy led by Andreas Vesalius (1514-64), see above, that tended to undermine the authority of the ancient Greeks and led to the notion of therapeutic effectiveness. This position was further developed 26 Pelling, Margaret. The common lot. Sickness, medical occupations and the urban poor in early modern England. Longman. 1998.

by Paracelsus, a German-Swiss, who attacked classical medicine and advocated the use of inorganic substances in treatments. According to Pelling (1998), academic physicians, those of the College of Physicians London, had little to say about diseases and remedies. Changes in religious perception, the arrival of new plants and minerals from the Americas, also concentrated minds on what actually worked. Cultural perceptions: Changing perceptions caused different treatments to be applied. For example, Protestants saw sickness as linked to spiritual corruption with suffering perceived as a necessary part of a cure. Even by Victorian times, the medical opposition to anaesthetics was based upon the belief that pain was necessary for the soul. Treatment of the mentally ill, even today, has largely followed this pattern. High risk intervention, still employed today, is based upon earlier concepts of punishment of the ill or of the corruption within the individualâ&#x20AC;&#x2122;s body. Medicine during this period was very different to present day treatments. It did not fit a process but was subject to competitive claims based on novel discoveries and assertions of authoritative knowledge. It was greatly influenced by the continent. Medicine consisted of astrology, traditional practices and religious attitudes. Diagnosis, based upon testing of a number of factors, remained unlikely. Bloodletting was commonly used, advice on diet, and on increasing or decreasing sexual activity. While early physicians were sufficiently altruistic in their approach, their attempts to help genuine, medicine was slowly taken from the hands of the community into the hands of those who claimed personal and group justification for the treatments they gave. From this point on, although it took time, medicine ceased to be a shared phenomenon based upon objective and subjective experience, thereby debate and discussion, but one colonised by a central authority. Social and economic change: custodial care, discipline, training, education and work State involvement in the provision of medical treatment came with Poor Relief , which had become a matter of national concern during the 16th century. This period provided identification of the poor in a way that is still with us, itinerant, lazy, abusing the system, but also helped construct public forms of medical care based on segregation, incarceration connected to lazar houses, constructed originally for lepers. The breakdown of master/servant relationships also contributed to the extension of state interest in local matters along with migration into the towns and cities.

Vagrancy: From 1520 to 1640 the most pressing concern of government was that of vagrancy, or to re-categorise, mobility. John Pound27asserts that vagrancy became widespread and organised. It became a problem for villages and towns. Consequently, urban centres began experimenting with methods of dealing with the problem, and with poverty in general. Medical treatment was employed to deal with the matter. Municipal authorities, epitomised by the Elizabethan poor laws of 1598 and 1601, and group charitable activities enjoined to limit the social effects of both. Pound (1986) views begging as one result of recent warfare and of many armed and experienced ex-soldiers finding ways to survive without resorting to the humdrum existence of the average urbanite. Men who had previously been retainers of one lord or another gathered together in bands, equating vagrancy and criminality. This was partly solved by the provision of pensions to ex-servicemen in 1593, although many impoverished men who had not served in the army suddenly thereby claimed to have done so. Another cause was the effect of an increasing population not met by increased employment opportunities. A situation exacerbated by the need for greater agricultural output, more efficient farming and the disposal of surplus labour. Landowners often turned their land over from agricultural usage to sheep farming, resulting in enforced enclosures, because of the greater profits accrued from the sale of wool and rising prices. With farm workers now dependent on wages and without owning land of their own more and more workers became subject to the vagaries of market forces. The nationâ&#x20AC;&#x2122;s growing dependency on the cloth industry, likewise susceptible to external threats, increased the chances of poverty and homelessness. Although some experts dispute the overall negative effects of economic change (Pound, 1986) there appears to have been increased mobility throughout this period. This may have been due to social and psychological factors, the mercenary quality of workers associated with wages, the resulting greater instability and the breakdown of traditional master/servant relationships. It appears that the poor, temporary workers, returning soldiers, displaced rural workers, habitually congregated in urban areas. By the end of the Tudor period they often made up two thirds of a town. Of these, a number would be widows, many with children. In retrospect this 27 Poverty and Vagrancy in Tudor England. Longman, 1986.

seems a consequence of high populations, especially within a market forceâ&#x20AC;&#x2122;s context where wealth is increasingly directed towards an elite, as a similar situation exists at the time of writing. Segregation: Before considering how municipalities dealt with these problems, I will consider methods already at their disposal, and connect that, where possible, with similar institutions and methods in the present day. The 16 th and 17th centuries certainly provided the institutional and perceptual roots of social organisation in the present day. In order to evaluate these institutions and perceptions I will first look at incarceration as initially employed for leprosy sufferers and victims of the plagues. Michel Foucault 28 places immense importance on the segregation of lepers within excluded communities, a policy employed as a response to the plagues that ensured the effective control of diseases. He viewed this as instrumental in the production of Other, a useful sociological term to describe societies discarded members who do not comply with the capitalist system. This practice he believes led to the construction of mental illness by authorities in order to control disenchanted elements within society. He points out that there were a number of leper colonies within England throughout the medieval period but of course the practice of isolating unwanted groups in England came much later than it did in France where it does appear to have been built into national perceptions. Foucault in addition notes how unwanted people were routinely driven outside of the city or townâ&#x20AC;&#x2122;s walls. The space within the walls was symbolically for working, settled populations. The segregation of groups, the separation in terms of both space and perception, created divisions between normality and abnormality. Leper colonies in England were called Lazar Houses after the diseased beggar in a Jesus parable (Kelley, 2009). Once individuals were diagnosed with leprosy, often incorrectly, they were not allowed out again thereby predicting the arrangements in later mental institutions. As the disease was considered highly infectious lepers were avoided and rejected naturally occurred. By 1225 19,000 leprosaria had been built across Europe. A link between attitudes to lepers, regarded as dangerous, unclean, and undesirable poverty and madness is made through the incarceration of each group that became commonplace within European societies, 28 Madness and Civilisation. A History of Insanity in the Age of Reason. 1961. University Press, Cambridge.

usually under the auspices of the developing middle class who may have used such positions to define their professional and authoritative roles within society. Middle class professionals cleaned up the mess made by less agreeable types, keeping it away from aristocrats’ homes and clubs. This attitude can be found fully formed in the latter part of the 17th century. Connected to Lazar Houses was the development of hospitals in England from places run by monks for wayfarers to stay to institutions that primarily looked after the sick. Later some hospitals were concerned only with the old or indigent (Sloan, 1996). In France, hospitals, also created and run by the church, were called incurabili as anyone entering such a place was likely to die. Nursing provided care rather than the delivery of possible cures. From these satisfactory attempts at care evolved the Bridewells where correction was instituted to control the immorality of idleness and non-production. Although state medicine developed much earlier in Europe, as analysed below, the English counterpart emerged during the above period of social crisis and had more to do perhaps with social change and only later to do with virulent diseases like plagues and the French disease. Ideas of the ‘Poor’: The social and economic change that caused landless gentry to become urbanised, led also to a less structured supervision of the countryside, greater unemployment and vagrancy. This led to a greater number of illnesses amongst the poor. The migration to urban areas, with the differences in economy, one communal and the other expressed through group or individual economic attainment combined with wage earning resulted in a knife-edge economy, which greatly increased the number of poor. During the Tudor period prices rose fourfold. Beier29 has examined what he has called two variables: the appearance of great numbers of property-less persons and the authorities’ reactions to them. This occurred in both England and Western Europe. Although the authorities’ response was enlightened in some ways, assuming responsibility for a difficult phenomenon, they also defined and labelled the poor in a way that was to last within Western urban societies (see above). By the Tudor period the poor had become a national problem, with a third to a half living in near poverty.30As with any problem, where state action cannot supply an immediate 29 The Problem of the Poor in Tudor and Early Stuart England. Methuen. 1983. 30 Beier, 1983, page 5.

resolution, analysis prevails. The poor can be divided up into settled and vagrant, although probably neither definition describes a static phenomenon. Under the poor laws the first were liable to poor relief, but, according to Beier, the second group were regarded and treated as criminals. In fact, urban societies for several millennium have demonstrated immense fear of mobile groups, often with justification. The rise in urban poor, whether settled or vagrant, can be located in the changing economy of the countryside, its breaking down into small holdings and subsequent dispersal of wealth.

Medicine, the poor, social control: This period saw an increase in poor-relief but also of severe punishments for an increasing number of often petty misdemeanours. Idleness, usually the result of an inability to participate in the prevailing economy through social circumstances, itself became a crime deserving of the severest punishments (An Act Concerning Punishment of Beggars and Vagabonds of 1531, Statutes of the Realm, iii, 328). Although Norwich was not affected by the above economic and societal changes until late in the 16th century its practise of state medicine can be viewed as part of an attempt to control the situation of greater poverty, especially concerning the migrant poor. To keep people industrious and able to earn was the authorities’ civic duty. Although patronising in their approach, municipal authorities provided genuine help and assistance to the poor. Licences were employed to pay for treatments and the poor were aided in other ways, with scholarships for example (Pelling, 1998). Norwich authorities displayed admirable social conscience although we must bear in mind this was ameliorated by religious perceptions of ‘self-help’ and deserving, and whether or not the sick had residences. Municipal authority provided for sick poor children but largely because children then were an important part of the city’s economy. There appear to have been a large number of medical practitioners during this period, which may have been due to the municipal provision of medical services, especially in larger urban areas. Mary Pelling (1998) has looked exhaustively at the records of Norwich, then the second richest city in England, with one of the best examples of state medicine in England, noting that the city officials demonstrated an understanding of the economic effects of sickness, using licensed doctors to enable the sick to return to work. As the poor did the essential physical labour, poor relief and state medicine was important for the local and national economy. The poor as a separate entity was emerging and identified through both

poor relief and state medicine. The poor were not only to be looked after (Pelling, 1998. Pp 81-84) but also defined through the principles of Catholicism, Protestantism and Humanism, each of which emphasised improvement and change. Unlike the rich, the poor were often divided into the deserving and undeserving according to their place in the economy or attitude to it. The deserving poor were always those who worked. Again, such concepts have remained with us. Vagrants could be subjected to confinement, quarantine, forced labour or cure (Pelling 1998). Pelling (1998, page 82) describes Norwich as instituting short term care that involved custodial care, discipline, training, some education and work. The poor were infantilised, requiring the intervention of enlightened authorities. Illness, poverty and morality were closely linked. To be poor, especially if a vagrant, was to be corrupt and immoral. Pelling (1998, page 97) describes a doctor contracted by the Norwich authorities to heal two boys, one of whom escaped to live in the streets. He was subsequently picked up and returned to the doctor but did not prosper and was thereby sent to Bridewell, see below. The other child suffered worse. What appears to have concerned the authorities is that the boys would pass from the doctor to residence in a home as apprentices, exhibiting thereby all the desired traits of domestication. In both cases this expectation failed to materialise. While there were many admirable innovations in the Norwich Poor Relief scheme, in many ways there and elsewhere a war of attrition was begun by the urban authorities on the victims of economic change that deftly corresponds to later ruling manifestations. Houses of correction were set up to deal with the poor, definitions of which were labour based, if, for example, an individual was healthy and sturdy they should be working. Entertainers and peddlers too came under this dictate. According to Beyer (1983, page 31) the statutes of the period were to keep the sturdy in service under masters, a tradition now largely shunned. As a consequence Bridewells appeared, institutions to reform the idle, in which punishment and rehabilitation was linked to labour. In some parts of the country, settled poor were required to wear insignia, like the Jews during earlier and later pogroms. In such an environment, state medicine can be seen as a means of official control. Has that changed? Medical care, based upon deserving and impotent poor, who the city wished to retain for their labour and who to punish, can be viewed as the re-assertion of authority in a civic not feudal fashion. It was in line with the ejection of unsuitable individuals or groups. From this period valuable citizenship and therefore normality became constructed upon settled home

lives. Moving away from that ideal state indicated criminality and, reviewing Foucault, unproductive and therefore disturbed behaviour.

State medicine: Whatever the connection between medieval forms of incarceration and later treatment of the mad and poor in society, models of state controlled medicine certainly did. Although public medicine formed in many ways, from the contracting of a variety of medical experts by municipalities within Europe, the statistical approach, developed in Milan by Catelano (d 1497) but employed by the Milan authorities as a method of identifying when plagues were likely to strike, thereby how best they could be controlled. Jacob Soll 31 demonstrates that the pioneers of Florentine civic humanism connected medicine, politics and civil law, a model for much later developments in England. This method was used to minimise contact between ill and healthy and was at first in the hands of parish elders but then placed in the hands of the College of Physicians.32Descriptions of illnesses began to be routinely collected as well as evidence that in matters of plague physicians were often passive witnesses, diagnosing illnesses through the narrative of victims and their families and through visible marks on victimâ&#x20AC;&#x2122;s skin, just barely useful in noting symptoms and causes of death. While I have already suggested that municipals helped to create professional medical identity, the administration of plagues in Italy and later throughout Europe strengthened the public role and power of physicians. Collecting data certainly proved a decided move towards modern medicine, directed from the top of state hierarchies to control virulent diseases that destabilised states. Physicians therefore became, at this early stage, an arm of the state, which they remain still. Of interest in the development of my general theme, according to Roger French33physicians only became interested in the management of hospitals when these institutions began to be identified with civic pride.

31 Healing the body politic: French royal doctors, history, and the birth of a nation 1560-1634. Renaissance Quarterly 55.4 (Winter 2002) p1259 32 Carmichael, Ann C. Epidemics and State Medicine in Fifteenth Century Milan. Ed. French, Arrizabalaga, Cunningham, Garcia-Ballester.Medicine from the Black Death to the French Disease. Ashgate, 1998. 33 Medicine before Science. The Business of Medicine from the Medieval Age to the Enlightenment. Cambridge University Press. 2003. Page 152.

Examination: Professionalism did not mean exactly the same as it does today, and the growth of professional doctors was locked into the social conflicts and competition of medieval and early modern times. Doctors, one of the most prosperous of the middle-class groups to emerge at this time, did not acquire wealth and status through the efficacy of their treatments but through their connection with high learning, use of Latin and Greek, corporate expertise, separating from other medical groups, the marginalising of cleric physicians and religious influence, and gradual distortion of community healing and healers into quackery and quacks. For example, at a later date, in the mid-17th century, Nicolas Culpeper contrasted the cheapness of his native god-given remedies, within the means of the poor, with the expensive, often exotic remedies of the Galenic physicians.34 Although physicians were an urban phenomenon, their taking over management of hospitals from clerics, positions in royal and aristocratic households, increased their influence and control of society. Physicians were mainly intent on creating power and influence for their corporate, for as Leon Joseph of Carcassone commented: ‘the learned physician is he who asks for a large sum of money and does not heal free of charge.’35 While many other commentators may deny such overall self-interest, pointing to the effects of Christian altruism and concerns for the poor, as a group I believe the description remains valid. Although other medical practitioners, such as apothecaries and surgeons, competed in the medical market-place these groups were not quite so tainted by accusations of avaricious and self-interest. In the 17th century, as will be seen, changes in religious perceptions were to allow the already influential medical body to expel another rival, religion, from their growing monopoly of healing. The assumed superiority of Academic physicians, a trait of many modern doctors, should not then or now delude us to the efficacy of their methods. Medical treatment is a contract, both visible and invisible, that requires both sides to engage in a pre-arranged role replete with psychological, almost magical, properties. For example, Erasmus immediately trusted Linacre’s integrity and expertise, necessary for a cure. The good doctor might have acquired his successful compound from the good woman next door or a cunning man in the next town. 34 Ed. Wear, Simon, Geyer-Kordesch, French. Doctors and Ethics: the Earlier Historical Setting of Professional Erhics. Rodopi. 1993 page 113. 35 Ed. Wear, Simon, Geyer-Kordesch, French. Doctors and Ethics: the Earlier Historical Setting of Professional Ethics. Rodopi. 1993. Page 59.

