1. Medicine, the Renaissance, New Sciences and the ‘Age of Reason’

2. Medicine & the Renaissance Paracelsus (1493-1542) Anatomy: Vesalius’ dissections let to the publication of his Fabrica in the early 1530s—Galen’s authority could now be challenged. The printing press meant that these new ideas circulated more quickly, widely and cheaply than in the past. The greatest anatomy school was at Padua in Italy—it continued Vesalius’ work—William Harvey was to study there. Physiology: Harvey (with knowledge of one-way valves in veins, and mechanics of water pumps) ‘discovered’ the circulation of blood in 1628. More careful use of ‘scientific method’—careful use of measurements and experiments. Cause of illness: Ideas of causation not much changed from Middle Ages. Diseases send by god, due to the planets, bad air, or imbalance of the humours. Gradually scientific advances and technologies (microscope and chemistry) would lead to better understandings of disease in the 1700s. Cures: a) bleeding; b) prayer; and c) herbal remedies. Physicians: Only 1000 doctors per country as education was expensive. Apothecaries in most towns selling medicine, but they lacked formal education. Most medics were barbers, midwives, and tooth-pullers who worked in towns and cities. Surgery: Most performed by barber-surgeons who were craftsmen. Developed idea of ligature to stop bleeding. Some improvements resulted from treating war wounds. Preventative medicine: Limited government activities during the Plague—quarantine, burials and inspections—but still no widespread public health. Paracelsus: Swiss doctor who had studied in Italy—he challenged Galenism and believed that nature was the key—contemptuous of medical authorities. In 1526 was appointed professor of medicine in Basel and lectured not in Latin, but German; he also refused to teach Hippocrates or Galen, and he publicly burned Avicenna’s Canon. Bases his natural philosophy on chemical principles—salt, sulfur and mercury. Also ridiculed anatomy as ‘dead’ as it could teach nothing about the living.

3. Surgeons and Guilds As the number of healers (of all kinds) grew during the middle ages, medicine as a profession began to organize itself. This began first in Italy, where medical guilds started to supervise apprenticeships, examinations of candidates, the location of pharmacists, and the supervising of drugs, foods and herbs. In southern Europe (Italy—where surgery was a part of the required 5-years of medical study before a license was granted) there was not a huge gulf between physicians and surgeons, but elsewhere the two were distinct, and only united in their mutual distaste of the barbers below them. When dissections did resume, they were directed by the educated physician; but actually performed by surgeons. In London the Fellowship of Surgeons was founded in 1368; and the Company of Barbers was chartered in 1376. The College of Physicians (with university education) did not have their College in London founded until 1518—after which it regulated their trade. The growing conflict between the different classes of doctors reflected their growing numbers, and the increased competition for revenues and social status. Henry VIII Presenting Charter to Barber Surgeons of London, 1540 [Above]; and Late Medieval Surgery [Image to Right]

4. Anatomy & Medical Education During the 1500s, anatomy was gradually but surely incorporated into the broader humanist revival that we call the Renaissance. In England, the leading figure in this movement was John Caius who was a Galenist physician and protégé of the great Thomas Linacre (1469-1524; physician to Henry VII who prepared a new Latin translation of Galen’s works and who had helped to found the College of Physicians in 1518 as well as the medical lectureships at Oxford and Cambridge). Caius received his early education at Cambridge, and then at Padua, where he also taught Greek and collected manuscripts related to Galen—his hero. He returned to England and was admitted Fellow of the College of Physicians in 1547. He was president of the college nine times, and worked to reform it to be more like those on the continent. He also introduced anatomy formally into his lectures, and demonstrated anatomy to the Barber- Surgeons Company. In Cambridge, he helped establish Gonville and Caius College as a medical college—where William Harvey would later attend. Caius College, Cambridge University [Above]; and John Caius (1510-1573) [Image to Right]

