Medical Ethics, History of Europe: II. Renaissance and Enlightenment
II. RENAISSANCE AND ENLIGHTENMENT
Medicine in early modern Europe (from the later fifteenth century to the end of the eighteenth century) is best characterized by its diversity of practitioners, practices, and conceptual foundations. Even by the end of the eighteenth century, few places in Europe had effective regulations to restrict medical practice to people with certain kinds of certification, or to regulate their practices. University-educated practitioners differed sharply with one another about the true conceptual foundations of good and effective medical practice, while among the merely literate, or even the illiterate, practitioners, views about the constitution of good medicine varied even more.
Many medical changes occurred during the period: The number of university-educated physicians rose considerably, as did the number of other formally trained (usually apprenticed) practitioners. With the proliferation of schooling, the educational level of many ordinary practitioners rose. And while the beginning of the period was marked by the proliferation of various philosophical and medical systems, by the end of the eighteenth century most of those systems had been set aside by the educated elite in favor of varieties of a more unified "science."
Throughout the period, no formal systems of medical ethics existed per se. Yet medical practitioners took varying degrees of interest in ethical issues, issues that commonly focused on the personal character of the practitioner. The discussion of the period that follows is therefore divided into two parts: a description of the general structures of the period and the organization of medical practice; and the debates among the literate, and especially among the learned, over the foundations of good medical practice and behavior.
Social Structures of Medical Practice
European society underwent a major transformation from the fifteenth to the eighteenth century. Throughout the period, Europe remained an overwhelmingly rural region, and at times the population grew rapidly. And, because of demographic, economic, political, and intellectual changes, city life came to typify refinement. As a result, most of the great changes in medical practices and mores took place in the cities, although most of the people needing care continued to live in the countryside.
The vast majority of the people in Europe—nine in ten, or more, depending on when and where—lived in a rural environment: in small towns or villages, in hamlets, or on rural manors; a few even resided in the forests and fields. In the fifteenth century, many rural laboring people lived relatively well, since after the fourteenth-century plague (the Black Death), there was land enough for most. But during the sixteenth century, the European population increased rapidly (perhaps about 1 percent per year); it generally leveled off during the seventeenth and early eighteenth centuries; and late in the eighteenth century again began to increase rapidly. While at first, people could generally grow enough food for themselves and their landlords and a little extra, with the increasing population of the sixteenth century, the number of rural itinerant laborers and destitute began to rise rapidly (Flinn).
Ordinarily, rural people bartered with neighbors and used money only occasionally, relying on mental accounts of who owed what to whom. At local markets, though, they might purchase a few goods manufactured locally or imported from afar, and sell their own goods or labor. When they needed medical care, most ill people and those caring for them relied on practices long used: self-help; recipes for home remedies (or "kitchen physic") passed down through kin or neighbors; and other traditional practices that could be gathered from local people, which might include ritual and invocation (or what the educated sometimes called "superstitious" practices). Beyond the resources of neighbors and kin, the sick often had available to them the services of people with special knowledge or powers: clergymen, herb wives, sorcerers or witches, and people who healed by special powers of touch. In return for medical help, payment might be in coin, but probably more commonly added a debt to the mental balance of favors, or earned the practitioner goods or services such as chickens or eggs, pasturing an animal on the patient's land, or the patient's help in doing certain chores.
In a few regions, however—mainly from northern Italy along the Mediterranean coast to southern Spain, in the Low Countries and northern France, a thin strip along the south edge of the Baltic, and in southeastern England—urban life was more common. In the fifteenth and early sixteenth centuries, people in towns and cities raised animals for slaughter, and sometimes kept a plot of ground nearby on which they grew food. But by the later sixteenth century, many towns were becoming too large and too densely settled for such practices. Much of the increasing population was drawn from the countryside into the cities or, later, pushed to the overseas colonies. Many people spent a part of their lives in a city working as laborers or servants, returning to their towns or villages after accumulating enough money to establish a family. Others migrated to the towns and cities permanently, causing a huge expansion of wealthy, middling, and poor neighborhoods. The largest city in Europe, Naples, soon had rivals in Paris and London. Just how brutal were the conditions of urban life has been vigorously debated; what is clear is that urban mortality and morbidity rates in the age before plumbing and sewerage were very high indeed.
The cities wrought important economic changes, especially a greater use of money. The demand for food among the urban populations also transformed nearby regions into centers of market agriculture where individuals or landlords produced cash crops. In some areas, such as southeastern England and the Netherlands, this agricultural revolution brought into being a free yeomanry; in other regions, such as Prussia and Russia, it brought about a reenserfment of the peasantry by great landlords. Whatever the local consequences, throughout Europe people increasingly grew used to buying and selling labor and goods, and to handling money; even rural laborers often had a few copper pennies at their disposal.