His apparent secretiveness testifies to any number of mysteries surrounding its discovery as well as the tradesmen’s desire to protect his goods. As in Europe and later in England, physicians began taking a supervisory role in the management of data and of hospitals the beginning of the modern scientific/managerial physician began to appear. Although municipal authorities had in many cases assumed directive control over medicine throughout most of Western Europe, with doctors merely contractees, continued control over wider state medicine was to release them from such tradesmen like subservience. In England, physicians did not serve as municipal health commissioners as they did on the continent, further restricting their influence. Margaret Pelling36 demonstrates that only a few doctors played a part in public life, which she suggests affected their masculine authority, but just as likely demonstrated the slow evolution of full professional status in England compared to the continent. Municipal authorities certainly helped increase the number of medical practitioners, as well as deciding who was to be treated and through the issuing of contracts what treatment was to be used. In turn, they pioneered a concept of normality, based upon urban ideals of domestication. Of importance in the growth of medical influence is the definition of the poor as a group, identified also as itinerant and workshy, needing observation and incarceration. They were outside of productive stable urban groups, and often were seen as inhabiting space outside of urban centres. In fact, the poor were usually casualties of war, over-population, and social change. France: Any examination of French medicine must include the greater role played by royal doctors in forming an empirical political science, becoming not only the king’s physicians but his counsellors as well. The body became a motif connected to royalty, with the term ‘body of the king’ taking on state relevance. Royal doctors fashioned a new vision of the monarch as a practicing physician of the state, thereby conflating political and medical responsibilities. Notions of political and social corruption, visualised as corporal in nature, proliferated.37 The state was henceforth seen as healthy or unhealthy, wounded or broken-a term used 36 Ed. Scott Mandelbrote. The Practice of Reform in Health, Medicine, and Science.1500-2000. Essays for Charles Webster. Ashgate, 2005. 37 Jacob Soll Healing the body politic: French royal doctors, history, and the birth of a nation 15601634.Renaissance Quarterly. 55.4 (Winter 2002) p1259.

vicariously by a recent British Prime Minister when reviewing British society in a marvellous display of projected inadequacy and wishful thinking. The Royal doctors claimed that by examining the state a king could evaluate its humours, and so rule better. Soll (2002) demonstrates that the idea of examining institutions forensically was given utterance by Niccolo Machiavelli, postulating a political science, and taken up by successive political groups. In this fashion, politicians and doctors shared, and share, concepts of those they govern or treat that imply more than a common economic and social background. In France at least, state and medicine became both closely allied and aligned. Historians have examined the growth of state involvement in health involving those subject to poor relief with particular reference to France from the 17 th century and the United Kingdom from the 18th and the effects of the Enlightenment. The growth of institutional medicine is nevertheless only one aspect, albeit an important and long-lasting one. McHugh believes that institutionalised medicine in France grew out of Catholic Reform activism that insisted not only that the rich should be devout but also they must provide for the poor. Of course this belief was not new but can be located in the earliest Christian texts and had never died with Christian societies. The Jesuits, founded to check the spread of Protestantism, took up this ancient paradigm and employed it politically. As occurred later in British poor relief and prisons, poverty was blamed on flaws in individualâ&#x20AC;&#x2122;s characters and not seen as a social phenomenon or a chance of birth. The Jesuitâ&#x20AC;&#x2122;s sought to relieve poverty in order to keep or reclaim people for Catholicism. This view of the religious beginnings of institutionalised care is in conflict with the belief that an absolute state initiated such care for its own ends. What occurred in France often seems in conflict with the market-forces development of medicine in the United Kingdom. In France, the crown assumed control of the Hotel Dieu De Paris, and Louis XIVâ&#x20AC;&#x2122;s 1662 Edict that authorised the establishment of hopitaux generaux in every town in the kingdom. This legislation, although the crown was intent on secularising the running of hospitals, was enforced by the Jesuits. By all accounts, this looks truly like the establishment of official uniform forms of medical care. In fact, the crown had taken a leading role in the formation of charitable health care from the 14th century onwards, assuming positions of patronage over a large number of hospitals (McHugh, p41). Treatment nevertheless remained in the hands of the religious. By the 16th century municipal governments had taken over the hospitals and few were run by religious orders.

Control of social perception: The poor need to be identified. Apart from places set apart for lepers, the poor appear to have been largely beggars, often transient, who arrived in some localities from others. Many appear to have been refugees from famines or poor country conditions. The provision of poor hospitals may therefore have gone some way to create transient beggary, a particular group dependent on the state from those engaging in the ordinary processes of migration from one form of society to another. This group effectively changed its character when, in the late 17 th century, with the increasing move towards internment, with in 1699 the crown demanded that all localities should imprison their poor. The â&#x20AC;&#x2DC;poorâ&#x20AC;&#x2122; were it seems a paradigm created by a nobility who then as later had little engagement with other sections of society. Then, as often now, power encouraged many positive characteristics to be applied to the powerful, wisdom and great maturity, while those without power were regarded as children requiring help and control. Many commentators have judged that as hospitals remained in control of the urban they served to exert control over the lower orders who they considered capable of creating instability within the growing state. McHugh (p56) employs the term cohesion of interests to describe elite control outside of the occasional use of force to ensure order. This is done in a number of ways, one of which is the manner in which other groups are perceived in relation to self-serving paradigms of an elite. These are often developed through dichotomies. For example, the above, maturechildish or enlightened-ignorant, hard-soft, normal-abnormal, weak-strong. This work will demonstrate the use made of such dichotomies in modern medicine to ensure the prominence of physicians. Control of perceptions is an ancient tool of rulers from Sumer to the present day. In essence, power alters or reshapes reality in order to fit it in with the strategies of those who wield power, no matter how small, and provide machinations to enforce and sustain the restructured reality to such a point that people in general cease to notice the joins. In this instance, the political construction of sickness has to be itemised. There is a difference, peculiar to the modern world, between self-designated illness and public illness, subject to the decisions of an elite expressed through variable authority roles. These can be intertwined as in the case of epidemics. Public control of sickness and the sick has grown.

The above can be seen as directly linked to urbanisation, but most of Europe remained rural, possessing a variety of environments and therefore of sicknesses and treatments. In England, as in France, a mobile population moved from country to town, and the difference between rich and poor appears to have increased. The Poor Law evolved to meet â&#x20AC;&#x2DC;apparent threats to social and economic stabilityâ&#x20AC;&#x2122;, in England as in France. As on the continent, famine was a reason for vagrancy, largely an urban phenomenon. In Tudor times starvation affected the population in 1557-59 and 1596-98. In Tudor times medicine was known for its eclecticism, based upon different world views. An impetus in medical effectiveness appears to have come from the New World with its plethora of medicinal plants. Much use was also made of local flora to effect cures (Pelling, p35). Protestants: Although the role of Catholicism in poor relief has been noted above, many commentators associate its growth with the rise of Protestantism. Often poor relief in Protestant countries went hand in hand with social control and the idea of poor and deserving poor emerged as a method of limiting relief. In Protestant countries, welfare for the poor seems to have been linked to prevention of begging. Medical treatment of the poor remained, unlike in Europe, laissez faire and uninstitutionalised. Until recently, it was largely in the hands of voluntary agencies and therefore perhaps escaped the extreme authoritarianism of medical care elsewhere. Although it has generally assumed that there were few physicians in the 16th century in England, Pelling (1998) has produced evidence that in the larger towns there were a considerable number. Nevertheless, in England as in France, definitions of service delivery seems to have been entangled with religious and moral paradigms regarding the poor, creating the other so loved by sociologists. As in France, sickness appears connected to rootlessness and to work, that is the lack of, the suitability for, and the obtainment of. Sickness, the poor, moral instability and lack of work were closely connected as they were not with the rich and middle-class. Although the concern with its poorer citizensâ&#x20AC;&#x2122; health was commendable it seems always to be defined through avoidance of poor relief and swift return to work and therefore independence from the municipality. This delivery, by and large, remained ad hoc.

The number of

practitioners to patients in Norwich has been assessed at 1:200, which reflects well with present times except for their different activity: barber-surgeons, surgeons, bonesetters,

apothecaries, physician-surgeons and those of other trades involved in medicine. An eighth of these were at any one time employed by the city. Of these, in contrast to later practice, a third were women. Pelling (p 86) cites a woman surgeon and women managers of poor houses. There is little evidence of religious associations. Bonesetters appear to have received the highest remuneration, perhaps evidence of their relative success. The ad-hoc nature of medicine was possible because knowledge of traditional remedies, particularly in the country, was open to a range of people within the population, and not dependent upon wealth and professional expertise. Healers could be oneâ&#x20AC;&#x2122;s neighbour or aunt. Individuals could assume the authority to cure a number of illnesses, including smallpox to syphilis with local competition between villages and families as to who had the most effective medicine. Women were particularly involved in effecting cures and attending to a number of illnesses. Knowledge of and providing cures seems to have been part of being an efficient wife and mother. There is no reason to believe that these were any less effective than physician surgeons. Shakespeare, amongst other commentators, often associates doctors with money and not necessarily with the efficacy of their treatments.

2: Choice, Change, Conservatism in 17th Century European Medicine

This chapter will consider the development of the medical professions throughout the 17 th century in order to provide understanding of the profession in the present. Then as now, contrary to popular belief, many of the theoretical and therapeutic interests of the profession separated it from the general needs of the populace and in effect its development was principally in the social and political arena. The growing attachment of medical practitioners to municipal authority and continued connection of physicians to courts, alone recommend such an approach. As the French kings played a crucial role in the formation of the different practitioner groups, the development of physician power in France was more clearly structured than during the same period in England and therefore that is why its development is considered here. In France, kings had assumed authority over the medical profession from the 14th century and thereafter royal decisions often determined professional outcomes. As seen above, physicians early identified with the state and other centres of power and influence. This chapter will also look at the emergence of modern science and its effect on medicine during the 17th century, holding that, contrary to belief and expectation, it had little practical effect on medicine. Medical understanding of illness remained based on humours, not on the mechanistic perceptions of Descartes and Newton, and prejudice against empirical approaches continued. I will also introduce into the discussion the idea that medicine is not quite a science, although this matter will later be scrutinised in depth. Medical practitioners acquire much of their expertise from a supposed connection to science. On occasion doctors are referenced as scientists notwithstanding that most medical discoveries have emerged from outside the profession and that as a group physicians are noted for their conservatism. Drugs are perceived of as scientific remedies even though their use and effectiveness may not be clear cut. This alternative viewpoint may seem odd to present day readers brought up on this belief of medicine as all-conquering and beyond criticism, its success irrefutable. I propose that medical practise is both more complex and less successful than its supporters allow. Alfred E. Cohn38 suggests that medicine remains a craft, its practitioners applying outside theoretical knowledge to their subject matter, seen not only in the theories and practices of early modern 38 Medicine and Science. Reprinted from the Journal of Philosophy, Vol.XXV, no. 15, July 19, 1928,403.

physicians but also in present-day psychiatry, combined with practical knowledge from continuous testing and experience. Coln further examines the artisan nature of medical practice. French physicians called their profession a science, although the term then referred to associations with academic learning, and constituted the historical authority of physicians. This connection defined the learned nature of the physician, their classical education based upon Galen, Aristotle and the apparent logic of their observational skills, perceiving patterns in illness that amounted to a clear design. Graduate physicians employed reason, overconfident analysis of cause and effect, to understand the sick individual. At this stage, medicine remains largely a social phenomenon with the therapeutic elements of medicine played out elsewhere. It was part of a discourse on the nature of authority and power, state control and class development. It is mainly referenced in medical histories because physicians had a public presence and were able to record their deliberations. Therefore this section will look at how French physicians protected and extended their power through Royal authority and the courts.

17th Century French Medicine.

Plagues remained prevalent in Europe during the 16 th and 17th centuries. Brockliss and Jones39 suggest that almost as many people died of bubonic plague during this period as during the more infamous Black Death of the 14 th century. These regularly recurring diseases, not all bubonic, reached their highest point between 1628 and 1630. So devastating were these epidemics and pandemics that the state became directly involved in their control. At the same time other new virulent diseases appeared, such as typhus, due to the greater involvement of Europeans with the Near East, the greater occasion of scurvy, and, possibly, whooping cough. Until a period of more exact, state wide recording it remains difficult to know the progeny of diseases but many were the result of urban conditions, little fresh drinking water, and unsanitary disposal of human waste. The odour of dead bodies was prevalent. Close proximity to animals, for example the connection between cowpox and smallpox, encouraged new diseases to emerge. Unlike today, few people died of old age. 39 The Medical World of Early Modern France. Clarendon Press. Oxford. 1997.

Perceptions of illness and disease are subject to change involving social ramifications. In the present world of a dominant NHS disease, illness has become physical or mental features that cause inconvenience. Stoicism is no longer preached as one of the determinants of character. Drugs are prescribed for a variety of real or imagined conditions without any genuine evidence of efficacy. Brockliss and Jones (1997) point out that in 16 th and 17th century France skin infections, diarrhoea and vomiting were universal and probably not viewed as pathological. During this period, people did not see illness through the projections of scientific agencies (physicians, chemical companies), but through humankind’s pride, the incidence of behaviour coupled with divine mood swings-‘The malady is too public to doubt that God is irritated with his people.’40 For most people in the modern world, god has been reduced to the supervisor of the afterlife not the decider of who lives and dies. The French physician’s claim to represent science mainly referenced their adoption of the ancient Greek physician, Galen (see previous chapter), who had married the observational methods of Hippocrates and Aristotle’s natural philosophy, which offered causal explanations of phenomenon. Galen linked disease to the body’s functions producing thereby a logical framework of sorts to justify diagnosis. As this resulted in medical physicians attempts to prove theory rather than adjust theory to the results of experience and experimentation, this clearly cannot be justified as a science in modern terms. Such an approach confirms power, and does not equate to a developing epistemology. In France, medical training was focused on Paris and Montpellier universities, which emerged at approximately the same time. The educative processes of both institutions mirrored that of the law, theology and arts faculties, being taught through lectures followed by oral exams and further examination through observation. The training, as already seen, was rigorous and lengthy. Licensing was performed by bishops and their representatives. By the 15th century Paris had become the more prestigious of the two. During the 13th century colonisation of medicine by university trained practitioners was well underway, justifying their right to exclusive healing through the above scientific training and to the exclusion of full and part time healers who had not undergone university training. This development was given recognition by the church in 1220 and through royal warranty in 1271. Medical practitioners were henceforth distinguished by illegal and legal practice, not by efficacy. The physician’s unwillingness to engage in hands-on practice, as seen above, was part a consequence of their clerical calling, guaranteed the division of responsibilities see 40 Cited in Favre, La Mort, 72.

throughout Europe. While French medicine produced outstanding individuals, as viewed in the context of medical history not treatments, such as Jean Fernal, throughout the 16 th and 17th centuries, when modern day science based upon demonstrable outcomes emerged, Galenic Science became sanctified by tradition and Catholic Church. The medical science of this period was informed, as I will prove that medicine largely is, by theoretical knowledge obtained outside its own practice, not only with regards to its dependence upon Classical ideas. It concentrated on observation of phenomena and from that position sought causes without thereby utilising practical methods to resolve causes or effects. Physicians worked on the Aristotelian principle that bodies were composed of matter and form, the latter seen as a separate immaterial substance drawn out of matter. There was therefore a separation between body and these immaterial aspects of the body that required treatment. These could be regulated by individual behaviour. 41 A physician dealt with balancing humours and not directly with the body, as modern medicine deals with intrusive bodies within the material human body or failures of specific parts of the body. The former is connected to concepts of soul, the other to concepts of species survival indifferent to god or morality. The physicianâ&#x20AC;&#x2122;s reputation depended on correct identification of causes not on also curing them. State recognised medicine was already removed from close consultation and interaction with patients. While the philosophical stance of western medical practitioners will be considered at length, an attempt will also be made to demonstrate that many cures came from elsewhere and only Euro-centricity separates medical developments in the Near East and further afield from that within the Christian states. There were numerous similarities between Ancient Indian and Western medicine going back to Classical Greece. 42 Indian medicine tended to be absorbed by theories of the origin of disease, with an early historical belief in causation as regards individual behaviour, followed, as in Western medicine, by an epistemology concerned with observation and reasoning based on humoral theory. While the Indians called these three elements dosas or defilements they seem connected to Hippocratic and Galenic humours. In this system, disease came from outside and invaded the body or were inherited in some fashion or another. Indian medicine at this stage more closely resembled modern medicine than its Western counterpart, except in its belief in the workings also of divinities. 41 Brockliss, Jones. The Medical World of Early Modern France. Clarendon Press. Oxford 1997. Page 113. 42 S. K. Bagchi. The Interaction and Dissemination of Knowledge. Ed. Juthika Maitra. Medical Science in Ancient India. Centre of Advanced Study in Ancient Indian History and Culture University of Calcutta. 1995.

Indian medicine, by the 11th century CE, had a concept of contagion.

Traditionally Indian

medical practitioners formally emerge in the 6th century BCE, exhibiting a concern with surgery. According to Dr Kutumbiah44there were two systems of teaching, Brahmanical and monastic, although Dr Bhattacharyya (1995) raises doubts that it was quite so clear cut and suggests that the profession was open. As with religious training, a master was chosen as a teacher. As with Western medicine, an apprentice was expected to demonstrate character, including good manners, purity of mind, courage and endurance to pain. A medical student learned both theory (Sastra) and practice (Karma). Although a physician might be adept at practice, without the theory he remained a quack. There were a number of educational institutions where medicine was taught, including monasteries. Although Bramanical texts stigmatise physicians, they appear to have achieved considerable influence as part of state apparatus. In medieval times a number of educational facilities and hospitals were established for the training of physicians.45Indian physicians, once qualified, attained disciples and often engaged nurses, establishing thereby surgeries. The economic basis of their profession is indicated by their wealth. As with Western medicine, practitioners emerged out of serious thought and hard study, but their understanding of disease and health does not seem to have permeated down into the masses who still believed in Karma and devils. Notwithstanding different societies and religious perceptions, Indian medicine seems to have been on a par with Western Medicine. Islamic medicine during the same time-period espoused many of the same concerns with science and the nature of diagnosis, but appears to have been more concerned with relationships with patients and their dependents.