5. Anatomy vs Surgery Fabrizio: A pupil of the great anatomist at Padua, Gabriele Falloppia (1523-1563), Hieronymus Farbricius (1533-1619), was not interested in structural architecture of the body (as had been Vesalius), but with a comparative approach which stressed description, action and use of body parts. His major work was De venarum ostiolis (On the Valves of the Veins) (1603)—and this work was to be crucial in Harvey’s later work on the circulation of blood. Fabricius, while Chair of Anatomy at Padua, also wrote on the egg, generation of the chick, and foetal growth. While the anatomists of this generation noted errors in the works of the ancients (Galen in particular) they continued to support the works of antiquity by constantly referring to them. They did, however, forever improve the status of anatomy within medical education and the humanist medical movement. After the Renaissance, the separation between anatomy (as a field of learning for physicians) and surgery (work with one’s hands) was closing. Surgery as a distinct discipline, however, did not advance very far during this period, and overall was not much influenced by the new anatomical knowledge. Surgery remained a skilled craft: “one needed the heart of a lion, the eyes of a hawk, and the hands of a woman” (John Halle, 1529-1568). 16 th Century Dissection Class, Italy [Above]; and Hieronymus Fabricius ab Aquapendente (Fabrizio) (c.1533-1619) [Image to Right]

6. How the Body Works: Harvey’s Discoveries The most important anatomical/medical discovery of the Renaissance, was William Harvey’s revolutionary demonstration of the circulation of the blood. Prior to Harvey, Galenic physiology ruled: two types of blood: venous (originated in the liver and supplied nourishment to body); and arterial (originated in the heart and supplied vitality). Both types of blood were expended and thus did not need to circulate—the heart did not even pump or suck the blood around, the blood moved via the pulsing of the arteries themselves. The problem, as anatomists such as Vesalius were noting, was how did the venous blood and air move from the right ventricle to the left—there were no hidden pores in the septum separating the two sides! William Harvey attended Caius College, Cambridge, and then studied at Padua under Fabricius. He returned to England in 1602, was elected a Fellow of the College of Physicians in 1607, and 1609 became a physician at St. Bartholomew’s Hospital, six years later becoming a college lecture in anatomy, and then in 1618 was named royal physician. He used the scientific method, but did not use the new invention the microscope to discover the capillaries (links between the arteries and veins), but used logic to deduce their presence. William Harvey (1578-1657) [Above]; and Illustration from Harvey’s Circulation of the Blood [Image to Right]

7. The Science of the Microscope Use of microscopes (most made in Holland) became fairly widespread by naturalists after 1600—led to knowledge of cells and microscopic organisms, and debates over creation of life. A draper from the Dutch city of Delft, van Leeuwenhoek constructed a total of 247 simple (single lens) microscopes, which despite their tiny size (2mm in width) were extremely powerful (+250X). His lens grinding techniques were not matched until the 20 th century. A religious man, he hoped that his work would counter atheistic arguments for spontaneous generation (in dew, mud, putrefaction). A tradesman without formal education he studied a wide variety of materials and animal structures, including: the texture of wood, cells of planes, red blood corpuscles and blood capillaries, the crystals associated with gout, organization of nerves, muscles, bones, teeth and hair. His most important discovery was the observation of the animalcules in fluids—first person to see spirogyra, hydra, protozoa, bacteria and human spermatozoa. He estimated population densities of these animals at more than 1 million per drop of water. Van Leeuwenhoek Demonstrating the Microscope to Catherine of England [Above]; and Antoni van Leeuwenhoek (1632-1723) [Image to Right]