With the increasing importance of money as a means of exchanging value, more and more people supplemented their incomes by engaging in medical practice for money, or relied upon it entirely for their living. Many, undoubtedly most, such people offered their services to ordinary people, doing so in their neighborhoods or traveling to offer their services among strangers. If itinerant, they found their customers wherever gatherings occurred: markets, crossroads, taverns, inns, alehouses, coffeehouses, and even street fights. They might also gather a crowd by saying something interesting from a platform or from horseback, or by presenting an entertainment from a table, wagon, or stage: These people soon acquired the name of quacksalver or quack (a term of obscure origin), or mountebank (probably from climbing on benches).
With the spread of the printing press and the growth of literacy in the later sixteenth century, medical advertising could be used to heighten the practitioner's reputation or to attract more people to the shows. Medical advertising could also publicize the practice of someone who did not travel but practiced out of a shop, inn, or house. By the later seventeenth century, as the postal systems of many regions of Europe developed, advertisements could be sent to agents for posting throughout a region, and medical customers could order remedies through the mail. The medical practitioners who relied on such methods for their incomes might offer special services (like cutting for cataracts or bladder stones, or setting bones), or sell special remedies (what became known by the eighteenth century as "patent remedies") (Cook; Porter, 1989; Porter and Porter).
In the cities and a few large towns, craft guilds of medical practitioners came into being or expanded from their late medieval roots. Guilds had municipal charters allowing their members the rights and privileges of citizenship, and the group the right to act as a corporation: to stand as one person before the local courts, to own property, to pass internal rules regulating their members and organizing them by rank, and often to restrict certain practices to their own members. Throughout early modern Europe, guilds of barber-surgeons and surgeons, or groups of barber-surgeons and surgeons in other guilds, could be found. In general, guilds of barber-surgeons and surgeons restricted the use of instruments on the body to their members.
The barber-surgeons undertook barbering and minor operations, such as opening a vein to let blood, and were ordinarily among the lower-ranking members of the guild (Pelling). The surgeons, far fewer in number and generally among the higher-ranking liverymen, undertook major operations, such as amputating limbs, setting bones, repairing hernias and fistulas, extracting teeth, and tending to wounds, sores, and ulcers. Among the armies and navies of Europe, surgeons performed most of the general medical tasks, and the kinds of operations that could be successfully performed gradually increased. Consequently, the status and income of surgeons grew during the period, and they began to be increasingly trusted by monarchs to develop certain kinds of medical policies for their kingdoms or principalities (Temkin; Gelfand).
Another kind of medical craftsmen were the apothecaries, or pharmacists. Originally wholesale importers of spices, by the early modern period many sold medicines from retail shops; some of the medicines they sold could be dangerous unless used under careful supervision. Many cities therefore had guilds of apothecaries, who were subject to rigorous municipal regulations. In the Scandinavian and Germanic lands, cities often restricted the selling of medicines to a very few official apothecaries, sometimes to just one. As their numbers increased, so did the tendency of apothecaries to give medical advice. It was from the surgeon-apothecaries that the general practitioners eventually arose (Loudon).
One other kind of medical corporation proliferated in the early modern period: that of the university-educated physicians, usually called a "college" (collegium) of physicians. Ordinarily, colleges of physicians had formal standing from a municipal or royal charter that gave members of the group sole right to practice "physic"—the giving of medical advice—in their city and the surrounding area. Regular members had to possess a university degree in medicine (by the sixteenth century, ordinarily Medicinae Doctor). The colleges of physicians ordinarily were not authorized to grant degrees (an important exception to this rule was the Faculty of Medicine in Paris, which had its roots in the medieval university; the professors of medicine of the university were elected from the Faculty). Independent colleges of medicine first came into being in several northern Italian cities, and by the early sixteenth century had spread to Spain, France, and England. By the seventeenth century, physicians in northern European cities like Amsterdam had established their own colleges. These colleges not only governed the physicians of a city but also, sometimes, took on other regulatory powers, such as inspecting the apothecaries' shops, examining apprentices in surgery and pharmacy, and even looking into the behavior of all local medical practitioners.