Western medical

practitioners, as a corporate group, searched for exclusivity, to remove themselves from everyday considerations. This provided Western physicians with perhaps greater political energy, without competing with or being subservient to priests or other groups concerned with healing. Medical development in the West has often consisted of propaganda rather than cohesive investigation of performance and the recent triumph of western medicine has hidden potential and real disasters. The idea that equilibrium equals health, and of course dis-equilibrium illness, would appear to have its roots in ancient Greek thinking, although in fact it has its roots in Near 43 Kenneth G. Zysk. Does Ancient Indian Medicine Have a Concept of Contagion? Ed. Conrad/WujastykContagion: Perpectives From Pre-Modern Societies. Ashgate 1988. 44 Ancient Indian Medicine. Orient Longmans. Revised 1969. 45 Dr Amitabha Bhattacharyya. Early Indian Society: Medical Education and Medical Profession. Ed. Maitra. Medical Science in Ancient India. 1995.

Eastern culture, where balance was seen as fundamental to the good life and is still evident in sayings such as ‘don’t drink to excess’ and in preventative medicine. Human behaviour was separated into naturals and non-naturals (human activity), with contranaturals, that is diseases. The four ancient elements of air, fire, water and air comprised the humours, which themselves possessed qualities: phlegm, cold and wet; black bile, cold and dry; blood, hot and wet; yellow bile, hot and dry. These allowed for the nature of responses to contranaturals combined with complexion and temperament, which reflected such things as age and sex. The body was seen as a ‘seething mass of fluids.’ (Lindemann, 2010, page 18). Alongside these ideas on the humours and balance were religious concepts on illness and moral corruption, although these were not consistently or necessarily generally held. 46 As in the previous centuries, few patients relied exclusively on religious or secular healing but tried all that were available or, just as likely, together. Medical treatment was usually combined with expiation of sins and penance.

Universities: By the turn of the 17th century there were a number of universities throughout France teaching medicine, often differentiated by religion. Toulouse faculty was Catholic, Caen Protestant. In the early part of the 17 th century the foreign tour was an essential part of higher education. Milton for example travelled into Italy, an essential destination, and met the old Galileo while he was incarcerated at home by the Pope. For medical students the foreign tour, or peregrination medica, visiting centres of excellence was essential to the creation of prosperous careers. From c1500 to 1789 a succession of universities became the medical schools of choice. These included Padua in the 15 th and 16th century, Paris in the 16th and Leiden and Edinburg in the 17th. The foreign tour neatly fits in with the importance of journeying to gain knowledge, returning to the original homeland to acquire greater status. Recently, student migration from Asia into Europe has met the same ends. William Harvey came back from Padua in 1602, equipped with anatomical skills. Foreign colleges operated as a finishing school for the sons of the growing middle-class, who had often obtained their riches in trade, establishing status and credentials.

46 Mary Lindemann. Medicine and Society In Early Modern Europe. Cambrisge University Press, 2010. Page 15.

Throughout the 16th and 17th centuries Galenic texts were referred to but not it seems fanatically. Paris lecturers began to reject Galen and focused instead on Hippocratic text, although very few of these are likely to have been written by Hippocrates, if, indeed, he ever existed. Notwithstanding, lectures in surgery and pharmacy were given throughout this period although pharmacy, anatomy and botany were not made compulsory until the time of Louis X1V. Throughout this time, a more dynamic approach to teaching emerged based on the development of textbooks written in the vernacular. Change was therefore evident, but outside of the normal educative processes of the main universities, amongst surgeons and through scientific investigation. Although by the early part of the 17 th century Harvey had demonstrated the bloodâ&#x20AC;&#x2122;s circulation, and Descartes had separated subject and object, medicine still largely kept to traditional ideas. Galen ceased to have untrammelled influence and there was an increased number of adherents of the Swiss physician Philippus Aurelolus Theophrastus Bombastus von Hohenheim, or Paracelsus, who died in 1541. A Protestant, probably inspired by Lutherâ&#x20AC;&#x2122;s desire to reshape Christianity, Paracelsus wanted to reject Galenism and construct a medical science based upon nature. Although this seems eminently satisfying in so far as he gave credence to folk remedies, and sanctioned the belief that all creation was interrelated, a boon for later scientists, he advocated astrology and alchemy. Paracelsus held that diseases were the result of poisons invading the body, placing him closer, by ignoring individual behaviour, to modern concepts. His importance lies in his belief that the works of the ancients could be dispensed with and with his advocacy of minerals as part of a cure. In fact his focus on cures rather than diagnosis set him apart and lead to accusations of empiricism. Although few Paracelsians became medical graduates he appears to have influenced medical thinking, and during the 16th century Paracelsian remedies were being promoted by Montpellier. Again, by concentrating on physicians it would be assumed that these represented a defined method of treatment and cure rather than representing social aspiration and change. If compared to folk or community methods physicians were still as likely to kill as cure, driven by theories that gave credibility to their authority but not their art or craft. Community methods relied upon natural and household substances that produced innumerable benefits, except of course in cases of wounding and wherever surgery was necessary.

Doctors at War:

The conflict over supremacy amongst medical professionals in France was overt and volatile, leading occasionally to legal action, and, was often played out before the king. The growth of physician’s power thereby took a slightly different route in France, but nevertheless reached the same end. In France the physician’s lofty position was further enhanced by an expressed association with science, not just academia, and through an entrenched position within the universities. While in England physicians’ power was contingent on the views of the prevailing monarch, not all of whom were convinced by their arguments, and therefore conflict over status and power between physicians and surgeons was less intense, in France according to James William Barlow47competition amounted to war. In France the differences between physicians and surgeons appears to have resembled overt conflict fought out in the public domain within sight of Royal authority. The battlelines were drawn between physicians, surgeons and barbers. As in England, physicians had emerged from the clergy, and surgery from the inability of the clergy to engage in the shedding of blood. Surgeons were by nature an inferior class of men. An equally strong reason for physician’s rejection of manual activities was the connection between such activity and the lower classes. Physicians needed to be socially closer to the aristocracy. Considered mere mechanics, surgeons were excluded from the Faculty of Medicine. In France, surgeons had long engaged barbers to aid them in their work. Over time they assumed more of the surgeon’s tasks until an edict of Charles V confirmed their right to apply plasters, ointments and to treat open sores. Thereby, during the latter part of the 15 th century three powerful medical corporations existed in France; surgeons, physicians and barbers. The competition for clients was, according to Barlow (1914) fierce and made worse by the Faculty of Medicine that allowed barbers entry to their ranks, perhaps in order to undermine surgeons. The surgeons promptly took the Faculty of Medicine to court, which consequently legalised the standing of all three groups: a doctor could lecture on anatomy, but could not touch the body; a surgeon could perform dissection, with barbers present. The status quo was confirmed. In 1505 barbers were nevertheless admitted into the Faculty after passing an examination and agreeing not to practise surgical arts. Although the surgeons continuously applied to the French kings for the right to be part of the university the Faculty each time barred their admittance by appealing to the authority of the Pope. In 1576 the surgeons attempted to gain admittance by force only for, after an 47 Doctors At War, Studies of the French Medical Preofession circa the 17 th Century. London David Nutt. 1914.

unceremonious fist fight, the doctors to emerge again triumphant. Eventually, doctors and barbers quarrelled, as the latter attempted to increase their status, until, the matter was brought before Parliament, and the Court reduced them to their original status. The physician’s fight for their privileges and status terminated in 1660 when the law courts decided against the surgeons, and the profession was effectively banned from involvement in university processes and formally amalgamated with barbers. Effectively, surgeons became ‘the humble servants of the doctors’48, not their equals as earlier in the century they had hoped. Combined with protecting their status and professional power, French physicians, especially those who had graduated from the University at Paris exhibited disdain for recent medical and scientific discoveries, and even towards the end of the century could express belief in the infallibility of Aristotle. William Harvey published his book on the circulation of the blood in 1628, but even by 1672 it was argued against in the Faculty: “Circular motion, being perfect, belongs not to any but simple bodies, such as the stars; but the blood, being composed of four elements, is not a simple body. Ergo, circular motion is unsuitable for the blood. Moreover, if the blood circulates, bleeding would be useless, because the loss undergone by any organ would be instantly repaired. But it is impossible that bleeding can be useless. Ergo, the blood does not circulate.” (Barlow, 1914, page 104). Establishing again the superiority of theory over practice. If Harvey’s proposition was true, this made nonsense of the Galenic belief in the separate functions of the venal and arterial system. New blood was not continually made in the liver, but venal blood flowed back to the heart and not to the extremities. Attacks on Galenic belief systems came also from the proposal of the Leuven physician Val Helmont that physiological and pathological changes were the result of chemical reactions, and the second, mainly by way of Descartes, that the body is a machine. But contrary to popular belief, Galenism survived and reason and evidence did not make inroads into medical thought as neither played much part in medicine of the day, rooted as it remained in social influence and power. Until the 19th century bloodletting remained part of a physician’s techniques, based though it was on an already outdated understanding of the human body. 48 Barlow, Doctors At War, Studies of the French Medical Preofession circa the 17 th Century. London David Nutt. 1914. Page 62.

The physician’s role remained to determine whether an illness was likely to be fatal or not and report the matter to someone in authority. As can be seen in the case of Erasmus, nonintervention was considered the correct approach, certainly given the confused outcome of medical procedures. Physicians observed rather than actively engaged in cures. 49As already noted, this was considered part of their superior status. Although in Britain conflict between physicians, apothecaries and surgeons also continued it was of a nit-picking variety. Interfering or engaging in other’s expertise caused immense offence.50Nevertheless, the period now under review constituted the medicalization of society, in which resorts to the medical profession became preferred to that of neighbours, family, magicians and religious personages. Moss and Peterson, (Ed) 51have reviewed changes in the approach to diseases through approaches to medicine in Shakespeare’s plays. Physicians offer advice, but it is usually sound.

The growth of public medicine

In France, by the 16th and early part of the 17th century, legitimised medical practitioners emerged as a powerful, legally recognised, corporative medical community52headed by graduate physicians. This position did not reach deep into the societies of the time, it was after all a European phenomenon, but remained fixed to the elite. Nevertheless, medical power and influence, then and in the present, was a top down affair that only recently, driven by state medicine, has arrived to benefit at all the general population. The power obtained by the graduate physicians centuries ago, a mirror of aristocratic power and behaviour, has continued into the present in the guise of lordly consultants. And yet medical developments had, as would often prove the case, little to do with medical practitioners but were in the growth of public health. The above acquired a more practical expression during the 17th century involving greater state involvement as the 49 Traister, Barbara Howard. “Note Her A Little Further”: Doctors and Healers in the Drama of Shakespeare. Diseases, Diagnosis and Cure on the Early Modern Stage. Ed. Moss and Peterson. Ashgate. 2004. 50 Furdell, Elizabeth Lane. The Royal Doctors 1485-1714. Medical Personnel at the Tudor and Stuart Courts. 2001. 51 Disease, Diagnosis, and Cure on the Early Modern Stage. Ashgate, 2004. 52 Brockliss, Jones. The Medical World of Early Modern France. Clarendon Press. Oxford. 1997.

consequence of recurring plagues. In 1631 the Parlement of Paris established a health council. By 1660 royal administrators, intendants, had taken over the role of councils who later in the decade, with France again assailed by plague, established a cordon sanitaire around affected areas, localising the plague. Although public health began in Italy (Lindemann, 2010, page 199), French cities quickly followed. Surely the above author is right to note that administrative capabilities of states shaped communal health as much or more so than theories of medicine that invariably were wrong. In fact, whenever the state drove treatment and care, advances were often made. Although by the beginning of the 18th century plagues petered out, the use of quarantine may not after all have been the reason for its apparent containment. Also, there was a culture of flight before plagues, in that once it had appeared the rich would quickly leave a city or town. As Mary Lindemann 53points out, it would have been very difficult to stop everyone leaving if they wished to, many of the state apparatus developed much later, and therefore could not have affected matters, and that by the 17th century plagues did not arrive from outside Europe but were dormant in rats within Europe. She further suggests that the actual reason might have been alterations in trade routes and climate change. As in England, the authorities had realised the economic consequences of disease and the effect on manpower and overseas trade but unlike in England, which still engaged in an ad hoc fashion, public health became centralised under the king and his court. Physicians were employed only to manage central government policy. Concerns with military dominance under Louis X1V probably also encouraged central government involvement. Armies grew enormous during the 17th century culminating in the forces used by both the French, Germans and British in the early part of the 18 th century. To sustain such armies, a healthy population was required. Gathering statistics, a prolific and longstanding arm of epidemiology first noted in Italy and essential to present-day understanding of sickness, was exampled also by the London Bills of Mortality devised by John Gruant, a haberdasher and member of the Royal Society. The London Bills were a Table of Casualties for the period 1629-60, containing several nonspecific terms. Certainly, this provided an initial step towards what is now seen as a truly scientific approach. The Bills of Mortality were formed from searchers, those detailed to discover the causes of a death. Usually such individuals had little formal medical knowledge, indicating that as yet the distinction between everyday medical knowledge and elite

53 Medicine and Society in Early Modern Europe. 2010. Cambridge University Press. 2010.

knowledge had yet to develop.54Later, applying systematic methods, Percival Pott attributed scrotal cancer in chimney sweeps to their occupational exposure to soot and lack of hygiene. 55

The gathering of data on deaths warned of plague. In the 17 th century it was understood that the poor were the most vulnerable, and many commentators asserted that this stemmed from moral and lifestyle choices. It was recognised that plagues moved from the poor communities in the richer communities. While the middle-class and aristocracy were seen as less contagious, and, of course, fundamentally more virtuous, the poor were seen on the one hand as requiring help and charity and on the other as dangerous. They were â&#x20AC;&#x2DC;sluttishe, beastly people, that keepe their houses and lodynges uncleane, their meate, drinke, clothing most noisome, their laboure and travaile immoderateâ&#x20AC;&#x2122; (Wear 2000, page 283). The poor were linked to putrefaction, as was the plague. Constructs of the poor emerged from medicine as well as from concepts of societal structure based on work and residency. The data collected warned the rich of impending illness, allowing the aristocracy to flee, encouraged social control and discouraged the plague from being viewed as a shared experience. In this fashion, medical practitioners became arms of the state, reflecting the economic and political aims of the French king where national interests were concerned. Control of plagues through containment became successful until the incidences of epidemics and pandemics considerably lessened.

How people were treated:

Catharine Knight provides in How Shakespeare Cleaned His Teeth and Cromwell Treated His Warts. Secrets of the 17th Century Medicine Cabinet (2006, Tempus Publishing Ltd) an overview of treatments, both of the household recipes but also, in comparison, that of physicians. Her receipts are from original sources, often household books written down by wives or family members for the family group. These household books possessed a number of receipts for healing a variety of illness or simply providing advice. Coughs and colds, or 54 Andrew Wear. Knowledge and Practice in English Medicine, 1550-1680. Cambridge University Press. 2000 55 John D Potter. Epidemiology informing clinical practice from bills of mortality to population laboratories. www.nature.com/clinical practice/onc. 2005 Vol2 No12

cold Rhumes and Flegms, resulted in the provision of a variety of roots, herbs, alcohol and sweets serving as an expectorant with a high chance of success while for consumption a patient might be offered cooking ingredients. In Rude physic for common soldiers (Eric Sidebottom, 1977) it can be seen that many elements of 17th century society engaged in advising on or performing treatments. These community compounds fared well when compared with a judicious supply of well-washed snails, recommended by a Dr Gideon Harvey in a perhaps liberal interpretation of Galenic principles. Contrary to professional protestations, the physician’s receipts, composed of their remedies, may have been no different to household recipes. In early modern Europe, people did not go to the physician for a cure, but only the slim possibility of one, while also trying other remedies by other kinds of practitioners. The community employment of herbs continued into the near-past and I remember them being advised by neighbours before the juggernaut of medical drugs swamped all other recipes and viewpoints. It is likely that their use is as responsible for aspects of modern medicine as the theories of the graduate physicians. Plants are useful in medicine because they contain alkaloids, which affect the nervous system. They can be carminative, good for digestion, expectorant, encourage coughing, stimulant, acting as tonic or aiding concentration, diuretic, stimulating production of urine, antiseptic, preventing infection. In fact most people today exist and subsist on one plant or another to accomplish daily activities and provide requisite moods. Medical drugs often provide a more dramatic form of these, if more dangerous and uncertain in their long term effects. Apart from this, many modern drugs are based on plants from the Americas and Asia, often synthetically reproduced. Simples were plants used alone, both in household and community medicine but also in that of physicians and apothecaries. Paracelsus advised on their use and modern chemistry has confirmed their efficacy. Madness was dealt with through the use of purgatives. I will later consider how on occasion modern treatments have the same roots as their ancient counterparts. Most treatments were benevolent in their effects even if they rarely cured, and there seems little distinction between physician’s advice throughout the 17 th century and household receipts. Still, especially in England, physicians represented just one of several medical practitioners, and had not yet assumed exclusive rights to healing. Galenic and Paracelsian practitioners agreed in their attacks on ‘herb women’ and other community healers and methods of healing, based it seems on their lack of knowledge of

humours. What did they know when they applied them wrong? And yet, at the time, so widespread was community healing that many people would have agreed instead with Robert Burton: ‘Many an old wife or country woman doth often more good with a few known and common garden herbs than our bombast Physicians with all their prodigious, sumptuous, farfetched, rare, conjectural medicines.’56Where community medicine was acknowledged it was as the lowest point of a hierarchical tree, of which physicians inhabited the very top (Wear, 200).The difference between the two groups, notwithstanding the innovations made by physicians as evidenced by early forms of rhinoplasty (Lindemann, 2010, page 133), was organisation, authority, power and the tendency to propagate their shared views through writing. The literate tradition of the physicians continually asserted its superiority through aspects of communication, i.e. classical references that belonged outside of medicine. Disdaining the qualities and characteristics of others is a condition of colonisation. At the same time that physicians were lambasting community healers, while appropriating their methods, they wrote equally disparagingly about the medical practitioners of distant, foreign lands while praising the medicinal qualities of their plants. Far Eastern medical practitioners were merely barbarians who should be relieved of their cures and given to Western Europeans who were best able to employ them. In fact, not only is this the viewpoint of the coloniser but also of the merchant who thinks of medicine in terms of profit. Medicines from the Americas, such as guaiac used for the pox, brought a fortune to the Spanish government. The entrepreneurial pursuit of medicines can be linked to the colonising tendencies of European states in the pursuit of spices from the 15th century onwards,57during which Europe’s wealth increased dramatically. Conspicuously, as I will later consider, demotion of community medicine occurred simultaneously with the exclusion of women, who played a central role in employing and propagating the treatments, from medicine.

