Medical Theory and Practice

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Medical Theory and Practice

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Galen. At the top of the pyramid of medical care providers that characterized the medical marketplace was a small group of elite physicians who were extensively trained in the liberal arts and academic medicine at one of Europe’s universities. Medicine for this group was defined by an intimate knowledge of classical Greek theories about health and disease that was conveyed principally in the works of antiquity’s greatest medical writer, Galen (second century C.E). Galen’s medicine came to the Latin West first by way of Arabic versions of his writings or commentaries on them, which were rendered into Latin in the eleventh to the thirteenth centuries, and later in translations made directly from Greek manuscripts imported from Byzantium or discovered in remote monastic libraries. Recovery of these texts was uneven, with the therapeutic and general-theory treatises reaching Western readers before the research-oriented anatomical and physiological works, owing in part to Islamic emphasis on therapy and disinterest in anatomical knowledge for its own sake, beyond what was required for surgery.

Physician and Physiology. Galen had insisted that a proper physician be well versed in philosophy, particularly that of Aristotle, and this approach suited medieval readers, who wished to develop medicine from the mere craft of healing, handed down by apprenticeship, into a learned profession. Aristotle’s philosophy was introduced into the curriculum of medieval universities early in the thirteenth century and came to dominate the curriculum by midcentury. By the time of the Black Death, medicine had joined law and theology as one of the three graduate departments that a well-endowed university featured, and achieving a medical degree presupposed a solid preparation in Aristotelian philosophy, especially natural philosophy. So close was the connection between theoretical medicine and natural philosophy that the Greek terms for nature (physis) and natural philosopher (physiologos) caused the term physicus to replace medicus for the educated physician, resulting in the modern usage of the terms physician and physiology in a predominantly medical sense.

Emergence of Modern Science. This connection is crucial for understanding the nature of elite medicine in the Renaissance and Reformation as well as the importance medicine as a field had for the development of natural philosophy and thus the emergence of early modern science. Even in 1600 there were few professional opportunities for those engaged in scientific research or teaching, other than in philosophy and medical departments at the universities or the practice of medicine. Consequently, many of the innovators in science and technology were, like Nicholas Copernicus and Georg Agricola, trained in medicine, the concerns of which bore directly on fields such as astronomy, alchemy, and physics, as well as on the early development of zoology and botany.

Conservatism. The practice of elite medicine was intrinsically conservative and did not change much from the time of Galen until the nineteenth century, nor was it

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At age 45, after a years of wandering from court to court, job to job, the Swiss-born physician Paracelsus settle down for a couple of years in Carinthia (Austria), where he composed three treatises that are known collectively as his Carinthian Trilogy. The first of these is a vigorous defense of his novel medical ideas, which were ridiculed by contemporary court physicians, titled The Reply to Certain Calumniations of His Enemies or Seven Defences. The following is an excerpt from the fourth defense, “Concerning my journeyings.” In it one sees Paracelsus’ praise for the Spartan life of the wandering student of nature, who sacrifices personal comfort and monetary gain for sake of true knowledge of nature. His demand that one must travel to learn must have been old already, but appealed to his sixteenth-century followers, who took up his cry to abandon books and seek the knowledge of medicine from alchemy and other experiential sciences; by talking to artisans and peasants, rather than reading the books of Galen and Aristotle. The Book of Nature (codex naturae) that he mentions at the conclusion of this passage refers to the idea that God’s revelation is written in both the Book of Scripture and in the Book of Nature, and therefore personal study of nature is a religious process analogous to formal theology.