In the view of the learned physicians, a medical hierarchy should exist: the physicians at the top, governing the practices of the apothecaries and surgeons, and most other practitioners being outlawed. While this ideal could seldom be thoroughly enforced, physicians often worked to obtain its legal foundations from municipal or national governments. As an important part of their argument, they fostered the idea that physicians ought to be trusted more than other practitioners because of their learning, which not only gave them knowledge but also inculcated good character. Physicians spoke often of defending the "dignity" of their profession, and concerned themselves with cultivating the outward manners that would best exhibit their inward virtues.
A final medical institution must be mentioned, that of the city physician and, eventually, the physician or surgeon officer of state. In the later Middle Ages, on the Continent, some large cities began to revive the ancient tradition of employing a physician to see to the needs of the municipality. In return for an annual salary, the city physician treated poor citizens, advised on medical regulations (including plague orders), and often served in one or more of the municipal hospitals for the sick poor (if the city had any) (Russell). By the later sixteenth century, city physicians had become important officers of local government in many places. Moreover, as unified territorial states came into being in the seventeenth century, and sovereigns tried to impose more uniform codes of law and government, they, too, began to use medical advisers to help them govern. Given contemporary international competition, princes deeply felt the need to try to increase the general wealth and power of their countries. Part of their domestic policy therefore was concerned with bettering the health of the public and increasing the population. To do so, sovereign rulers frequently tried to co-opt existing medical corporations or to establish new ones.
In central Europe, by the later eighteenth century, medical advice had become important enough to government that the phrase "medical police" (meaning medical policy promoted and enforced through government agents) had become a common topic in discussions about the structure of state institutions (Rosen; Hannaway; Jordanova; Fischer-Homberger). But associating themselves with magistrates and government might give physicians and surgeons more authority among those who supported the government; it also might make them more subject to criticism during periods of public unease. The revolutionaries in France, for example, demolished most formal medical institutions during the mid-1790s.
With a rising population, increased urbanization, the spread of the market economy, greater literacy and formal education, and the development of nations, the significance of medical help outside networks of kin and neighbors increased. These changes had many implications for those who practiced medicine. With regard to the gender of the practitioner, for example, women seem to have dominated the practice of traditional medicine, while it was predominantly men who flourished in the commercial medical market (although not to the total exclusion of women). When it came to medical guilds, outside of Italy, memberships were generally limited to men or to the widows of members. Since virtually all European universities excluded women from receiving degrees, nearly all medical doctors were men. In the eyes of the governments, if not always in the eyes of the public, a group who recognized themselves as professional men sat at the top of the medical hierarchy: the physicians, and gradually the surgeons. They obtained many new mechanisms of medical regulation from the state (for example, the French crown established a new College of Surgery in Paris in 1750, and a Royal Society of Medicine in 1776), and increasingly tried to regulate all other practitioners. They could not always succeed in imposing medical order on society, but their professional ideals were influential.
Debates about Medical Practice and Practitioners
Because the increasingly literate and monied public of the towns and cities had a host of medical practitioners from whom to choose, the medical professionals could not impose their ideals on others. While noble and wealthy patients often consulted physicians, they often also consulted surgeons, apothecaries, "quacks," and traditional healers. Without a single, inclusive medical profession and firm regulation to govern practitioners or establish uniform requirements for their training, patients could pick and choose the kind of medicine they preferred, as long as they could pay for it or obtain it through charity. Consequently, medical practitioners cajoled and persuaded their paying patients to do what they considered right (Jewson; Porter, 1985). (Those they helped through charity could take what was offered or go without.) As a result, the various medical groups, even the physicians, had few clear ethical codes on how to treat patients that were distinct from general sentiments. Notions of virtue and good behavior existed everywhere; concepts of "medical ethics" per se were few (Waddington).
The humanist movement of the Renaissance brought to light a plethora of ancient philosophies of nature, each with its own ethical foundations. Renewed Aristotelianism, Platonism, Stoicism, Epicureanism, Hermeticism, and Hippocratism: Among the learned, each had its medical adherents. When modern natural philosophers began to take precedence over the old, physicians of a Baconian, Cartesian, or Newtonian stripe often adopted moral notions consistent with their philosophical system. For instance, with a renewed interest in Hippocratism came a renewed interest in the Hippocratic Oath (Smith); with the spreading of Cartesianism came a hard-hearted attitude toward the use of living automata (animals) in bloody experiments (Guerrini). But none of these philosophical positions was solely medical, and so none of the ethical implications were strictly medical. The physician took no more and no less interest in the ethical implications of the natural philosophy he adopted than did any other learned person.