3. Scientific Revolution

“We have been misled by the subtle philosophical reasoning of Hobbes, the rigorous experimentalism of Harvey or Boyle, and the abstract mathematical analysis of Newton, into 56 The Anatomy of Melancholy. 1621. 57 Andrew Wear. Knowledge and Practice in English Medicine, 1550-1680. 2000. Cambridge University Press.

believing that the natural philosophers before 1700 thought in essentially modern terms, differing merely in lacking our considerable resources of experience and information.” Charles Webster. The Great Instauration. Science, Medicine and Reform. 1626-1660.

According to most histories of the 17th century from a European perspective, and the list is endless, a Scientific Revolution occurred that determined the nature of modern medicine. Hot on the heels of this cognitive and perceptual change came the Enlightenment, an intellectual ferment that altered Europe from an historical also-ran to the driver of human civilisation. This section will re-consider both these episodes in the light of medical developments, positing the view that neither constituted radical change and also that neither most certainly provides evidence of special European genius. In histories on medicine/medical profession Paracelsus and van Helmont loom large, each as opponents of scholastic or academic medicine and pioneers of modern European science. In such histories science is claimed for Europe, a European invention with an exclusive European heritage. Notwithstanding the example of ancient Greek thinkers, science, in the sense of studying nature directly without the clouding processes of the senses, culture and religion, combined with technical innovation and scientific discovery, has emerged in different parts of the world. Pushing the boundaries of knowledge and taking on the dusty harbingers of conservatism, many ‘innovators’, according to European thinking with its emphasis on change and originality, have achieved sainthood. This view that progress, for such is what these histories are reminding us of, can be identified and understood through famous men and single events is one of the notions that form the foundation of modern medicine’s influence and connect it to the secular force of science. Modern physicians, certainly grand consultants peering down from Olympian heights, gain energy, position and motivation from figures like these. Yet, the discoveries of the European Scientific Revolution can be seen in other countries, although European thinkers had the advantage of new technology, such as the microscope that, although invented earlier, did not impact on perceptions until the latter part of the 17th century. The Islamic thinker Abu Raihan al-Biruni, born in Uzbeskistan in the 10th century, mastered mathematics, astonomy, mineralogy, geography, cartography, geometry and trigonometry. He followed in the footsteps of other Islamic thinkers, such as Ahmad al-Farghani who wrote A Compendium of the Science of the Stars, which Columbus came across. Both these thinkers accurately calculated the earth’s

proportions. Biruni, through his research in mineralogy, discovered specific gravity and later established that the sun was stationary. Based upon his calculations on the actual size of the globe, he proposed that there was a large land mass yet to be discovered, that is, as it turned out, the Americas. In the present accepted manner, he presented his findings as hypothesis, subject to further testing. In all, he employed systematic and rigorous application of reason and logic, unconstrained by bigotry and cultural dogma. He expressed the nature of science c1000 AD in a way modern scientists can acknowledge and agree with, underlining its necessity58. This section will show that the scientific revolution (early 17 th century) and the Enlightenment (c1650-19th century) were based upon a change in the nature of knowledge, rooted in its emergence as an object of exchange outside of its association with status, of economic expansion and social alteration due to the processes of exchange, and, its ultimate use as a method of social enhancement. Francis Bacon’s dictum that ‘ the circumnavigation of the world and the increase of the sciences should happen in the same age.’ The exchange concerned, see above: personal status: involvement in new, developing networks such as travellers, sea-going merchants, colonisers, freebooters, and external networks usually involving trade liaison: organising frequent long distance travel and the opening up of new ports and markets, such as Antwerp, created new problems that required resolution, leading on to the creation of new institutions, such as exchange organisations: individual self-esteem caused by the dilution of ancient hierarchies and the growth of local self-sufficiency: and fresh and existing markets. This represented a new kind of knowledge very different from that of the guilds, based upon values placed into objects as transmitters of information, social and economic values as against the containment of knowledge as a means of retaining power and social status, consequent to Dutch trade in Asia, the impact of American cultures, the greater acquaintance with African societies, and the early days of European involvement in India. In this section, the Enlightenment will be viewed as a consequence of expanding trade, the discovery and conquest of the Americas, and of exchange with Asia. The growth of science, seen here only as gathering information about specific objects, was early expressed in Sir Francis Bacon’s philosophical work, contained within a collusion between experimental and rational methods of defining information. Science was therefore active, of the senses, not of the study and of theories obtained from ancient sources. Cook (2007) associates these factors with knowledge of natural objects required for expanding 58 S. Frederick Starr. So, Who Did Discover America? History Today. December 2013. Vol.63. Issue 12.

world trade. Bacon insisted that physicians should concentrate on collecting data. Van Helmont took a similar empiric stance. The Scientific Revolution that began early in the 17 th century was, according to Harold J. Cook59, rooted in a mathematical and mechanical world view. By that he itemises the use of mathematics to explain phenomena, evidenced in Newton, and Descartes mechanistic understanding of the world and our relationship to it. He goes on rightly to point out the importance of medical enquiry and natural history in developing the above views. The inclusion of chemistry through the influences of Paracelsus and van Helmont and allpervading alchemy, a combination that Cook suggests equals Robert Boyleâ&#x20AC;&#x2122;s â&#x20AC;&#x2DC;physiologyâ&#x20AC;&#x2122;, understanding the physical as a series of actions and reactions, the medical dictum of close observation, also drove this so-called revolution in perception. Sloan60proposes that natural history had description at its end, and natural philosophy analysis. There is a preponderance of plant description throughout the early 17th century, particularly in Holland, and books on human anatomy. While medicine, based as it was on observation rather than cure, which is a modern concept, impacted on both science and politics this was normally through the efforts of those outside of the healing professions, such as Machiavelli, Bacon and Descartes. Medicine remained tradition bound and conservative, with change from the fixed theoretic approach of the Renaissance achieved through greater use of dissection and thereby more knowledge of anatomy. Those who challenged and consequently helped evolve scholastic medicine usually came from outside the universities. Although today we tend to view such tilters at perceived wisdom as pioneers, their ideas were constructed within the market forces that affected all physicians. Being novel and opposed to other clinicians created a separate medical market with specific advertisable skills. Paracelsus employed mercury, thereby creating a new medical market. Van Helmont advocated and popularised chemical treatment, thereby creating another. These processes, theoretical, artisan, market forces remain with us in delivery of treatments. Although medicine played a part in the development of science, it was usually as a foot-maiden, not a central dynamic as medical historians such as Cook would have his readers believe. It was simply that humans remained an accessible commodity to be practised upon. Humanistic ideas were negotiated over human well-being.

59 Medicine and Natural History. Ed. Field/James. Renaissance and Revolution. Cambridge University Press. 1993. 60 As referenced,page 48, Medicine and Natural History. Ed. Field/James. Renaissance and Revolution. Cambridge University Press. 1993.

Health became an issue separate from the treatment of plague and illness, a generic constituent of humans distinguished from ill health that required constant attention in order to be sustained. Health as an important constituent of an entire population may have evolved through the use of medical ideas as metaphors to describe large human manifestations, such as organisations, with the clear association with body parts. Further examples are ‘chief organ’ of the state, implying a king or parliament, and that to be effective all organs must remain healthy, and ‘body of the state’, carrying with it the same fear of possible corruption. Paracelsian and Helmontian medicine, both based on chemical principles (salt, sulphur, mercury and water) saw chemical processes as providing vitality, reinvigorating the ill and failing body. Paracelsus continued to employ astrology. During the Civil War Paracelsian medicine became particularly popular. Paracelsians believed that physicians had become ‘quill-doctors’ who wrote prescriptions without any knowledge of the dispensed materials. Perhaps similar to the modern GP who writes endless prescriptions for drugs he or she has only the most tentative knowledge of, unmindful of consequences. They believed that empirics and old women had more genuine medical knowledge. They asserted, with foundation, that Galen had relied on the practical assistance of empirics, while producing theoretical works divorced from reality. Present physicians’ approaches will be later examined from the similar position, including how modern medicine has managed to conquer minds. Although van Helmont studied medicine in the 16 th century, dying in 1644, his views became especially influential in the 17th. His ideas are considered modern in structure, concerned with empirical reasoning and testing, and therefore he has a place in the pantheon of good or respected thinkers. Van Helmont rejected scholastic teaching, remembering, in his introductory treatises to his ‘Rise of Medicine’, his own medical tuition in logic, algebra and astronomy and his fierce annoyance at being taught worthless matters, such as magic, by university professors. His eyes were opened through a study of Greek philosophy, until he experienced a spiritual awakening, absorbed Jesus and Christian teaching. It was then he realised that there had been no advances in botany since Dioscorides and resolved to study natural science. In this manner he rejected Aristotle believing that Aristotle did not concentrate on the actuality of objects but put abstractions between the observer and objects of observation. The properties of the object were thereby lost. 61 In other words, naming and cataloguing were important functions for an understanding of recipes, how they worked and 61 Walter Pagal. From Paracelsus to Van Helmont. Ed. Marianne Winder. Valiorum Reprints. 1986.

how best plants could function as treatment. Sceptical now of Aristotle, van Helmont turned to the study of nature and by doing so he discovered gases and how acid aided digestion. As a consequence of the above two physicians, diseases are now classified according to the locus affected and the external cause responsible, that is a process of external interactions with the body at specific points. The process is objective, mechanistic, materialistic and based upon identification and naming. The individual plays little, or limited, part in acquiring illness as in this view the body is separate from the mind that inhabits it. Of course, neither Paracelsus nor van Helmont probably considered it quite like this as in each case they were reacting to methods of training, mind sets and philosophies. For van Helmont certainly, god played a crucial part in his alternative viewpoint. God was the motivator, van Helmont the tool. Van Helmont termed disease seminal, a real being with purpose. Unlike the usual medicine of the day, bloodletting, which involved the removal of bodily properties in order to deal with the body’s misfunctioning, van Helmont believed in removing the external cause of the disease. In the case therefore of the virus, the virus is treated through attempts to eliminate or minimise it and the body is then repaired. In modern medicine such processes may occur simultaneously. This transfer of subjective to objective, whereby both diseased person’s body and disease are considered separate objects, is safely considered modern. To fully acquire this point, Galen and Aristotle had to be ejected from both training and thinking and in its place the materialistic nature of things. One of the many things this section will consider is whether the position of both the above was due to economic and political change or of the inventiveness of outstanding individuals. For example, did van Helmont’s concern with botany arise as a consequence of the sudden arrival in Europe of hither to unknown plants used for medicinal, dietary purposes and relaxation; such as potatoes, tobacco and opium?62 It is usual amongst commentators (Lindemann, 2010) to ascribe the expanding popularity of Paracelsus and van Helmont to the expansion of Protestantism during the late 16 th century and into the 17th. Both, to differing degrees, claimed to be a Christian medical science as opposed to the pagan medicine of academic physicians. In this means their views acquired authenticity. Although many Catholics ascribed to Paracelsus’s views, the healer was excoriated by Catholic universities as well as dismissed by most physicians. Many Catholic 62 Kate Kelly. History of Medicine. The Scientific Revolution and Medicine. 1450-1700. Facts on File. 2010.

rulers in Germany took up Paracelsus. Henri 1V of France preferred Paracelsian physicians. Unfortunately, one reason for this preference amongst a host of rulers was its cosmological content. Paracelsus drove a growing interest in chemicals, or iatrochemistry, medical chemistry or explanations and the treatment of diseases in terms of chemistry, which brings us to van Helmont. He suggested that digestion and respiration were chemical in nature and that a special ferment or gas produced both. Iatrochemistry emphasised the chemical reactions of effervescence, fermentation, and putrefaction as the basis of all physiology. Certainly van Helmont believed that by understanding these processes it was possible to gain a greater understanding of god. The view that by studying the natural world, a scholar came closer to god was commonplace. While Paracelsus accepted the views of the ancient philosophers van Helmont rejected Aristotle and Galen as non-Christian (Lindemann, 2010). Scientific Revolution and Enlightenment: Although it is considered appropriate to assume that great thinkers initiate ontological change this work, as already stated, will not assume that position, basing change instead upon societal, economic and political change, the result of discovery and conquest of the New World, comparison and conflict with Islamic states, and the internal movement of peoples. This is often expressed within a literate methodology, and which historically appears to justify historical events. Descartes and Hobbes are thereby simply the expressed and expressive points of wider issues. This work considers the Enlightenment to be a global phenomenon, the result of greater trade and exchange of goods and values. The Scientific Revolution of the early 17th century involved a shift from Aristotelian ideas of a world made up of four causes, four qualities and four elements, to one in which the world was made up of particles of matter made up of different sizes, shapes and motions (Wear, 1992).63 On the surface this would appear to reflect changes within British society, moving towards power invested in larger numbers and the development of democracy. Medieval knowledge, based upon a hierarchical construct consisting of god, pope and kings, entrenched in the past and structures of power in the present, was giving way to one based upon class development and individual ideas/opinions. Although Webster shows in The Great Instauration (1975) that Puritan millennium convictions drove the desire for new and greater knowledge, this became increasingly secularised, separated from religion and supernatural force. Driven by the belief 63 Health and the environment in early modern England. Andrew Wear editor. Medicine in Society. Cambridge University Press.

in a new world, no doubt reflecting the discovery of the Americas, intellectual activity in England occurred outside of institutions, resulting in the establishment of the Royal Society. This process occurred over centuries and was not located principally in the 17 th and 18th centuries. Historians often paint an absorbing picture of physicians as part of the scientific revolution, but evidence presented here indicates a highly conservative group, with one or two exceptions. While discoveries were made, physicians remained in what would now be seen as an intellectual time warp. Harvey held to Aristotelian views on nature, Tulp remained a propagator of Galen, and many were deeply consumed by superstition. In the late 1700s universities were still principally concerned with teaching Galenic medicine, although this had been somewhat altered by iatromedicine and greater knowledge of anatomy. Many outlooks combined within single intellects, as evidenced by Newton and Harvey.

Nevertheless, in universities until 1640 there seems to have been little evidence of new ideas, with teaching reliant on Euclid, Galen, Ptolemy and Aristotle (Webster, 1975). Many intelligent people looked for stimulation outside of universities. Webster provides as one example amongst many of Seth Ward studying at Sidney Sussex College who finding no lecturer competent enough to teach from the mathematical books in the college library, eventually found help with mathematicians in London. Medical students, including Gilbert and Harvey, obtained their education abroad with those few medical faculties in England providing a traditional approach to medical education (Webster, 1975, page 120). Webster notes that impetus was acquired through the inauguration of Savilian chairs of astronomy and geometry in 1619, but that modern ideas were most visible during the interregnum. So far in this survey of medical practitioners two points have been successfully reached. Physicians, it has been noted, were engaged in defining status in society as distinct from other healing practitioners: surgeon-barbers, apothecaries, community healers, including quacks. This was part of the process of legitimising their activities. An additional part of that process was making illegal through the use of royal patronage and the law courts the pretentions and behaviour of other healing practitioners. These social and caste definitions were based on the authority of physicians, not legitimised by evidence of efficacy. This construction of a separate corporate identity, while rooted in acquisition at universities of classical learning, involved assumptions of class and intellectual superiority. In Hungary during this period, so important did physicians consider themselves that they left cities throughout a pestilence 64 Andrew Wear. Knowledge and Practice in English Medicine, 1550-1680.

leaving matters in the hands of surgeons, who often died. 65The expansion of the profession occurred through the overcoming of threats, consolidation, and the overcoming of additional threats thereby constantly enlarging its fields of expertise, status and influence.