A physician should first of all be an Astronomus. Now necessity demands that his eyes should give him evidence, in order that he may be such; without this evidence he is only an astronomical gossip. It demands too that he should be a Cosmogmphus: not to describe how the countries wear their trousers, but to attack more bravely what diseases they have. Although it be thine intention and desire to be able to make the costumes of this land from what thou hast learned here, and thou excusest thyself thus from gaining knowledge of strange lands, what concern is it of the physicians’s that thou art a tailor. Wherefore, as the things now mentioned must be experienced, they belong to us Parabolanis [doctors who attended patients in their homes] and are bound up with medicine and not to be separated from it. Thus it is necessary that the physicians should be a Philosophus and that his eyes inform him in order that he may be such; if he desires to be one, he must gather together from all quarters what is there. . . . For the arts have no feet . . . English humores are not Hungarian, nor the Neapolitan Prussian, wherefore must thou go where they are; and the more thou seekest them out and the more thou learnest of them, the greater is thine understanding in thy native land. Thus it is also necessary that the physician be an alchemist: if now he desire to be one, he must see the mother from whom grow the Mineralia, Now the mountains go not after him, rather must he go after them. Now where the Mineralia lie, there are the artists; if a man wish to seek out artists in the analysis and preparation of nature, he must seek them in the place where the Mineralia are, How then can a man find out the preparation of nature, if he does not seek it out where it is? Should I then be blamed because I have wandered among my Mineralia and learned the temper and heart, and grasped in my hands the art of those who teach me to separate the pure from the dross, by which I anticipated much evil? Nonetheless I must also repeat the philosophic saying, that wisdom is despised only by the ignorant; thus, too, art by those who do not profess it. . . . Wisdom is a gift of God. Where he gives it, there should one seek it out. Thus too where he has placed art, there should it be sought. It shows great perception in man that man is reasonable enough to seek the gifts of God where they lie, and understands that we are obliged to go after them. If then there is an obligation here, how can one despise or spit upon a man who carries it out? It is true, those who do not thus, have more than those who do: those who sit in the chimney-corner eat partridges and those who pursue the arts eat a milk-soup. The corner-trumpeters wear chains and silk: the wanderers can scarcely pay for ticking [straw for a mattress]. Those within the walls have it cold and warm according to their wishes; those in the arts, were it not for a tree, would have no shade. Now he who would serve the belly, he follows me not; he follows those who go in soft raiment, although these are unfit for wandering. . . . I think it praiseworthy and no shame to have thus far journeyed cheaply. For this I would prove through nature: He who would explore her, must tread her books with his feet. Scripture is explored through its letters; but nature from land to land. Every land is a leaf. Such is the Codex Naturae; thus must her leaves be turned.

Source: Paracelsus, Four Treatises of Theophrastus von Hohenheim called Paracelsus. translated by C. Lilian Temkin and others, edited by Henry E. Sigerist (Baltimore: Joans Hopkins University Press, 1941), pp. 26-29,

ever particularly successful from the modern point of view. However, while it is true that therapeutic methods as a whole remained much the same over this period, inasmuch as bloodletting was still a preferred treatment for “fevers” in the eighteenth-century Enlightenment, there were, nevertheless, several innovations, such as the use of chemically prepared, mineral-based drugs. Also, the use of even traditional therapeutic methods varied by practitioner and was often subject to changes in theory and debates over proper procedures. Moreover, the historical actors themselves— patients and physicians—clearly believed that they could achieve some measure of relief, if not always a cure. In a world characterized by frequent mortality at any age in life, and lacking adequate record keeping, medical care and longevity could not easily be correlated.

Balance of Fluids. Galen’s medicine was based on theories of health and disease that were handed down from the earliest medical writers, the Hippocratic physicians, but supplemented by the extensive anatomical and physiological researches carried out at the Museum of Alexandria during the Hellenistic period (the third and second centuries B.C.E.). Galen regarded health as a state of balance, where the body’s four basic fluids—blood, phlegm, yellow bile (choler), and black bile (melancholia)—are mixed in a proportion that is suitable to the individual’s natural state. Each of these four fluids was associated with a pair of the four basic qualities that Aristotle had defined as fundamental to material substances—hot, cold, wet, and dry. Blood was wet and hot, phlegm was wet and cold, yellow bile was hot and dry, and black bile was cold and dry. According to this system, an old man, for example, would naturally be drier and colder than a young man, who would have a warmer and moister temperament, or natural constitution. One would expect an elderly patient to have a balance characterized by more black bile, which was by nature dry and cold, and less blood, which was warm and moist. Older people were, therefore, by nature more melancholic, since they had more black bile, and younger ones more sanguine (from sanguis, the Latin word for blood). Women were naturally colder and moister than men and therefore had more phlegm (were phlegmatic) in a state of health, although old women were as a rule drier than young women. The system was extraordinarily complex, taking into consideration many factors that were idiosyncratic, such as one’s profession (students and scholars tend to be naturally melancholic, that is, rich in black bile), the positions of the planets at one’s birth, the time of the year one became ill, which part of the body was affected, and so on. The first job of the physician was to know the patient’s normal constitution and evaluate the various factors that may have affected it in order to determine if he or she were imbalanced and in what way. Such an imbalance was not regarded as a symptom of disease, but rather as the disease itself.