Moreover, it is possible to discern some of the general public's ideas of ethical medicine. One can see such general notions at work in the plague. During the first outbreaks (from the mid-fourteenth century), the best advice on avoiding the pestilence that a practitioner could give or take was to "flee fast and far." But as magistrates worked to prevent or ameliorate epidemics, in part by working with city physicians, a sense that the legally privileged physicians ought to help in times of crisis grew up alongside older notions of charity and self-sacrifice (Amundsen). By the seventeenth century, colleges of physicians suffered public embarrassment when many of their members (even those who held no public office) left town during an epidemic. In the London plague of 1665, for instance, many of the physicians' rivals, especially the chemical physicians, gained the respect of the public by staying and treating victims of the plague, showing by this disinterested public service that they ought to take precedence over the cowardly physicians. For whatever reason, the public was beginning to expect higher standards of behavior from medical practitioners than from all but a few others.
Another place where public notions of ethics in medicine can be found is in the general sense that physicians should not be overly commercial. Journals of literate sentiment, like The Spectator or Gentleman's Magazine (both of London), made fun of medical commercialism. For their part, physicians generally tried to avoid becoming personally involved in public medical disputes, frowned on advertising their practices or medicines as beneath the dignity of their calling, considered fee splitting and the taking of part of a fee in advance as "quackish," and even began to accept "honoraria" instead of fees. They also continued to treat without charge some of the poor who sought their help and, when they took up hospital posts (where they saw the sick poor inmates), received no fees for their once-a-week (or so) visits. Such general notions of good and charitable behavior, ordinarily shared between patient and practitioner, underlay the more detailed treatment of medical etiquette in the statutes of the various medical corporations.
The topics of more specific debate about moral medical behavior in the early modern period included what constituted the best medical learning; what kind of person made a good practitioner; what kinds of people ought to be prohibited from practice; and what medical practices should be encouraged and which discouraged. Debates about each of these topics could hardly be separated from the others, however, since they all surrounded what might be called the early modern equivalent of "virtue" ethics.
The two most numerous kinds of documents regarding early modern medical practice illustrate how interconnected were ideas about good practice and good character. One kind is the internal regulations of medical guilds and colleges of physicians. The statutes of the London College of Physicians, Society of Apothecaries, and Surgeons' Company, for instance, governed the behavior of the members closely but had almost nothing to say about medical practice per se. (One of the few explicit prohibitions in the College statutes is against making prognoses from the inspection of urine alone; the practices of "urine-casters" came in for much scathing comment from physicians in the early seventeenth century.) In drafting the statutes of the College of Physicians, the officers devoted much attention to whether and in what kinds of cases members might consult nonmembers, how members should behave during consultations, what the order of precedence would be during meetings and on ceremonial occasions, how they should write prescriptions, and so on, all trying to maintain the dignity, gravity, and exclusivity of the group. The same is true of the College of Physicians in Amsterdam, and colleges elsewhere in Europe; and it is equally true for guilds. One sees the same concern with character in the record of whom the London College of Physicians tried for medical misbehavior: They rarely distinguished between illicit practice and malpractice, insisting that in their examinations for membership, applicants had to show that they were the right sort of people in character as well as in knowledge, anyone else being de facto and de jure incapable of practice.
The second major class of historical documentation discussing the foundations of good or ill medical practice is the antiquackery tracts that proliferated during the early modern period. In them, physicians and others discussed practitioners' behavior far more than their medical practices. In England, perhaps the best-known early piece of antiquackery literature is by John Cotta, who passionately condemned the multitude of nonphysicians: empirics, women practitioners, fugitives, jugglers, quacksalvers, practicing surgeons and apothecaries, practicers of spells, witches, wizards, the servants of physicians, "the methodian learned deceiver or hereticke Physition," beneficed practitioners, astrologers, urine-casters, and itinerants (Cotta).
Cotta not only condemned the ignorance and bad practices of such people, he condemned above all their undisciplined characters. He explained how even good remedies cause harm when recommended by those who do not possess the learning, and hence the virtue, of physicians (Cotta, pp. 2–8). As one of his contemporaries noted, because learning and character were so closely associated, ignorance in medical practitioners could be recognized by bad behavior: "loquaciousness," "haste" in judging diseases and promising cures before the cause had been ascertained, "forwardness" in condemning and slandering proper physicians, and "boastfulness" about their own skills (Dunk, pp. 20–21). These behaviors exhibited by empirics were not tests of their knowledge but demonstrations of their indiscipline: outward signs of an inward character. Character had so foundational a role in medical practice because, as Cotta explained, "the dignitie and worth of Physicks skill consisteth not (as is imagined commonly) in the excellence and preheminence of remedies, but in their wise and prudent use" (1612, p. 7; emphasis added). Wisdom and prudence could be built only on the coupling of solid learning with good character. Similar works on how the good physician alone could exhibit proper medical behavior can be noted throughout early modern Europe: Gabriele de Zerbi's De cautelis medicorum (1495); Laurent Joubert's Erreurs populaires (1578); Govanni Condronchi's De Christiana ac tuta medendi ratione (A Christian and Careful Manner of Healing, 1591); Rodericus à Castro's Medicus-politicus (The Responsible Physician, 1614); Paolo Zacchia's Questiones medicolegales (1621); and Friedrich Hoffman's Medicus politicus (1738).