Threats overcome New Threats revealed

Threats to status

Threats to ideas

Physicians

Threats to remuneration

Threats to power

Position consolidated, new threats to be overcome.

65 Norbert Duka Zolyomi, The Development of the District Medical Officer in Hungary from the Middle Ages to the Eighteenth Century. The Society for the Social history of Medicine. Dec. 1079.

Threats overcome. New ideas/positioning emerge.

Core ideas. GalenAristotle.

Threats overcome. New ideas/positioning emerge.

New ideas/positioning emerge in order to increase or consolidate power. Each new idea is only slightly different from the previous one and is accompanied by improved status and change in market position.

From the 16th century the rhetoric of medicine, as distinguished from its practice, was used to symbolise ideas on politics and the state, particularly in Europe. The idea of the observing, rational, and analytical physician, more fantasy than reality, served as a model for politicians and for scientific enquiry. In practice, physicians clung to traditional views of body and mind, putting more energy in propagating, like Galen, their superiority than displaying it. The gap between intentions and practice was enormous. Although generally it is assumed that â&#x20AC;&#x2DC;doctors, anatomists and physiologists (were) on the side of reason against superstition, of sense against nonsence, of experiment against authority, andâ&#x20AC;Ś..of scientific medicine against folk-cures and quacksâ&#x20AC;&#x2122; 66 , certainly at the beginning of the Enlightenment (c1650) the evidence does not concur with this estimate. As I 66 Andrew Cunningham. Where there are three physicians there are two atheists. Medicine and Religion in Enlightenment Europe. Ed. Grell/Cunningham. Ashgate 2007.

have previously indicated, this medical myth-making appears to be part of the professionâ&#x20AC;&#x2122;s growth and its colonisation processes. It was feared that physicians (Sir Thomas Browne, Religio Medico, 1637) were inclined to atheism. It was believed until Newton that scientists normally were in that camp. This may again amount to historians writing of the past in terms of the appearance of modern ideas and overestimating their effects on society in general. Early Modern and Enlightenment physicians were not their modern counterparts, schooled in some fashion or another in modern secular ideas, modern equipment and solutions, but individuals who believed still in untested ideas on treatment combined with a sense of their superiority or distance from others. Nevertheless, there were physicians in Europe who were eager to challenge religious views of the period, as previously noted, promoting a mechanistic view of body and mind (Cunningham, 2007). There appears to have been radical physicians in Holland propagating materialistic perceptions of the world opposed to Roman Catholic ritual and spiritual flimflam. In this, they mirrored the religious division of Protestant and Catholicism that had been tearing Europe apart. While this view provided dividends it again affords material also for myth-making on two accounts: physicians were part of the vanguard of scientific development and that mechanistic viewpoints on the human body and mind are both superior and best. This conforms with both real and imagined conflict between scientific enquiry and organised religion, placing medical practice on the same footing as Galileo and Copernicanâ&#x20AC;&#x2122;s discoveries. A short essay by Keevil (2011) confirms this. Jonathan I Israel (Grell/Cunningham, 2007) proposes a solution to the above European medical viewpoints based upon the view that the majority of people can be understood as cleaving to one recent philosophy or another. He holds that there existed, with individuals paying lip-service to either one, a dominant moderate Enlightenment (based on Locke and Newton), which was Anglophile in nature and existed within Holland, France and Italy: an entrenched traditionalism and religious orthodoxy of Counter-Enlightenment ideas: a radical philosophical tendency, anti-Newtonian and Lockian that was inspired by Helvetius and Spinoza, and reflected materialistic concerns. While this puts physicians at the centre of intellectual debate, this does not connect to the evidence. While many important minds of the period, such as Wren, dabbled in medicine they were not really physicians. Actual physicians believed in Galen, by and large, humours, purging, and of frogs and toads providing cures.

While Dutch radical physicians may have been at the scientific forefront, makling natural history collections, French physicians were more traditionalist and religious in orientation (L.W. B Brockliss, Grell/Cunningham, 2007). Here are two examples of early Enlightenment physiciansâ&#x20AC;&#x2122; remedies: A) Medicines for the Head. To purge the Head of evill humours. Take the root of Pellitory of Spain, and chew a piece thereof on either side of they mouth, between thy gums, and close thy mouth fast, till the water cometh down; then let the water go forth, but hold the root still a quarter of an houre.67 B) Medicines for the Head. For the weakness of the Brain. Take a handful of Rosemary, Sage, Marjoram, Hysop, Betany, the leaves, and roots; and the seeds and roots of Pyony; wash all these said herbs, put them in a pottle of fair Water, and let them seeth together until the one half be wasted;then take out the herbs, and put to the said water almost half a pint of Honey clarified, and let it boil well together with a dram of Stecados knit in a linnen cloth; and let it boil till the sweetness of the honey be boiled out: then take out the Stecados, and put thereto a quarter of an once of Cinamon, three Nutmegs well bruised, and put them to the same liquor, and seeth them together a good while;then strain it through a linnen cloth, and for use to drink it morning and evening, and it shall comfort the brain.

These remedies remain no different to housewivesâ&#x20AC;&#x2122; recipes, dependent equally on adept cooking processes. Treatment methods are not differentiated from popular treatment methods. Michael McVaugh has resurrected the written observations of a Restoration London surgeon, consisting of his dealings with physicians.

Within this work the surgeon quotes

from Galen and Celsus, and contemporary medical authorities. Most of his cases are of everyday accidents or matters. There is evidence of ad hoc experimentation mainly concerned with blood flow, and a deep concern with dissection. But like many such works, from Galen onwards, the surgeon, as with physicians in general, records successes or apparent successes 67 http://b-womeninamericanhistory17.blogspot.co.uk/2011/05/medicines-for-head-17th-centurymedical.html 68 Wiseman and Restoration London Medical Practitioners. Journal of the History of Medicine. Vol.62 April 2007.

only. Drake’s Anthropologia Nova describes anatomy by looking at and cataloguing separate body parts. He at the same time tends to refute the old Scholastic physicians and considers matters through chemical processes and acknowledges blood circulation. The introduction declares the necessity of an exact book on anatomy and lauds dissecting knife, and its writer admonishes Drake for his theorising, warning him of how dangerous such activity is comparing modern views with those of past healers, who were equally strong in their beliefs. Such books demonstrate intellectual development away from Galen but still do not realistically provide efficient medical practice. Thomas Sydenham’s Observations Medicae (1976) looks at the apparent seasonal recurrence of fevers, his understanding determined by comparison of symptoms, a curious view on the nature of blood, insisting that its heat is a reason for bloodletting. He prescribes for treatment of pox ‘insteed of milke and saffron I order five or six spoonfulls of old Malagoe tincted likewise with Saffron’. Clearly convinced of the power to heal of the exotic. Also hot Canary Wine is prescribed. Once again we have here the use of kitchen mechanics and a chef’s perceptions applied to healing. To his credit, Sydenham recognised that diseases can be picked up by visiting localities where it existed, thereby producing an early notion of transmission. In all cases, god has largely disappeared from the treatment process. Harold Cook’s work, Trials of an Ordinary Doctor,69 describes the appearances in a court of a Dutch doctor whose patient died as a direct consequence of the compound he gave her. Cook demonstrates the case reveals the policing activities of the Royal College of Physicians London, 17th century enthusiasm for experimentation, connecting these aspects to market forces, elements of the sales pitch. Teaching of medicine had changed by the 17 th century, and many European Universities now had courses on physiology, pathology, semiotics, therapeutics and dietetics, or hygiene. Botany, chemistry and anatomy were also taught at some institutions. Medicine continued to be the profession of the developing middle-class, as like now training involved immense expense, growing with that groups assumption of power within the state apparatus and locally. Physicians continued, by and large, to view themselves as learned gentlemen, separating themselves from others lower down the social hierarchy. Although theories on medicine changed, giving thereby a reason to hold that the craft developed throughout Early Modern times to the present, life expectancy did not improve, nor were better cures 69 The John Hopkins University Press. 1994.

produced.70As Wear testifies (1992, page 121) and which I have constantly referred to, altered theories were often driven by market forces and were and are not examples of objective knowledge. Institutions and individuals gained financially from the position they took regarding new or old ideas, their assumptions of learning from this or that viewpoint. Driven by external factors, this is why the idea of scientific enquiry cannot be fully attached to 17 th century medical activity, even with evidence of extensive anatomy books, an interest in chemistry and concern with the nature of things. Medical doctors tended not to test the efficacy of a treatment, applying methods taught to them, or assuming that alteration of symptoms, such as fevers, implied efficacy. During the 17th century, medicine thereby consisted of description, observation (where suitable), use of cooking based treatments infused with antique ideas of plant uses often based on the plant’s novelty. While the assumption that physicians were radical thinkers cannot be upheld, historians of the period also appear to insist on the complete separation of medical and scientific enquiry and religion, which again is not sustainable and merely evidence of modern mythmaking. There is not necessarily conflict and separated viewpoints necessary in the pursuit of truth. The clear separation of intellectual and artisan seems rarely noted by medical historians. Technological advances by 17th century Netherlanders in microscopes enabled medical advances that impacted much later. It is difficult to find physicians in the forefront of scientific discovery in England, apart from Harvey. Whither Enlightenment: The 17th century view of science was different to our own. Although not as powerful a system of ideas as it once was, Galenic medicine was still viewed as scientific. Treatments such as bloodletting were considered scientific rather than harmful and barbaric. Pepys applauds Dr King, ‘that excellent chirurgeon as well as physician’, for postponing King Charles 11’s death by judicious bloodletting. At the same time Pepys recognises the innovative practice of blood transfusion demonstrated on dogs, a common part-trick of the time. As physicians do both, group practice is considered scientific not the outcome. In the same passages, Pepys appears not to notice that the physician’s intrusive treatment of Charles hastened his death, drawing blood from him whenever he complained. Many 17th century figures now seen as scientists, such as Boyle and Newton, were also alchemists believing in forces. Out of such a belief, Newton fashioned gravity. Many of the 70 A. Wear. Medicine in Society. Historical essays. Cambridge University Press. 1992.

apparently innovatory techniques of the Enlightenment were the result of transmission, Tagliacozziâ&#x20AC;&#x2122;s revival of Indian rhinoplasty, the employment of invention, as learnt from ancient Greeks., to extend knowledge, the international experiments with microscopes. As Harold J. Cook71 observes the Enlightenment was born out of commerce, the expansion of commerce and involved not just Europe, and the Atlantic states in particular, but the rest of the world that made a voluntary or involuntary contribution. The Enlightenment concerns European territorial expansion and the use of discoveries to control and exploit others. Cook (2007) sees this as subsequent to matters of facts being gathered, transformed and exchanged as part of a worldwide commercial network. Charles Webster 72 notes: â&#x20AC;&#x2DC; while a number of principles were adopted in the seventeenth century which are congruent with modern scientific knowledge, the general conceptual framework in which these principles were maintained was entirely different.â&#x20AC;&#x2122; He holds that contemporary events and concepts, now forgotten or ignored shaped the period. It is hard sometimes for historians of ideas to realise how much innovatory episodes in human thought rely upon economic changes. If the Enlightenment involved perceptual and philosophic change, which it did but only to a degree, how did this come about? Cook (2007) suggests that this involved a process of regarding the world objectively. He declares this has to do with the rapid increase in European trade with other parts of the world. This established a form of knowledge based upon the nature of objects due to the amount of new plants coming into, specifically, Dutch society. The objectification of the human body coincided with this change, allowing for bodily mechanisms to be described and segregated. But for Cook the main thrust towards objectification was through exchange mechanisms where descriptions of exchange objects and their value had to be clearly known. Spices were much sought after by European traders. These were formed from roots, seeds, flowers, trees and fruits with the most desired coming from Southeast Asia, in the form of pepper, clothes, ginger, cinnamon, nutmeg and mace. As they were thought to have medicinal qualities, the Venetian merchants who originally acquired them and shipped them to all parts of Europe were known as spicers or spicer-apothecaries. These merchants also brought greater amounts of sugar into Europe, which also was regarded as a medicine.

71 Matters of Exchange. Commerce, Medicine, and Science in the Dutch Golden Age. Yale University Press. 2007. 72 The Great Instauration. Science, Medicine and Reform. 1626-1660. Duckworth.1975.

The most energetic of the original traders were the Portuguese, who arrived in India during the 14th century and expanded their concerns there. Spice became the way towards increased state wealth. Into this individual and state adventurism came the Dutch and for a period of several centuries travel became a way to obtain wealth. The greater the distances travelled the greater the wealth, it was assumed, would be acquired. As can be seen in the previous section, travel became a necessary activity for not only wealth but also learning. This meant an expansion of individual and group outlook, changes in status, as travel often bestowed greater status when individuals returned to their original societies, and increased the power of both travellers and the states that officially sanctioned voyagers. Through the pursuit of wealth, greater knowledge arrived in Europe and through the same process the transformation of systems and minds. Colonisation evolved from the attempt to control trade in the East and from competition between European states in the West. From here the Enlightenment began. Not only did travel come to be viewed as essential for a proper education, it was recommended, and often engaged in, by all the important philosophers of the period including Petrus Ramos and Montaigne. Descartes believed that travel allowed an individual to absorb the perceptions of others. In this fashion, European thinking moved away from introverted scholarly learning invested in the past but towards one invested in the natural world and individual experience. From the early 16th century onwards, the Netherlands, especially Antwerp, was foremost in developing trade. Such was the success of their merchants that in 1531-32 Antwerp built the Nieuwe Beurs, a place for merchants to meet and exchange goods and information. In the following century Amsterdam built its own Beurs. With the wide use of currencies, these developed into Exchanges, where currency was converted to facilitate trade. From this point exchange was subject to systemic conceptualisation, resulting in the modern global economies. This Dutch dynamic encouraged a greater involvement in and exploitation of the accessible wider world beyond the aggressive powerful Islamic states that until the 16 th century had hemmed Europe in. Conflict ensued with the Portuguese in the Far East over trade and influence which the Dutch eventually won. While of course spices were used in cooking, their medicinal importance was immense. Pepper cloves, nutmeg, mace, long pepper, galleguen, ginger, cinnamon, camphor, Benjamin (a gum), dragonâ&#x20AC;&#x2122;s blood, spikenard, were designated for use in medicine and cookery (Cook,

2007), bearing in mind the very close connection between the two both for lay healers and doctors. Cook (2007) takes his arguments on the intellectual stimulation of world trade a step further, noting the values inserted into rare, beautiful and exotic objects. This was symbolised by the tulip, both beautiful and exotic, but also invested with financial properties. Briefly, tulips represented wealth. From this, Cook conjectures that the movement of people and goods precipitated a desire to know more about the natural world. To discover facts about other people, the worldâ&#x20AC;&#x2122;s geography and plants. Investing objects with values and knowledge created our present world. But in fact, this is a common activity, discoverable in many past cultures. In Europe this combined with and accelerated social change, the growth of the middle class, and this classesâ&#x20AC;&#x2122; peculiar use of objects to transfer status. Collections were made of plants, from these developments we have the objectifying of other people, bodies and thought process of modern medical professionals. Cook (2007) believes that this new materialism impacted on philosophy and medicine. He holds that these developments resulted in the view that humans are merely mechanisms, reflected in Descartes. From here, phenomenon became investigated through their physical properties, often separated into smaller components. For example, although the arm (lung, heart, blood) is attached to the body it can be examined as an object in itself, with its own properties. The dissection of human corpses and of animals, especially dogs, afforded evidence for the mechanical properties of the body. In this way, the truth of nature, seen as mechanistic, continued to be pursued. While Cook and other writers place physicians at the centre of the scientific revolution others hardly mention them at all leading once again to the dual activity of healers, between artisans and learned. The involvement of Descartes in medical enquiry induced or coincided with physicianâ&#x20AC;&#x2122;s involvement in enquiry. Dorinda Outram73 sees the Enlightenment as evolving from increased literacy and changes in the experience of reading, a later development, which came with the possession of many books rather than a few. An increase in media, including pamphlets and newspapers, aided the growth of reading extensively, reading more printed works only once rather than a few endlessly.