8. Europe During the Enlightenment

9. The New Sciences While the majority of Renaissance Humanists wished to restore medicine to its Greek purity, by the 17 th century a new view came to dominant thinking in the ‘modern’ West—this was the idea that medicine could only thrive if it threw off the deadweight of the ancients (Galen, etc.). This was a radical and subversive doctrine, but given the general intellectual, social, economic and political transformations that were taking place in Europe as a result of the Protestant Reformation, new and serious challenges could now blossom in the fields of science and medicine. A leaders of this radical camp was Theophrastus Philippus Aureolus Bombastus von Hohenheim (1493-1542)—more commonly referred to as Paracelsus. Born in Switzerland, Paracelsus received his early education from his father (a physician) who taught him botany, medicine and natural philosophy. At the age of 20 he went to Italy to study medicine, but soon quit, only to become a wandering student, who picked up knowledge from a variety of sources (artisans, miners, “tramps, butchers and barbers”). As he did not have a classical, university education based on the old canonical texts, he was able, and in fact eager to repudiate Galenism and the works of antiquity and the Arabs. (“I tell you, one hair on my neck knows more than all you authors, and my shoe-buckles contain more wisdom than both Galen and Avicenna”—compare his attitude to those of Vesalius and Harvey!) Paracelsus (1493-1542) — A 1568 Engraving

10. Observing Society: The Writings and Work of Samuel Pepys Educated at Cambridge, Samuel Pepys was one of England’s more able naval administrators, and was a major supporter of the ‘new sciences’ (as a fellow of the Royal Society he witnessed one of the earliest blood transfusions in history). Pepys experienced the Great Plague of 1665, and provided a vivid eyewitness account of the terror the disease brought, including the flight of the fashionable physicians from London to the countryside. In London, Pepys witnessed the painting of red crosses on victims’ homes, the inhabitants of which were forbidden to leave. As the plague spread, most Londoners with financial means fled the city, but Pepys stayed behind. His diary is one of the best historical sources on the 17 th century plague in England. During his life, Pepys had a large bladder stone removed by surgery, and also suffered period disruptions in his eyesight. As with many of his generation, Pepys was reluctant to consult medical doctors, although many were his personal friends. He believed that prevention was better than cure, and he followed the old advice that diet, exercise, climate and avoiding draughts and damp would to more than any therapeutic. One superstition of old that Pepys followed (and is still alive today), was that he wore a rabbit’s foot around his neck to ward off illness. Samuel Pepys (1633-1703)

11. Plague continued to be a major killer in Europe in the early modern era, devastating the populations of Germany, Holland, Italy, Spain and Russia (Muscovy) in the 16 th century. The figures from the 17 th century were even worse: –Venice between 1630-1631 lost 30% of its population; -- in Genoa in 1656 ¾ of the population died; -- in Naples in the first five months of 1656, more than 300,000 died; and -- in London during the outbreaks of 1563, 1603, 1625 and 1665 a total of more than 80,000 perished. After this last oubreak, plague disappeared from England. During the early 18 th century, plague was still active in Turkey, eastern Europe, Poland and the Ukraine. It made its final appearance in central Europe (Germany, Austria and Scandinavia) in 1713. The last major outbreak in the West was in France in 1720-1722, where it killed approximately 100,000 people in Marseilles and 2/3 of the city of Toulon. Why did the plague retreat from Europe? 1) the black rat (rattus rattus) was forced out by the brown, or sewer rat (rattus norvegicus); or 2) public health measures such as quarantine and cordon sanitaire finally started to be enforced and work. Engraving of the Plague in London in 1665 Plague’s Return to London, 1600s

12. Medicine and the Enlightenment While the 18 th century witnessed tremendous advances in the fields of anatomy and physiology, there were only minor improvements in the clinical application of the new medical knowledge. This period also saw Europe’s population stressed by epidemics, famines, wars, and the growth of major urban centres (Naples, Paris and London would all have populations of more than 1 million by the late 1700s). This was also a time of hope, and a belief in new philosophies of progress, science and reason. Science and technology were bringing new levels of prosperity and control over nature, and their was a belief that the conquest of disease would soon follow. The centre of learning was also shifting from southern Europe (primarily Italy) to the northern nations of the Netherlands, England and France. One of the greatest achievements of this period was the realization by governments of their role in providing for the welfare of their citizens—the results were public health schemes throughout much of Europe that were associated with infant and maternal welfare, improving urban conditions, hygiene for the armies and navies, and the development of public hospitals to care for the poor. Such measures, however, were more pronounced on the continent as England continued to rely on private philanthropy. Joseph Wright of Derby, An Experiment on a Bird in an Air-Pump (1768) [Above]; and The Orrery (1768) [Below]