In countering the links made by physicians between learning and virtue, other practitioners discussed their own notions of the sources of good character, frequently arguing that it came not from academic discipline but from an inner light. Since all knowledge ultimately stemmed from God and God's creation, they argued, their direct apprehension of things through experience and a properly prepared intuition made them the possessors of a more immediate wisdom than that of the pagan- and Islamic-influenced university physicians (as they often put it). Such arguments had been put forward forcefully by the influential chemical physician Paracelsus in the early sixteenth century; by the seventeenth century, these views had spread widely among medical chemistry's advocates (Debus; Webster).
Not only chemists but also many nonphysicians took the same view about godly practice. For instance, the Swiss Protestant surgeon Gulielmus Hildanus Fabricius wrote:
Though godlinesse be needfull for all sorts of men, yet it is most requisite in such as practise Physick, for God Almighty doth often abate the power of the Medicines, when he which administers them, is an ungodly and blasphemous man: and contrariwise, doth give wonderfull power to things despicable and vile, when they are administered by good and godly Physitians. (Fabricius, pp. 53–54)
Given the deep and bloody struggles over religion in the early modern period, comments about character and godliness divided people. Fabricius's ideas about the personal godliness of the practitioner affecting the efficacy of his medicines is quite different from the learned physician Cotta's view that even good medicines used by the unlearned could cause harm. Different kinds of medical practitioners had very different views about the inner qualities necessary for good practice, and how those qualities could be acquired. For a good Anglican like Cotta, or for his professional colleagues in all orthodox churches, sentiments about intuition and inner light such as Fabricius's smacked of dangerous religious "enthusiasm" (the sense of being inspired directly by God); for practitioners like Fabricius, linking virtue with higher education could only reinforce the position of the "dogmatists" (those who privileged reason over intuition and experience).
By the later seventeenth century, however, many physicians, too, had come to accept the importance of learning from experience, although they continued to believe that it had to be coupled with a disciplined and knowledgeable mind rather than based on intuitions. The scientific revolution had introduced notions that associated virtue with knowledge as much as (or even more than) dignity, and associated knowledge with experience (or, in English, "experiment") rather than learned debate (Shapin and Schaffer). The "virtuosi" of Europe launched detailed investigations into things, finding the best evidences of God not in human testimony and argument but in creation itself. Consequently, by the eighteenth century, many physicians, as well as surgeons, apothecaries, and empirics, placed great weight on furthering curative and preventive medicine through scientific trials.
The foundation for experiments such as James Lind's work on scurvy, or William Withering's on digitalis, or Lady Wortley Montague's on smallpox inoculation and Edward Jenner's on vaccination, or Antoine Mesmer's on "animal magnetism," had been "folk" custom. Ignoring what they considered the superstitious explanations of what happened, and concentrating instead on the material causes and consequences of various practices, such medical investigators throughout Europe explored new medicaments and treatments. In this enterprise, surgeons and apothecaries, and even unlicensed ordinary practitioners, could make contributions equal to those of physicians. Debates among medical practitioners still implied notions of who might be the best sort of person; but as the nineteenth century loomed, medical debates focused increasingly on what might be the best treatment rather than who might be the best treater.
Throughout Europe in the early modern period, one finds implicit and explicit notions about what constituted a good medical practitioner. Given prevailing public ideas about morality being linked first to character and only second to behavior, the question of who ought to practice what dominated medical debates. Oral codes and written rules governing medical etiquette proliferated, while people devoted relatively little attention to what we might consider medical ethics per se in the rules of good practice. Without a united and powerful profession, no group of medical practitioners could hope to universalize their own rules, although they often tried. Instead, they had to abide by the ordinary notions of virtue and morality held by their peers and the public. Notions of public and private virtue could be vigorously contested and undoubtedly affected the behavior of practitioners, but they were seldom strictly medical.
harold j. cook (1995)
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