73 The Enlightenment. Cambridge University Press. 2013

Apart from establishing an alternative, even antagonistic, approach to religion, the Enlightenment and medicine in particular is considered to have in the early modern period represented antagonism to Aristotelian and scholastic philosophy. Once again any clear demarcation from earlier ideas and present ones is hard to find, presumably because it hardly exists. The ideal state of present day medical ideas is as fragile under scrutiny as the myth of medical scientific progression based upon a set of known values and events, such as materialism and secularism. This view excludes the continuance of scholastic viewpoints, situated beyond testing, in the present day. Radicalism was in short supply amongst English physicians, so how did this small corporate body, which in England unlike France, was not at the centre of state political life, come to achieve such a position as in the present day of excessive influence and power? Doctors have many powers, which I will later review, only given at best to police and politicians, and, at times are equivalent to those of officials in dictatorships. And yet, by and large, the general population colludes with this. At present it seems to be expanding, not decreasing. I believe there are two possible historical reasons for medical practitioners encompassing involvement in national and private life. These I will now consider. Development of identity. In France physicians provided a corporate image of the state, and throughout Europe became involved in social control through concepts of the poor and dispossessed. While some commentators perceive a revolution in science as behind medical improvements the conservative nature of physicians prevented any real improvements until the 19 th century. William Harvey discovered the circulation of the blood as an acolyte of Aristotle. He was in the line of other great Renaissance anatomists who did excellent work discovering how the body actually worked. Nevertheless he believed that the soul was responsible for the workings of the body. If, Coln, science concerns thinking on subjects without concepts outside of the subject then Harveyâ&#x20AC;&#x2122;s discovery was in part accidental. As servants of municipals and managers of containment of populations during plagues physicians became increasingly involved with secondary or central powers, making decisions that affected other groups. It is within this context that the development of medicine can be found, not in the so-called Science Revolution, which medical practitioners largely ignored.

So far, we have ascertained that the medical profession had a hand in the definition of the poor as a distinct group occupying a separate space and with a different relationship to health and treatment from the affluent. As previously recounted, this also concerned how plagues were disseminated, in part through the poorâ&#x20AC;&#x2122;s habitual bad behaviour. Of course, unlike the rich, the poor often could not afford to flee cities so they were most affected by it, causing thereby several to observe that as they were most affected by plague the poor must be its cause. While health authorities throughout Europe insisted that they took necessary steps to stop the spread of plague, their goal was to maintain social stability by controlling the poorâ&#x20AC;&#x2122;s movements.74 Through such activities the poor became a monolithic group that required control, seclusion, ejection, rejection and punishment. By perceiving illness as something that prevented an individual or group from working, invalid or fragile poor people were considered inferior. During the period 14-1700 AD medicine became a corporate profession, although it largely remained a free-for-all. Physicians retained diagnosis and prescription, with apothecaries and surgeons their subordinates. Physicians rarely went into the countryside, so other crafts doubled up as doctors. Although Pelling and others speak eloquently about doctors in Norwich and elsewhere, these were rarely physicians. By the end of the 17 th century the distinction between legal and illegal medical practice was clear cut, as a consequence of social and ideological reasons not to efficacy of treatment. During the first half of the 17 th century medical responses to the body were changing, a process which reached greater fruition in the second half of that century, although in general the four humours were still accepted, with the idea that the humours needed to be kept in balance. Bleeding, purging, vomiting and opening lesions in the skin for draining purposes clearly reflect this theory and thereby fulfil a justifiable rationale. The early part of the 17th century witness perceptual changes within a few medical commentators and practitioners. Beginning with Paraselsus (d.1541), who was intent on rejecting Galenism because of its roots in paganism, the idea surfaced that diseases were specific and not subject to individual temperament. In general, this idea took a long time to be accepted and until recently people referred to the connection between personality traits and the kind of illness they were likely to suffer from. In learned parts of society, they dominated up to the 18th century. 74 Dorothy Porter. Health, Civilisation and the State. A history of public health from ancient to modern times. Routledge 1999.

CITY and TOWN: The negotiation of urban life involved domestication, a term taken from archaeology (Hodder, The Leopards Tale, 2011 ) to describe the process of constructing group habitation and defining and controlling the natural world. What occurred in the early modern world, with changes in country life, migrant populations and increased migration into towns and cities, comes under this process. Domestication means that cities and towns were employed to define and contain people for political and economic ends. Healing practitionerâ&#x20AC;&#x2122;s involvement in this process created modern medicine. Municipal authorities continued to negotiate health and illness through bourgeois concepts of work, that is for money not fulfilment, identification of the poor through aspects of social dependency and constructs of urban life, that is the town engaged in productivity, with money as an exchange rate, achieved through the properties of settled life. Learning and knowledge as commodities distinguished the poor from the rich. Outside of city life was the countryside that provided food and the national ruling elite, with its wealth and power based in land, and destructive elements which lived in the waste areas between both. This reflected the triad of earth, hell and heaven and perhaps caused the perception. The medical practitioners, still a motley bunch, were involved in the identification of who occupied which space. This process can clearly be seen by the location of lazar houses outside of city walls, often run independently, that provided transit stations for disabled people or maimed and disabled soldiers the cities or towns did not want to take responsibility for thereby acting as dumping grounds. To solve this problem, the lazar house keeper would be given money to retain such people, who were still subject to punishments meted out to those who did not work or who refrained from a settled existence. Mad people were forced out if they had no long term residence. All were liable to physical punishments. Lunatics who belonged to a town or city were looked after in Bridewells, their incarcerations paid for by municipal authorities. At times of economic slump, the lazarhouse keepers were paid not to look after the ill or lunatic not already connected to Norwich. Modern medicine has its antecedents in public health, control of diseases and social control, and not the scientific revolution. Ghada Karmi suggests that public medicine, and

thereby modern Western medicine, has its roots in Islam. 75 This suggestion will be continuously reviewed, although the origins of organised medicine probably lie in a number of sources including imitation of Catholic religious orders. The beginnings of the Islamic hisba , established to exert control over moral and commercial behaviour within the state, coincide with the emergence of medico condotto in Italy but later developments of medical organisations may have been influenced by Islamic institutions. Caliphs also affected control by appointing and paying chief physicians of hospitals, and were ordered to visit prisons and to journey to outlying districts to attend patients. Islamic doctors also had to pass an exam in order to practise. Islamic states also had physicians who worked outside of state control, only for money. It can nevertheless be seen that already here is the modern model of private and public medicine. It seems that a muhtasib supervised physicians, ensuring that their skills were appropriate and that they behaved ethically according to Muslem dictates. As a model of state involvement and organisation it surely had some influence on developments in Western Europe? Other developments, such as the use of hospitals, may also have been influenced by Islam.

In Europe public health is usually considered as beginning in Italy where the first medico condotto appeared at Reggio in the Po valley. In 1214 Ugo Borgognoni arrived in Bologna to be hired by the city authorities and given a feudum or stipend to provide free treatment for city residents.76 While this seems to have broken down in Italian cities in the early modern period, continuing in small towns and villages, it became a market system under the aegis of city and small town colleges.77While in Germany and elsewhere in Europe the salaried town or district physician was not widely emulated in France, but came under policing operations. Accordsing to Matthew Ramsey78in the final decades of the Old Regime it was recognised not only as a sub-division of medicine but also as a branch of the police. It was not until the 75 State control of the physicians in the Middle Ages: an Islamic model. Wolfen-Butteler Forschungen1981, Herzog August Bibiothek, Wolfenbuttel. 76 Vivian Nutton. Continuity or Recovery the City Physician in Classical Antiquity and Medieval Italy WolfenButteler Forschungen1981, Herzog August Bibiothek, Wolfenbuttel. 77 Richard Palmer. Physicians and the state in post-medieval Italy. Wolfen-Butteler Forschungen1981, Herzog August Bibiothek, Wolfenbuttel. 78 Public Health in France. Ed. Dorothy Porter. The History of Public Health and the Modern State. The Wellcome Institute Series in the History of Medicine. 1994.

end of the century that terms such as public hygiene, but also medical police, came to be used. The control of diseases was also about social control, as already noted. In England public medicine in the 17th century appears, according to Christopher Hamlin79to have been reactive and to have emanated from the Privy Council not Parliament. Hamlin similarly offers the view that Britain was unconcerned, compared to the centralised European states, with their top-down approach to medical treatment, and their citizenâ&#x20AC;&#x2122;s fates. Counties, boroughs and parishes largely conducted their own affairs with occasional laws from central government affecting motivation or direction of governance. Public health appears mainly to have concerned itself with protecting the affluent from infection by the poor.

State of Medicine.

At this juncture it needs to be established that European medicine was no more advanced or scientific than oriental medicine. In fact the procedures put in place by Islamic societies, see above, probably, within its remit, provided healthier citizens. Of interest is ideas of health, where in Islam it was top down, the duty and obligation of ruler to concern himself with the health of the weak and vulnerable, in Britain, for example it seems to have been largely pragmatic and un-centralised, while in France and many parts of Germany it was like Islamic states determined by the ruler. In France and Germany the emphasis was on keeping order. Although Christianity had a notion of healing and attending the vulnerable, it was mostly put in the hands of the charitable and illness deemed largely a moral and lifestyle issue. These views have persisted. Although no more advanced scientifically or as a society, European states began to express a superiority to other cultures that would probably not have been expressed in the previous century. Then, the Musselman was a rival, to be feared. What may have changed this attitude is European expansion to the West and their overcoming of powerful if technologically backward states, thereby lessening the Westâ&#x20AC;&#x2122;s rivalry with Eastern societies, the subsequent military triumphs from the 16th century onward over Islamic states, and the successful 79 State Medicine in Great Britain. The History of Public Health and the Modern State. Ed. Dorothy Porter. 1994.

paradigm of colonialism implicit in internal and external development. Of equal importance were perhaps the scientific events of the 17th century, Harvey, Boyle, Leinitz and Newtonâ&#x20AC;&#x2122;s mathematical discoveries. A particular concept of science was triumphantly unleashed based upon innovation, experimentation and individual accomplishment. As the Koran focused on human behaviour, it provided, as with Judaic religion, general guidelines and rules on nutrition, cleanliness and relationships establishing a relationship between food and behaviour, and behaviour and health.80 It (Khan, 1986) gave causes and treatments for a number of diseases, such as leprosy, and detailed the importance of training for physicians. In the 8th century Greek medical writers such as Galen were translated. Notwithstanding, Islamic medicine claims a spiritual rather than mechanistic understanding of human disease although it appears to ascribe qualities to food beyond its capacities. Caliphs funded research into science, inventions and knowledge in pursuit of knowledge, a holy notion. The knowledge sort by Islamic scientists was/is the search for the nature of knowledge, not the search for specific principals.81 The connection between medical treatment and science is connected in peopleâ&#x20AC;&#x2122;s perceptions although this connection mainly goes back to the 17 th century, embedded in both the medieval period and new plant and animal discoveries from the Americas. It is at this point that some commentators82believe that science and reason had supplanted religion as the principal source of knowledge about the natural world, although I suggest that is both wishful thinking and/or a gross exaggeration. Keevil (2011) similarly believes that at this point that the main scientific disciplines had been formed as spheres of study distinct from each other and philosophy. Again, unproven. In The Sociology of Medicine and Illness 83stress that great improvements in knowledge during the scientific revolution, although they are considering a later date, did not involve medicine. Science in France was already subject to institutionalisation and linked directly to the Faculty of Medicine. According to James William Barlow 84 in a book that, although written a 80Muhammad Salim Khan. Islamic Medicine. Routledge and Kegan Paul 1986. 81 Ahmad Y. al-Hassan Factors behind the Rise of the Islamic State. The Different Aspects of Islamic Culture. Ed. Prof. Al-Hassan, Prof. Ahmed, Prof. A. Iskandar. Unesco Publishing. 2001 82 Stephen F Keevil Physics and Medicine: a historical perspective. Physic and Medicine 1. Lancet 2011; 379: 1517-24 Published Online April 18-2012 Cambridge University Press. 2000 83 Kurtz, Chalfant. Allyn and Bacon, 1991. 84 Doctors At War, London David Nutt, 1914.

long time ago, mirrors this paper, the Faculty demonstrated fixed ideas on Science, rejecting everything that did not emanate from its own chambers. The entire medical curriculum was divided into two categories Anatomy/Physiology and Pathology/Therapeutics. During the 17 th century these were added to, and Surgery, Pharmacy, and Botany were added to the programme. The war of dominance between the professions was fought successfully by the Faculty as it consumed more of the employment engaged in by others.

Although Newtonâ&#x20AC;&#x2122;s mechanical definition of the universe, best conceived of as a clock with a winder (God), and earlier Vesalius had discovered the role of the heart as a pump, and William Harvey the circulation of the blood all these notions stemmed from an understanding of mechanics based upon interactive dependency found in earlier understandings of health. The discovery that the body had specific internal workings, exposed by anatomy, allowed individual imaginations to assign specific properties to organs and other physical phenomena. Although Descartes decided that humans were material not corporeal he assigned rationality

to internal aspects of the body, the pineal gland. But too much is made of the emergence of rationality and science, especially now we know that Newton, for example, was motivated in his science by alchemy and God. Nevertheless, it is possible to identify cheminstry, physics and anatomy by the end of the century but few advances in medical treatments. Bedlam:

As Foucault 85 noticed, perceptions of madness changed, although this change can be seen from the 17th century onwards and not from the onset of ideas of rationality. Foucault holds that this was a consequence of mad people, previously considered as possessed by diabolical elements, 86being seen through the prism of profit and wage labour, noted above in regard to the poor, and therefore becoming a variety of pauper, and thereby metaphors of social instability and a threat to organised society. Although I can find much to agree with in this view, changes towards mad people were also the consequence of expanding state power and professional evolution in line with the desire for domestication, which has its roots in early urban societies. The mad have come to represent the opposite of the professional stereotype and therefore required marginalisation and restraint. According to MacDonald (1981) during the latter part of the 17 th century the English population became increasingly concerned with madness, gloom and suicide. He also, with which I concur, holds that in this period the governing classes embraced secular interpretations of the signs of insanity, championing medical methods of curing medical disorder. By doing so physicians were provided with the greatest scope for experimentation with and negotiation over their power. Mad people were, he holds, as with Foucault, removed from their normal environments and placed with other mad people, losing social rationale for their existence, power and relevance. Private entrepreneurs created specialised institutions to manage mad-people, thereby providing an economic reason for their existence, and municipal officials established public madhouses. From approximately 1580 madness began to be of interest to intellectuals, replacing for many the old types or archetypes, subsuming many of these into one state of behaviour, thought and feeling, thereby producing the one-dimensional construct of madness and mad 85 Madness and Civilisation. 86 MacDonald. Mystical Bedlam: Madness, Anxiety, And Healing in Seventeenth Century England. Cambridge University Press. 1981.

people. Medical writers, playwrights and philosophers fretted over melancholy. It became quite the thing to be, the scourge of both the wealthy and intelligent. It became a symptom of inactivity, man, in particular, removed from his role as knight and warrior. Hamlet, for example, overwhelmed by too much reflection, is unable to avenge his father’s death and sinks into melancholy. Human beings are no longer seen in terms of god, social position and action but on internal subjective responses to the environment. The middle ages produced extensive iconography on madness, described by S.L. Gilman 87 as those associated with any divergence from society’s norms, the maniac, idiot, melancholic, wild man or possessed. He describes also an interchangeable set of icons by which the insane were observed or identified. There are many instances associated with wildness, of individuals who cast off their social graces and roam wild in woods, such as the Ywain legend and in Wirnt von Grafenberg’s Wiglois, which features a wild woman who has become animal-like. This may have its roots in Nebuchadnezzar’s madness as described in the Bible. Although Gilman points out how blackness was also connected to madness, he further demonstrates how, in the Bible, blackness is associated with falls from grace. But these matters may have a far longer genesis. Gilgamesh, on the death of his companion, becomes wild and melancholic. Here, the reaction is connected to grief but in addition has a philosophic element. Galen expresses an understanding of madness as connected to an excess of black bile. The medieval world, or at least its medical practitioners, tended to see madness as thereby resulting from two causes, a single event, such as grief, whereby black bile is induced, or from temperamental predilection. In fact, this approach resembles closely modern ideas based upon nature and nurture. The Wildman archetype fits in with concepts of domestication, whereby wildness is outside of society, and once an individual has lost their close connection with the urban environment, playing an identifiable, useful role, they can no longer inhabit society nor express its conventions. Medieval iconography shows mad people, in its various forms, through disordered appearance and the carrying of a staff, which can also denote possession. The staff becomes transformed into witches broomsticks, individuals who also function outside of society usually inhabiting wild natural areas and often living in caves. It seems possible that images and concepts of the mad are related to ancient archetypes. During medieval times, and into the Enlightenment, the mad are often portrayed as naked or partially naked denoting on the one hand an existence outside of conventions, of society itself, and 87 Seeing the Insane. John Wiley and Sons.Inc. 1982.