13. The Sparks of Life: Volta and the Inspiration for Mary Shelley’s Frankenstein During the 18 th and early 19 th centuries, scientists continued to debate and to conduct research on the topic of what distinguished living organisms from inanimate matter. However, in an age of science and reason, wherein huge leaps were being made in the fields of chemistry, anatomy and physiology, there appeared to be a growing divide between research and clinical medicine. The debate over vitalism continued to intrigue scientists and philosophers, but there was little agreement between the contending schools of thought. Alessandro Volta, a professor at Pavia conducted experiments that demonstrated that electric stimulations could cause a muscle to contract. This work, termed the electricity of life, would later shape early research in neurophysiology, but found its most popular spokesperson in Mary Shelly who used it as a basis of her 1818 novel Frankenstein – a story in which life is artificially created with the aid of a massive electric charge. This story illustrates an element of public fear towards the new science of the period. Alessandro Volta (1745-1827) Frankenstein’s Peers—Cartoon from McLeans Monthly, 1832

14. England’s Famous ‘Doctor Wriggle’: The Physician John Coakley Lettsom One of the most successful English physicians of the period was John Lettsom, who built a huge private practice in London that generated upwards of £12,000 per year—more than most nobles received. He worked extremely hard, seldom taking a day off, and was also popular due to his philanthropic activities and essays on topics such as charities, prostitution, the deaf and mute, religious persecution, Sunday school, food (porridge) for the poor, the virtues of smallpox inoculation, and the evils of quackery and tea drinking. Although he was a Quaker, his contemporaries often caricatured him in the press as ‘Dr. Wiggle’. The key for physicians such as Lettsom was their bedside manner and clinical skills. During the Enlightenment, some doctors expanded their bedside diagnosis to more than using the ‘five senses’. Now they would feel the pulse, sniff for gangrene, taste urine, listen for breathing problems and observe skin and eye color. Skilled practitioners throughout Europe began to judge their patients by close personal attention—except when examining women due to social etiquette and sexual propriety. Doctors also began to gather patient histories—the clinician was becoming a good listener. Portrait of John Coakley Lettsom (1744-1815) Naturalist’s Companion (1774 ed.) by John Coakley Lettsom

15. Theories of Disease: Miasmas, Fevers & Scurvy Early theories of contagion had difficulty explaining why some people caught a disease while others were spared. The most widespread models were miasmatic—arguing that sickness originated in the environment. Intermittent fevers like ‘ague’ (malaria) were linked to wetlands and marshes. ‘Putrid’ fevers such as typhus were recognized as infecting slum-dwellers and occupants of ships and poorhouses. Generally, miasmatic disease was believed to arise from putrefying animal remains, rotting vegetation and stagnant water. The debate during this period was between the miasmatists and the new contagionists. James Lind, a Scottish navel surgeon protested against the poor conditions on board British naval vessels (cramped quarters, rancid food, foul water). In the mid 1700s, the British Navy was plagued by a number of illnesses during the lengthy sea voyages. For example in a round- the-world expedition in the 1740s, of the 1955 men who left England, 320 died of fevers and dysentery, and a staggering 997 died of scurvy by the time the fleet returned after its 4 year voyage. Scurvy, the scourge of the fleet, involved swollen, spongy, bloody gums, bruises, swollen joints, lassitude, heart failure, and death. Lind wrote a treatise on the disease in which he relied on his own experiences, and proved that citrus fruits were effective in preventing the deadly disease. However, Lind’s ideas were not quickly adopted by the Navy—although by the 1790s fresh vegetables, fruits, vinegar, and better ventilation and hygiene were common on most ships. James Lind (1716-1791) Miasma, Mists and Malaria — Painting from the Early 1800s