Therapeutic Approaches. Treatment for a fluidic imbalance, a state of disease, took one of three forms, according to classical medicine. The physician first sought to rebalance the patient’s fluids by adjusting his or her diet and lifestyle (regimen), in an attempt either to diminish those fluids that were in excess or to supplement those that were deficient. If this approach failed, or if the disease was acute and demanded more-radical therapy, drugs would be administered in order to alter specific qualities in the body or to force the expulsion of the excess fluids by vomiting, excreting, secreting, and sweating. Medieval and Renaissance pharmacies were filled with diverse natural drugs that were harvested from various parts of plants, derived from animals and their excrements, and mined from the earth as mineral salts. These drugs were used alone as “simples” or were compounded together according to recipes, and used either to alter the body’s qualitative balance directly or else to promote vomiting (emetics), excretions (purgatives), sweating (sudorifics), and various other real or imagined means of evacuating excess fluids and restoring balance. As a guide to adjusting the patient’s temperament, according to the principle of contraries (that is, use a hot, dry drug to cure a cold, wet disease), Galen associated qualities with drugs and rated these on a scale of one to four degrees. A drug might be hot in the third degree and dry in the first, for example. Such a mathematical system pleased those who sought certainty in medicine, but stymied physicians who thought that the specific characteristics of diseases and drugs could not be reduced to a calculus of the four qualities.

Bloodletting. In cases where blood was in excess, as evident by fevers, inflammation, and skin lesions, which were thought to indicate the body’s natural attempt to get rid of excess and corrupt blood, balance was restored by the removal of blood by one of several methods, the most drastic of which was venesection, the cutting of a vein to let out some blood. This process was regarded as a surgical procedure, the third form of chemical therapy, and was routinely practiced by surgeons or barbers in the Renaissance. The professional symbol of the barber, the red and white striped barber’s pole, is thought to have represented the blood and bandages that were associated with this trade when such emblems were needed to advertise to an illiterate public. Elaborate theories dictated the part of the body from which the blood was to be removed and how much. Bloodletting was so common that it was even used as a preventative, along with diet, and patients would ask to be bled in the spring, in anticipation of an outbreak of plague, and at other times they deemed healthful. Bleeding patients with acute fevers seems particularly misguided from a modern standpoint, but the loss of an appreciable amount of blood would have cooled and calmed the medieval and early modern patient, giving relief from the symptoms, if not actually curative. Moreover, having blood let was probably less stressful than another surgical treatment, the use of caustic chemicals or hot iron rods to cauterize the skin and thus heat and dry the body.

Other Options. Surgery also comprised other sorts of invasive surgical procedures, such as lithotomies (cutting to remove bladder stones), repairing hernias, excising cancers, and lancing infected glands. However, throughout the Renaissance and Reformation, treatment involved a mix of the three forms of therapy, and physicians and surgeons attempted to heal wounds by administering oral drugs as well as through surgery. The application of drugs to the outside of the body as oils, salves, and poultices, for example, was commonly regarded as the province of the surgeon, even if they were being used to heal such diseases as leprosy, syphilis, and plague, and although internal medicine was in theory left to the physician, in reality practices overlapped. One must keep in mind that there were few physicians per capita and that the prescribed methods of treatment were often known and practiced by surgeons, elders in the community, or members of the family. This situation was especially true in rural areas and provincial towns where M.D.s were rare.