beyond rationality. Sane people not only dressed themselves but often impeccably. Even today, slovenly dress implies lack of self-respect, self-esteem and mental distraction. The first comprehensive treatise on suicide was written by John Sym, and prefaced by William Gouge, a puritan divine, in 1630, placing it not only with the devil but also within society. Sym looks at the sweetness of life and produces reasons against its self-premeditated loss. MacDonald (1981) reviewing this work accepts at the same time suicide as a mental disorder, which appears to be a leap into the colonial activities of physicians. Also according to MacDonald, clergymen and humanist intellectuals had become concerned about abnormal behaviour, but he appears not to question if such behaviour is really abnormal but whether such a construct stems from increased state control. One marked change in this period is that mad people are no longer just observed but subject to control. Polonius observes Hamlet and control is discussed but not enacted. Madness is based on anecdotal evidence, what neighbours or families believe. Madhouses existed as charities. Although such places have been described as almshouses and detention centres, Jonathan Barry and Colin Jones88 hold that this view does not give credit to their therapeutic intentions. While at the same time as providing a feisty approach they concede to madhouses involvement in the market place (page 65) through architectural design and demands for charity. It was as a dispenser of charity that Bethlam was at the time considered, rather than a place of treatment, but charity then as now was a marketplace tool that ensured a steady income. Bethlam provided phisicke, dyett and lodging with concepts of cure only attached in order to legitimise status and also because the provision of charity meant also the attainment, or attempt to obtain, a cure (Andrews. Ed. Barry, Jones 1991). It is from the 17 th century that the status and realignment of the mad can be seen, as objects of care and pity. Although the charitable aspects of such facilities, taking in mad vagrants, should not be underrated, equally it is possible those same individuals were cared for within the community through charitable efforts. This concerns a change from private to public care. Even at this stage there is evidence of inconvenient people being selected for incarceration (Barry, Jones 1991, page 68), and Although there has been an understandable reaction to Foucaultâ&#x20AC;&#x2122;s examination of madness and the role of society in its construction, this work will also view madness not only 88 Jonathan Andrews. â&#x20AC;&#x2DC;Hardly a Hospital, But A Charity For Pauper Lunatics?â&#x20AC;&#x2122; Therapeutics at Bethlam in the seventeenth and eighteenth centuries. Medicine and Charity Before the Welfare State. Routledge 1991.

as a definable condition but in terms of state and medical profession expansion, as the two are inseparable. Although ideas on and of madness can be found in the 16 th century and early part of the 17th century identified problems are not medicalised. It seems often to refer only to heightened states without any certain connection to helplessness and poverty. These were passions and connected to the body. The imagination, seen mainly as an image-making form, was able to influence the body through the emotions created. 89 Robert Burton powerfully rendered the effects on the individual of the mind, certainly should it become morbid. There was already at this stage a conception of madness by those who communicated it and those intent only on containing anti-social behaviour requiring charity from others. At this time, mad people inhabited personality types, hypochondria, melancholic, and hysteric affections, somatopsychic rather than psychosomatic.90 People who acquired mind-illnesses thought too much and were perhaps too remote from physical activity. The present debate on the nature of madness appears to mix up two distinct trends, the intellectual, emotional, mystical understanding related to direct experience and state recognised containment, the medical position that is affected by social status and social activity. While the medical profession concerns itself largely with the very vulnerable within society, even then it failed to take account of the effects of stresses or physical illness on incarcerated patients. The records indicate that many patients were particularly susceptible to lethargy, or in modern usage ‘depression’,91inhabiting a pacific disposition, as equally were those assigned to Newgate or Bridewells. Within these facilities control over behaviour seems also to have been early established, in that way imitating the ethos of the expanding state. The Bethlam patients were restrained from begging and ordered into needle work. Jonathan Andrews sees this as evidence of therapeutic practices but may in fact be less charitably explained. Conclusion: While there is no evidence of improved medical treatment during this period, there is evidence of the public expansion of medical ideas and influence. This appears to have been a consequence of the involvement of the state in treatment of its population through aspects of 89 Theodore M. Brown. Dualism and Psychosomatics. Ed. W.F Bynum, Roy Porter and Michael Shepherd. The Anatomy of Madness. Essays in the History of Psychiatry. Vol1. People and Ideas. Routledge 1985. 90 Theodore M. Brown.1985. 91 Jonathan Andrews. ‘Hardly a Hospital, But A Charity For Pauper Lunatics?’ Therapeutics at Bethlam in the seventeenth and eighteenth centuries. Medicine and Charity Before the Welfare State. Routledge 1991.

social and political control. Although perceptual changes are evident, such changes barely seem to affect physicianâ&#x20AC;&#x2122;s training or behaviour. Already, new medical solutions are created by those outside of the profession while physicians mainly continue conservative practices, while, of course, claiming substantial efficiency of purpose. What remains is a market-place ethos, where new treatments involve new pricing and acquisition of custom. The new medicine, connected to Protestantism, gains custom for its acolytes from other forms of treatment. New ideas are therefore, in part, a consequence of the changing market-place, connected also to increased interest in plants, especially of those from distant lands. The Scientific Revolution and Enlightenment are presented here as a consequence of exploration and colonisation. The latter provides the belief that European genius is unique and innate, excluding in the process knowledge acquired from elsewhere due to either pillage or as the outcome of interaction with other cultures. Europeans colonised global knowledge, claiming it as their own. The growth of trade stimulated European societies allowing them to separately identify intellectual pursuits. The enhanced market-place created objects out of material and abstract properties, allowing the subsequent objectifying of the environment to create a new perceptual outlook. Certainly, religion played a part, motivating many intellectuals to create a new world based upon seeking god in nature. But although Newton was profoundly and superstitiously religious, alchemy also played a part in his discoveries by his identifying forces as essential to the natural world. We still rely on that concept as an explanation for physical phenomena. In this era, there were no patients, a recent invention. There were agents. People seeking treatment as active participants in the market-place not passive beneficiaries, defining and changing treatment, establishing the authenticity of medical ideas. The general population engaged in the development and identification of effective treatments and, in addition, were often treaters themselves. Equally, physicianâ&#x20AC;&#x2122;s authority was a property of their reputation for learning and access to those in power. Finally, the focus on mental health that emerged out of the 16 th century and became formed in Bedlam, is symptomatic of an ontological and social change based upon waged employment and urban growth. Although Roy Porter claims that incarceration as a method of dealing with vagrants, criminals and mentally ill emerged in Britain in the 19 th century its genesis was clearly in the 17 th. Here, individuals were identified as inefficient and socially incapable, often through anecdotes provided by relatives, and required controls to become

suitable citizens/humans. The parasitical, mutually dependent relationship of Treater and Treated, essential to modern medicine, was being established.

3. BECOMING THE RULING CLASS.

‘Although there was much talk of a ‘profession’ in the eighteenth century (Wear, GeyerKordesch, and French, 1993), medicine as a profession in the intellectual and moral senses of the term did not yet exist. Before the eighteenth century physicians and surgeons lacked a stable body of knowledge and they lacked an ethics to guide the appropriate use of then nascent scientific knowledge that such knowledge was about to create. In short, the concept of the physician as a professional in the intellectual and moral senses of the term and therefore the concept of the profession in its intellectual and moral senses did not exist, at least in the English-speaking world, until the eighteenth century.’ McCullough, Lawrence B. John Gregory and the Invention of Professional Medical Ethics and the Profession of Medicine. Kluwer Academic Publishers. 1998: page 4.

Introduction: According to research done at a medieval graveyard outside London, there are no clear differences in health between c950 and c1850. Although many new philosophical positions were developed, the medical profession kept largely to a belief in humours, still employing leeches and other tried, but rarely tested, procedures. This work will dip occasionally into ‘An 18th Century Physician’s Handbook’ (Cockayne, Stow 2012) to demonstrate the profoundly conservative nature of medical practice. Therefore this paper will not necessarily concern itself with medical achievement but rather with how the profession ingratiated itself with a

disbelieving public.92 This paper will consider how physicians throughout Europe increased their status, wealth and public presence without offering clear evidence of efficiency, 93 focusing on the professions increased power in comparison to the influence it had enjoyed before through its intimacy with the court. The social complexity of care and healing, involving lay patronage for example, prevented any clear, authoritative distinction being established between orthodox profession and fringe practitioners. This paper will also consider how lay people or those claiming medical knowledge from other sources were ejected from practising medicine, especially women, and how the medical profession became more organised, becoming rapidly an elite male preserve. Was it in the end merely the result of the professions drive towards professionalization, creating, according to McCullough (1998), what amounted to corporate positioning, exclusive rather than inclusive? Lastly, the actual nature of medical treatment will be considered in an attempt, once again, to reveal the reality behind the rhetoric.

In apparent contradiction of the above, Adrian Wilson (The politics of medical improvement in early Hanoverian London)94 asserts that in Britain the 18th century was one of medical improvement, that is, peopleâ&#x20AC;&#x2122;s health became better. He demonstrates this by referencing improved housing, hygiene, and more efficient police and prisons. Although not immediately identifying perfected medical practice, he shows how society improved, with the provision of voluntary hospitals, the first of which, the Westminster Infirmary, was founded in 1719. Unfortunately for this viewpoint, it seems that the general population fared no better, still suffering from early death and plague, while the rich did, from 1750 living considerably longer than their much poorer counterparts. Developments in medical provision, status and organisation were evident throughout the 18th century. In order to clarify the processes of those developments, many of which did not thereby involve better treatment for patients, several European countries will be considered. This assumption underlying this investigation is that each change influenced 92 Porter and Porter, 1989. 93 Barry, Jonathan, Publicity and the Public Good: Presenting Medicine in Eighteenth-Century Bristol. Ed.Bynum, Porter. Medical Fringe and Medical Orthodoxy. 1750-1850. 1987. Croom Helm. The writer declares: â&#x20AC;&#x2DC;No hard and fast lines are evident between fringe and orthodoxy in the areas of therapeutic efficacy, choice or remedial methods, or involvement in trade and marketplace.â&#x20AC;&#x2122; 94 The medical enlightenment of the eighteenth century. Ed. Cunningham, French. Cambridge University Press. 1990.

changes elsewhere. Certainly, during the 18th century, the distinction between professional, in other words graduate and lay healers remained blurred. During the 17th century until the early 18th century, there is greater evidence of state involvement in ordinary lives and day to day activity. This varied from country to country, state to state. Concern with the poor and their harbouring of disease, incubators and distributors of plague and thereby their effects on the elite, is one example, while the effects of centralised law courts and policing activities are others. Although Great Britain remained largely free of government control throughout this period, authoritarian examples throughout Europe impacted on medical organisation. In Europe, inoculation against small pox, which originated in the Middle East, began in the early part of the 18 th century. Wilson holds that its extensive use in Britain was the result of approval from Crown and ministry.

I have raised doubts on the ordinary medical practitionerâ&#x20AC;&#x2122;s involvement with the medical philosophies of the time and that only a small number were engaged with the contemporary controversies. Joanna Geyer-Kordesch (Whose Enlightenment? Medicine, Witchcraft, Melancholia and Pathology, 1995) describes an 18th century Europe little touched by enlightenment tropes, with medical practitioners still caught up in metaphysical, spiritual and superstitious interpretations of illness. Reason and science as colonising tools were yet to effectively marginalise opposing forces and ideas. Not only did they affect the approaches of a number of influential individuals inside and outside of medical practice, but often provided the rationale for physician power. Nevertheless, the predominant theories must be considered. The concept of nature as a representation of god, evidence of his workings and of his omnificence, was held by the growing number of empiricists both within and outside of medicine. Observing nature was increasingly preferred to learned perceptions of medicine based upon Galen. But, nevertheless, there were differences between concepts of nature, following individual thinkers and practitioners. Philosophies of nature tended to involve the supernatural.95Atomists might be considered an exception, believing that life and the universe were formed accidentally, and therefore nature is simply chance, but few medical practitioners were informed by such views. Pierre Gassendi (1592-1655), although not an atheist like many atomists, was the principal component of this viewpoint, separating body (corpus) and matter (material), thereby identifying form and the potential of form. In fact, 95 King, Lester Snow. The Philosophy of Medicine. Harvard University Press. 1978.

divine causality seemed then, at a time before 19th and 20th century provided further evidence of the apparent insignificance of human beings, a more logical response. . Robert Boyle (1627-1691) was a later atomists who declared that all form, real or speculative, which occupied space and comprised the world, was nature. Boyle accepted an immaterial world, consisting of souls and the supreme deity, which he then made a separate issue from the material world. He also, with conditions such as the primacy of god, the mechanical nature of human bodies. Ralph Cudworth (1617-1688) provided a Neoplatonist model of this view (King, pages 23-24), which involved the word of god and nature as a receptive, plastic form that responded to his bidding. Plastic nature therefore is a divinely acted-upon form, an element of life itself, possessing recuperative, healing and transforming powers. It is within instinct-driven animals and human bodies. The generally held position, irrespective of direction, was that Nature required observation and understanding, and doing so will reveal godâ&#x20AC;&#x2122;s workings.

Physicians and the Inquisition.

Social and political change: In Germany, broken up at that time into many small states, learned physicians formed part of the power structure, with some access to absolutist power and state finances, 96 able therefore to control the process of professionalization. As Geyer-Kodesch asserts 97 the German universities were more subject to political influence than the insular and elite 96 Geyer-Kordesch, Court Physicians and State Regulation in Eighteenth Century Prussia: The emergence of medical science and the demystification of the body. Ed. Bynum, W. F, Porter, Roy. Medicine at the Courts of Europe, 81500-1837. Routledge. London and New York. 1990. 97 German medical education in the eighteenth century: the Prussian context and its influence. Bynum, Porter. William Hunter and the eighteenth-century medical world. Cambridge University Press. 1985.

universities of Oxford and Cambridge, allowing British medical organisations to develop more slowly. In Prussia, state involvement in the determination of what legally constituted a physician encouraged the profession’s institutionalisation and also, according to GeyerKordesch (1990), invested it later with scientific status. Practices remained nevertheless firmly within the religious and cultural belief in the place of the body in the scheme of things. In Prussia, Crown edicts of 1685 to 1725 separated learned medical doctors from other healers. The state oversaw examinations, specifying the character of a true medical doctor, linking university training to state power. Under State imperialism, medicine became united with the sciences and from thereon, with many detours along the way, expounded a reductive, mechanistic, hierarchical view connected to the demands of State bureaucracy and power. The above 1685 Edict justified state regulation of medical practice in BrandenburgPrussia through its attack on mal-practice by non-physicians. It particularly referenced barber-surgeons and surgeons, an approach that according to Geyer-Kordesch (1990) was largely the result of court physician’s initiatives. The state proceeded to establish a collegium medicum bound to court authority, run entirely by court physicians, and invested with enforcing powers. Systems of control were developed for the inspection of apothecary shops, barbers, barber surgeons and connected professions such as midwives and occultists. This development was civilised compared to events in Portugal during the same period. As famously revealed by Timothy D. Walker 98, investigating the activities of the Inquisition in Portugal at the turn of the 18th century, then a rich and stable country, he discovered (page 6) that many of its victims were ‘folk healers, peasant men and women who earned their keep in part by proffering magical remedies for common illnesses.’ Further research indicated that medical professionals were directly involved in the resulting persecutions, providing expert witness or/and the initial denunciation. Senior physicians attended the accused torture. In fact, although the involvement of Portuguese physicians with the Inquisition appears to have been conspicuously self-serving, in many parts of Southern Europe they colluded with the institution by attending torture and procuring the corpses of those killed under torture. The inquisition started later in Portugal but continued almost into the 19 th century, dropping quickly after 1772. Cases against popular healers (saludadores or curandeiros) continued with considerable intensity throughout this period. This persecution coincided with a period when medical professionals, physicians and surgeons, were entering the paid ranks 98 Doctors, Folk Medicine and the Inquisition. Brill, Leiden-Boston. 2005.

of the Inquisition in immense numbers (Walker, page 8). According to Walker, medical professionals, in competition with popular healers and also motivated by scientific medical ideas, employed the Inquisition to discredit their rivals and spread doubt about traditional forms of healing. A document from the Inquisition, Dos Saludadores (On Healers), determined that while some forms of healing were divine, others were inspired by the devil, thereby evil forces. Of course, licensed doctors inhabit the area of divine healing and poor, often uneducated, saludador inhabit the realm of evil healers. Education and power is seen as a cleansing force. In this process, scientific application is ordained by god (Walker, page 12) and anyone employing herbs, lotions (much used then and now by licensed doctors), blessings, unguents, incantations, etc, is a charlatan and liar. Walker stresses (page 13) that many of those tried for witchcraft in Early Modern Europe and New England were cunning women-that is female folk healers. Walker (page 14), in line with Roy Porter, identifies a European wide persecution of folk healers in concert with the rise of medical professionals. It does appear to be part of a normalising process involving elite agreement throughout the region based upon a growing ideology of reason and behaviour. Concepts of the natural world became fixed upon a rationalist agenda, run predominantly by males. In Galicia (Walker, page 19), women made up the majority of those accused of magical healing, a percentage found elsewhere prior to and during the 18th century. The inquisitions activities reached a high point between 1715 and 1760 during the reign of Joao V, continuing with less intensity into the Pombaline epoch (1750-1777). According to Walker (page 7), although the first group focussed on by physicians was New Converts, Jewish doctors who had accepted Christianity, shortly after popular healers were the accused in 60% of Holy Office trials involving crimes of employing magic or superstitions. Curandeiros and saludadores (Walker, 2005), usually functioned amongst the peasantry, were both men and women, often employed magical cures and did not elevate themselves above the poor groups, especially peasants, they normally treated. Walker (Chapter 2) provides short narratives of peasants prosecuted during this period, up to 1775, accused of employing magic or recipes often used extensively by licensed doctors in the previous century and still much used by medical doctors in the 18th especially outside European urban centres. Some curandeiros were denounced it seems out of professional jealousy, as their methods were more efficient than that of professional medics (Walker, page 47). While many popular Portuguese healers employed incantations and magic healing in their treatment processes, medicinal prepasrations were widely used, including beneficial folk medicine such

as sap from the elder bush that contains (Walker, 59) anti-rheumatic and anti-neuralgic properties. In instances of fresh wounds, olive oil was often employed to cleanse the wound before other treatments were used. Walker (page 65) asserts that Parteiras and cunning women possessed far greater knowledge of birth control than licensed practitioners. The main reason for the popularity of curandeiros and saludadores was the lack of medicos in the country, most drawn to the sea ports to deal with incoming seaborne diseases and greater chances of employment. Another reason was the flight of university-trained physicians from Portugal as the Inquisition gained in strength. These were usually New Christians, Jews who had converted under pressure. Such individuals were invariably targeted by the Inquisition within Iberia, selected for denunciation by their professional colleagues, the Old Christians. Although Walker asserts that the Inquisitionâ&#x20AC;&#x2122;s persecution of popular healers with the active assistance of medical professionals was the result of the medical doctors desire to rid themselves of competition, he stresses that it was also a way of the medical profession introducing Enlightenment ideas into the general community. The Faculty of Medicine at the University of Coimbra, the centre of medical instruction in Portugal, where doctors were taught, was controlled by Jesuits whose core beliefs were antagonistic to Enlightenment views. As a result of religious domination, the medical curriculum had not changed for three centuries with forward thinking physicians unable to instigate enlightened reform. There, doctors were taught in the old fashioned way based upon Galen. Enlightenment views entered the country via New Christians, by then living in France and England, specifically London. In order to establish a conduit for modern medical ideas into the community, that is materialism and empiricism, doctors collaborated with the Inquisition to obtain power and to direct oppressive measures against their medical rivals, practitioners of folk medicine, and by so doing establishing science as the chosen medical method of god.

New hospitals: religion and politics. As hospitals were probably more harmful than beneficial to health, 99it seems that the use of medical services then as now was for a variety of economic, social and emotional reasons outside of falling ill and the desire for treatment. Hospitals appear to have been used 99 Valgarda, Signild History of Public Health. Who went to a General Hospital in the 18th and 19th centuries in Copenhagen?

extensively, but in some European countries mainly for the dispossessed with curable illnesses (Valgarda, 1998), and mainly males in their twenties. They were primarily for the poor who had no one to care for them. In this, hospitals throughout Europe early simulated class structures, with the Upper Classes making decisions, the Middle-Classes providing treatment, and the working or poorer classes receiving treatments. In most of Europe, with the exception of Britain, hospitals were mainly initiated, set up and overseen by governments. As most European states held that large, healthy populations aided the production of wealth, it was considered that the treatment of illness was essential for the state’s cultural and economic health. Added to this, large armies had become the norm, therefore state survival depended upon preserving the health of young men. Control of the poor, a form of domestication, was another reason for the popularity of hospitals. United Kingdom: According to Wilson (page 9), the Bills of Mortality indicate not only the effects of improved environments but also of medicine. He bases his judgement on the introduction of inoculation, specifically for Smallpox, and the competitive establishment of hospitals during the period of the late 17th century until 1750100. By 1745, general hospitals existed throughout the UK. In that year Guy’s Hospital, St. Georges and Middlesex were all established in London. Although blood-letting was still employed, in marvellous contradiction of Harvey’s discoveries on circulation of blood, from the end of the 17th century there were new cures for malaria, guanine from the bark of the Cinchona tree from South America.101 Wilson identifies three types of voluntary hospital. London general hospitals, provincial general hospitals, and London specialist hospitals. None of the central drivers of these innovatory institutions were physicians but subscribers, those who volunteered their wealth to set up institutions. Subscribers appointed physicians and also recommended prospective patients for admission. The initiative for each hospital was entrepreneurial, a small group of subscribers gathering together to set up an institution, with only one established by a doctor who then, it seems, obtained financial backing. According to Wilson, the original idea was to infuse the Poor Law with Christian charity, medical practice based on relief and care, not cure. It proceeded, like a number of societies 100 Szreter, Simon. Health and Wealth. Studies in History and Policy. University of Rochester Press. 2005. 101 Sloan, A.W. English Medicine in the Seventeenth Century. Durham Academic Press. 1996.

and projects of this period, from a coffee house. Wilson, in addition, demonstrates that the model for these hospitals was based on the Society for the Promotion of Christian knowledge, which had begun in 1698, also with four founders. Wilson describes the founders as High Tory, closely involved with the Church of England. The founding of a number of workhouses appears connected to the establishment of hospitals for religious and political reasons. In Bristol, where a city workhouse was founded in 1696102described by Mary Fissell as the result of ideological aspects of Interregnum approaches to poor relief (page 7) and Low Church interest in the reform of manners. Hospitals she describes as serving as arenas for the negotiation of social power between elites. The Infirmary in Bristol embodied concepts of the relationship between rich and poor, according to the dominant and male elite who perceived themselves as stewards of the poor. It was nevertheless based upon the reforming nature of the Bristol workhouse, concerned with improving the behaviour and manners of the poor (Fissell, page 74). It involved therefore a measure of gentrification.103 Its charitable duties were of greater concern than its medical care, and originally doctorâ&#x20AC;&#x2122;s had limited power. The notion, still prevalent in modern day hospitals, that all inhabitants of a hospital must abide by a strictly imposed regimen within a structured environment appears to have come from medieval monasteries, 104

certainly those which engaged a physician and an infirmary for both monks and local

villages. Founded by John Elbridge, The Infirmary was under the control of its committee, mainly Quakers and city merchants. It was funded also by subscribers, who paid two guineas a year, allowing them to recommend one inpatient and two outpatients at a time. Within hospitals, based upon notions of power being negotiated within their walls, medical men gradually assumed the power of the elite groups, often members of the aristocracy in other provincial hospitals, who established these charitable institutions. 105 The abiding rational for available treatment was that only the deserving poor should benefit.

That, as we have already seen, meant those who worked and exhibited stable lives

102 Fissel, Mary.E. Patients, Power and the Poor in Eighteenth-Century Bristol. Cambridge University Press. 1991. 103 See, An Unusual Power: The Social Construction of Madness. 104 Bowers, Barbara.S. Ed. The Medieval Hospital and Medical Practice. Avis ta Studies in the History of Medieval Technology, Science and Art. Ashgate.

105

and behaviour. Its charity was not to be dispensed randomly but only where it would do the most good. Assessments and cures of the body, requiring close observations were necessary, involving different processes from the workhouse. A hospital setting also enforced passive and mannerly acceptance of charity, medical care, controlling demanding behaviour, and established a clear relationship between ‘giver and getter’ (Fissell, page 77). From its inception, The Infirmary, targeted on the working man, was concerned with returning individuals to daily work, increasing the city’s wealth and the wealth of the hospital’s benefactors, in effect, making, in the words of John Cary, a Bristol Merchant, who established the workhouse, “Multitudes of people serviceable who are now useless to the nation.” The Infirmary accepted patients only once their clothes were clean, thereby, according to Fissell (page 82), simulating the deserving poor. Once inside, patients could not play dice or cards, nor were they permitted to smoke. After breakfast, surgeons and their pupils and apprentices made their rounds, tending to dressings and cleaning wounds. Although Mary Fissell notes that the culture within The Infirmary simulated ideas of primitive Christianity, it also appears to have replicated nunneries and monks, with the apparently purposeless regimentation. The growth of medical power within The Infirmary appears to have followed a similar route to elsewhere, as in part the consequence of doctor’s changed relationship to the body, whereby it was seen as a machine, not harbouring a soul and the dignity that goes with such a concept. Also, teaching became an essential part of the institution. In 1740 Joseph Shapland was apprenticed to the hospital apothecary, who was in charge of the day to day running of the hospital. During the second half of the 18 th century, surgeons brought in apprentices and pupils. The increased number of medical practitioners throughout the century gradually altered hospital culture, allowing for increasing domination by medical staff with professional rather than charitable motivations, although lay people remained in overall charge. A further consequence of the gradual rise of The Infirmary as an educational facility, becoming by the 1770s the de facto centre of surgical education in the city, was that many sons of the gentle folk went into The Infirmary to train, and not into private practice. The Infirmary surgeons after all enjoyed a constant supply of raw material to work on, thereby improving their skills. The bodies of dead patients underwent autopsies, allowing greater understanding of the

bodyâ&#x20AC;&#x2122;s mechanisms. From 1728, burking increased, whole corpses or parts of corpses taken away to be dissected. The development and evolution of walled facilities aided the development of physicians, from laissez faire operators to that of an organised group with a fixed and powerful group identity. The ideal of a super-efficient, all-knowing, scientific-minded physician was forged within these medical monasteries separated from the rest of the community. Here, medical treatment was contained and ideas of medicine, treater, treatment and patient formed.

Monasteries and Workhouses: Hospitals of the 18 th century were informed by workhouses and monasteries. On the one hand containers for human bodies, and on the other bodies to be cared for. Separation and segregation emerged as an element of medical treatment, with that treatment removed from both the community and those lay people who practised community medicine. Although in medieval times hospitals were not solely about providing medical care, also offering spiritual care, nevertheless the physicianâ&#x20AC;&#x2122;s practice was separate from areas of worship, with medical care and patients segregated. As early as the ninth century a monastery consisted of an infirmarium for monks, a paupers hospital, where pilgrims could also find shelter and care, a place for guests, a leprosarium and a hospital for novices and nuns (Lindemann, 2010). In later hospitals, the segregation was complete with illness removed more and more from the general community.106Although the medicalization model asserts that care not cure was the abiding role of early hospitals, such a position tends to ignore the actual treatments on offer. Before medicine became fixated on place, medical personnel were not immediately identifiable, posing, in a way, also as priests and nuns (Lindemann, 2010.) There was not until much later clear hierarchical structures in place, with patients occasionally working as physicians or nurses. Certainly, 18th century hospitals made their mark on medical organisation and character, but also created the patient. They were separate from the general community, often by walls 106 Lindemann, Mary. Medicine and Society in Early Modern Europe. 2 nd edition. Cambridge University Press. 2010.

with gates. Beds, often used for more than one patient at a time, were arranged in rows for the celebration of Mass and other religious occasions. Within such institutions, physicians acquired greater power and control over their patients, and also patients had less choice in their treatment.

Man-midwifery/accoucheur: As during this period ‘accord between patient and practitioner was broken as medical men arrogated interpretations of the meaning of illness to themselves’ (Fissell, page 172), and sanctity and ownership of the body became disputed, the further colonisation of health was demonstrated by the rise of male mid-wives and the further exclusion of women from medicine. Lindemann (2010) sees this process as one begun in the Middle Ages, see previous papers, it increased during the 18th century and formed part of the masculinisation of midwifery. The invention of obstetrical forceps by Englishman Peter Chamberlen the Elder allowed his family to deliver babies who might otherwise have died. Midwives were banned from using instruments but nevertheless probably did (Lindemann, 2010). Contrary to popular belief amongst both medical historians and laypeople, the rise of man-midwifes was not, according to Lindemann, a consequence of male colonisation of medicine, although that had been going on for centuries, but in order to supervise and control women practitioners. Throughout the 18th century many women remained as authorities in midwifery, such as Madame de Coudray and Sarah Stone, who produced textbooks and generally acted as erudite physicians attending lectures and exhibiting theoretical sophistication in obstetrics.

Afterthought:

The above developments must be viewed alongside actual practices, otherwise it all takes on an unnatural tinge, with professional rhetoric posited once again as reality. The text forming ‘An 18th Century Physician’s Notebook’ demonstrates, according to the editors, the

day to day practices of an unknown physician active in the early 18 th century, influenced by Sydenham (1624-1689), who believed in bedside observation of patients not dogma, and Hermann Boerhaave (1668-1738), an influential physician of the time who believed that sickness was caused by an imbalance of bodily fluids and the excitation of fibres within it. He considered that the human body resembled a machine, perceiving health in terms (Porter) 107

of hydrostatic equilibrium. The editors consider the unknown author of the handbook to

have been a modernising exponent of his profession. Nevertheless, as a physician he advocates bloodletting and wood soot for the treatment of pleurisy, with references to alchemy for the treatment of Suffocating Catarrh, bloodletting and mercury advised for continued hoarseness, and sulphur and turpentine offered for impotence. These are just a few examples and do not clearly indicate a scientific approach, whereby treatment and cures are synthesised. Such methods reflect the premise that sickness is cured by stimulation and trauma, authorised and legitimised by the physicians of the day. Clearly, the fact that many failed to work on the various symptoms did not stop their use. Illnesses once identified were accompanied by an identified cure, often passed down through generations, which when established were rarely altered. Proportions were often the only part of the treatment subject to change. The curative effects of sulphur, once defined, encouraged sulphur to be administered for a number of illnesses that simulated previous identified illnesses for which sulphur could be used. Usually, a number of treatments and compounds were employed together. Formulae were created, their efficacy established by the toxicity and invasive nature of the ingredients. As I will demonstrate, this is often the case in modern medicine, where formulae overwhelms observation and reason.

Ideal bedside behaviour (Porter, 1999 page

257), how the physician appeared and behaved, was, as now, an essential part of treatment. Although Porter (1999) shows that religion, magic, salves, prophylactics and remedial practices were commonly used by the general population in the 18 th century he fails to acknowledge that these cures were also used by physicians. People made up their own remedies, or used folk healers, preferring the experience of an elderly woman, for example, than an inexperienced physician. Physicians cast their cures under the magic of learning and science, investing toxic compounds with non-existent curing capacities, occasionally (Cockayne, Stow 2012) through the prism of alchemy. Day to day medicine remained in the 107 Porter, Roy. The Greatest Benefit to Mankind. A Medical History Of Mankind From Antiquity To The Present. Fontana Press. 1999.

hands of cunning men and women and family members. Many of the treatments they offered were, I suspect, effective.

Advancements in medical treatment: from medieval times to the Enlightenment. From ignorance

science.

Bloodletting, involving venesection, was employed by Galen for fever, either as a result of yellow bile, black bile or phlegm (which Galen called cacochymia) or from blood excess (Plethora). It continued to be extensively used until the well into the 19th century. According to Porter (1999, page 313), it was employed by Broussais, chief physician of the Paris Val de Grace military hospital, for everything in his dispute with peers who localised pathological anatomy. He used leeches. His disciple, Bouillard (1796-1881) continued this treatment, often, like his master, to excess. While nowadays we consider the above practice pointless and often dangerous, many famous figures, such as Byron, bemoaning their early deaths as the consequence of this treatment, it seems mysterious that it lasted so long. While it may not have helped in fevers, it certainly tipped many into the grave. I believe that this kind of professional blindness remains with us, not just in medicine. Physicians believed that bloodletting was beneficial, as they had been trained to believe so. In this instance, evidence to the contrary counted for nothing. Bloodletting was an essential part of the medical practice of surgeons and physicians, which often set them apart from other healers. While it fitted in with the belief in a single source for all illnesses, a large degree of wishful thinking was involved, a flawed understanding of cause and effect existed then as now, devolved upon medical authority. Patientsâ&#x20AC;&#x2122; improvement would have been seen and recorded in changes in skin colouring, for example, or in other superficial physical aspects. As these were held to denote a patientsâ&#x20AC;&#x2122; progress, although there was no clear evidence of this, the treatment was considered advantageous. We therefore have here a particular kind of knowledge, one that is not based on evidence but on professional

authority entwined with ancestor reverence. This knowledge relies on material evidence being ignored or/and a different kind of evidence, peer-reviewed if imasginary, fulfilling the requirements of cause and effect.

Power. Physicians were gaining greater power as a consequence of the centralisation of authority within European states. In France, many became servants of the King, in Britain they assumed managerial roles within hospitals, in Portugal they acquired power through association with the inquisition, and in the German states through again becoming an arm of government. In addition, they marketed their importance through identification with science, even though they failed in most instances to practise the new intellectual discipline with their patients. Most medical innovations came on the back of Harvey’s discovery and were often variations of his breakthrough. In many instances their treatments appear little more than combinations of magic and alchemy. The colonisation of sickness by physicians reflected the groups developing sense of managerial efficiency compared to the sloppy behaviour of lay healers, no matter how experienced. The man-midwife, or accoucheur, were after all graduates who had access to equipment. These reasons gave impetus to physician’s involvement in child birth, as many claimed that mid-wives required supervision. Physicians diagnosed through the five senses-feel the pulse, sniff for gangrene, taste urine, listen for breathing irregularities and observe skin and eye colour (Porter, 1999 page 256). Physical examination was unusual and diagnosis depended on ‘interpretation of the patient’s own ‘history’ (Porter, 1999, page 257). In the early part of the 18th century, medical advances concerned patient/physician interaction. Understanding of sickness remained confined to personal factors such as diet and lifestyle, which was often evident in the lives of the rich, whom physicians mainly treated, but less so amongst the poor. Many of their patients suffered from gout, which was recognised as a consequence of excess (Porter, 1999, page 258). Apparent change was the order of the day, with physicians acquiring considerable power, while actual medical practice moved crab-wise