Chemical Malfunctions. Galenic medicine underwent several significant changes in the period from 1350 to 1600. On the one hand, university medicine moved closer to Galen’s ideal, as new texts from Galen’s formidable medical scholarship were discovered and better translations were printed and absorbed into the curriculum. The medical faculty at the University of Paris, to take the most extreme example, became more radically Galenist during the course of the sixteenth century, to the legal exclusion of competing theories and therapies. On the other hand, a novel blend of alchemical theory and use of mineral drugs that was associated with the Swiss-German physician, religious radical, and iconoclast Paracelsus challenged Galenism and won many adherents, particularly among surgeons and physicians trained in several German universities, as well as Basel, Switzerland, and Montpellier, France. The Paracelsians, or chemical physicians, viewed diseases as the result of specific chemical processes or malfunctions of natural, healthy chemical processes that took place at specific locations in the body, rather than as imbalances, and they sought to correct them by administering chemical drugs to restore the body’s normal, healthy chemistry. This approach was a very different way of conceptualizing diseases and conflicted with Galen’s theory.

Spiritual Elements. Where the Galenists reduced disease to a fluid imbalance resulting in a qualitative state— too hot, cold, moist, or dry (or an appropriate combination of these)—the Paracelsians characterized diseases as being caused by “inflamed sulfur,” “copper salts,” “nitre,” or other chemical substances. They thought that all such substances were reducible to combinations of the three spiritual elements: salt, sulfur, and mercury. Therefore, where the Galenist might prescribe a bleeding or a complex compound mixture of herbal drugs that was designed to provide just the right amount of heat and moisture to counteract a cold and dry disease condition, the Paracelsian might administer a somewhat toxic chemical elixir with the aim of expelling the harmful products of the disease process and helping the body’s native healing tendency restore its proper chemical operations.

Professional Differences. The differences between the Galenist and chemical approaches to medicine were striking on many levels of theory and therapy and were even reflected in the religious consequences of their philosophies. Controversies arose between the two kinds of medicine. Medical disagreements sometimes divided along political, confessional (religious), professional, and social lines. In late-sixteenth-century Paris, for example, chemical physicians were banned by the university, which controlled medical practice in the city, but were supported by the French crown and found employment at royal institutions and in aristocratic households. Chemical medicine was consequently shunned by Paris-educated physicians, while often adopted by those with degrees from the University of Montpellier, in southern France, and by apothecaries and surgeons. In addition, while French Galenists tended to be Catholic, chemical physicians were often Protestant Huguenots, although such distinctions were not so simple elsewhere in Europe. The ensuing controversy raged within the medical community during the latter part of the sixteenth century and through the seventeenth century, with the result that chemically prepared medicines came into wide use against diseases that were recognized as particular kinds (generic) rather than as imbalances limited to individual constitutions. As time went by, chemical drugs were slowly adopted by Galenist physicians, too, although their application was given new explanations that were consistent with Galenic theory.

Dissections. Another major change that medicine underwent in the Renaissance and Reformation was the increasing investigation of the human body and the teaching of anatomy to both physicians and surgeons. Before the rise of university medicine, surgeons and physicians dissected animals to study anatomy, if they bothered at all. Such training had apparently disappeared in the West during the early Middle Ages, and when medicine was again taught at Salerno, in the ninth to eleventh centuries, scholars depended on translations of Arabic medical treatises for guidance. Islamic medicine did not view knowledge of the anatomy of cadavers as useful to healing the living, and Galen’s anatomical research was not incorporated into their teaching, beyond what applied directly to surgery. Galen had been an avid student of human anatomy and physiology, and beginning in the fourteenth century, as his teachings gained influence, surgical and medical professors sought to emulate his example. By 1400 Europe’s best medical schools required its students to attend at least one annual public dissection of a human body. Sometimes these mandatory dissections included male and female cadavers for comparison. Cadavers were provided by the municipal or royal governments, which arranged to have condemned criminals executed at an appropriate time so their bodies would be fresh for the scheduled dissections. These events would be accompanied by dissections of various kinds of animals—a sheep, pig, or pregnant dog, for example—to enable greater understanding of human anatomy through comparison of similar parts.

Spread of the Practice. At the same time, particularly at southern European universities and municipalities, autopsies were made on the bodies of those who died destitute and without family, or in instances when the cause of death needed to be determined. These procedures were conducted by noted surgeons and physicians in front of an audience of their clinical students. The regular practice of dissection gradually spread to northern Europe in the course of the fifteenth and sixteenth centuries, and by the mid seventeenth century the foremost human anatomists were to be found in Copenhagen, Leiden, Amsterdam, Stockholm, London, Paris, Oxford, and several of the universities in Germany, as well as in the traditional medical strongholds of northern Italy.

Vesalius. Anatomists and their students at first relied on a dissection manual composed in the early fourteenth century by Mondino da Luzzi or on a commentary or other text based on it. Galen’s anatomical treatises were translated during the fourteenth to sixteenth centuries, but his level of knowledge and technical proficiency were not matched until the sixteenth century, when the Paris humanists began to consciously pattern their research after his. The most famous of these men were Jacques Dubois (Sylvius) and Johannes Guinter of Andernach, whose student Andreas Vesalius is credited with surpassing Galen and drawing attention to the fact that there was still much to be discovered through dissection. Vesalius insisted that people should dissect diligently and look for themselves rather than rely on written authorities alone. During Vesalius’s lifetime, the Italian universities of Bologna and Padua, where he taught in the late 1530s and early 1540s, became the premier schools of anatomy and drew students from all over Europe. They, in turn, took his techniques and insistence on verifying written texts through personal observation to other schools, thereby laying the foundation for many new discoveries about the organs, their functions, and the various systems of the body, all of which revolutionized human physiology in the seventeenth century.

Influence of Hippocrates. While some humanists were reviving Galen’s methods of anatomical and physiological research, others were seeking to emulate Hippocratic medicine, with its attentiveness to the individual patient’s clinical manifestations. Again, the northern Italian universities were leaders, making clinical (bedside) experience a part of a student’s education already in the thirteenth and fourteenth centuries, but the Paris humanists self-consciously promoted the clinical approach, in terms of writing down exemplary case histories, in emulation of the Hippocratic Epidemics (circa 420-350 B.C.E.). Although true clinical teaching in the modern sense was not developed until the early nineteenth century, the ideals and rhetoric of patient-oriented medicine were being touted by renowned physicians such as Jean Fernel in the mid sixteenth century and provided a needed corrective to what had become an overly elaborate, theory-dominated medicine of the university-educated Galenists.

Conclusions. In summary, four medical contributions emerged from the sixteenth century to fertilize medical discussion during the scientific revolution of the seventeenth and eighteenth centuries. First, the high level of ancient Greek medicine was recovered with Galen’s theoretical and therapeutic system. Second, his anatomical expertise was surpassed, providing the means to wholly revise understanding of the body and its operations. Third, physicians were again promoting the collection and recording of symptoms and results at their patients’ bedsides, which encouraged a reexamination of the nature of diseases and what seemed to avail against them. Finally, chemical medicine, which owed little to classical Greek medicine, emerged as a new way of looking at the human body, its diseases, and the workings of the world in general. These multiple streams of medical thinking flowed together to reshape medical theory in early modern Europe.

Sources

Vivian Nutton, ed., Medicine at the Courts of Europe, 1500-1837 (London & New York: Routledge, 1990).

Katherine Park, Doctors and Medicine in Early Renaissance Florence (Princeton: Princeton University Press, 1985).

Andrew Wear, Roger French, and Iain Lonie, eds., The Medical Renaissance of the Sixteenth Century (Cambridge & New York: Cambridge University Press, 1985).