16. Nosology & Naturalists: Sweeden’s Karl von Linne (Linnaeus) and Scotland’s William Cullen The Swedish scientist Linnaeus (1707-1778) invented new taxonomies in the field of natural history, and his work (and that by other naturalists of the Enlightenment) led to the search for symptom-based medical classifications of disease. William Cullen, a Professor of Medicine at the University of Edinburgh was a leading figure in the creation of a systematic understanding of disease (nosology—disease classification) in the 18 th century. He emphasized the role of contagion in the spread of disease, although he still incorporated the traditional belief in miasma, or polluted air as the primary cause of fevers. Cullen also argued that a properly balanced and stimulated nervous system was central to good health. He also worked to identify contaminated environments which could be disinfected and ventilated to prevent the spread of disease; such environments were hospitals, navy ships, jails, and the new industrial factories and spinning mills. A 1772 Portrait of William Cullen (1710-1790) Cover of 1749 Linnaean edition of Materia Medica.

17. Therapeutics and the Lure of the Spas Travel and spas became an important component of the health regime for the wealthy classes during the Enlightenment. With the spread of tuberculosis (called ‘phthisical’) in the increasingly crowded cities, gentlefolk often made winter pilgrimages to the warmer climates in Portugal and Spain in an attempt to restore their constitution and nerves. These travels were closely tied with the growth of the “Grand Tour” through Europe by the upper classes, who wished to visit all of the great cultural sites of the West. Spas, such as those in France (Vichy and Bourbon), Germany (Baden Baden), and England (Tumbridge Wells and Scarborough), were big business during the 18 th century. Thousands of upper middle-class patrons flocked to spas to enjoy the baths and natural environs, to make social and business contacts, to gamble and be entertained, and to visit with the facilities high-priced doctors. Seaside resorts were also touted as healthy locations, and people were convinced of the benefits of bathing (and drinking) sea water, and that the sea air could prove beneficial to consumptives. William Hogarth’s Pool of Bethesda, Painted for St. Bartholemew’s Hospital in London, 1740s [Above]; and an English Landscape Print from the Early 1700s [Below]

18. Madness in the Age of Reason The theory and treatment of insanity and the insane underwent a major change during the Enlightenment as the notion of demonic possession was finally discredited by both medicine and the courts. Mania and melancholy were no longer governed by the heavens (and spirits) but by the body. The old humoural explanations (yellow bile for mania, and black bile for melancholy) lost ground as the new scientific explanation which portrayed the body as a machine, and neuro-anatomy governed by the nervous system finally won out. At last a definition of insanity as a type of dynamic neurological disorder or neurosis was the standard amongst medical practitioners. The most famous case of ‘madness’ during this period was King George III. The British monarch first experienced an attack in the autumn of 1788, and his condition soon worsened. The Revd Dr. Francis Willis was brought in as a consultant. He argued that the king would only recover if Willis was allowed complete control—involving both physical and psychological domination of his patient. Willis believed that madness was a product of over-excitation, and thus the king needed calm (as well as a gag, straitjacket, and a restraining chair, along with attempts to mesmerize the monarch with his eyes). By February 1789 George has largely recovered (in spite of Willis’ treatment), yet the Prime Minister William Pitt secured Parliament to award Willis a pension of £1000/year for the next 21 years! In small private madhouses that were established during this period, as well as in large institutional asylums there was a great variety of care from hell- holes to pleasant environments. Physical treatments (the body was now key to madness) included blood- letting, sedation, violent purges, shock treatments, and rotating chairs and swings (disrupt idees fixes), and for the worst cases shackles and restraints. Restraining an ‘Inmate’ in Bedlam Bethlem (‘Bedlam’) Hospital, Early 1800s

19. Surgical Improvements Surgery also underwent rapid change in both improved techniques, scope of procedures, and status within the medical community. Traditionally, the lowly surgeon was mainly responsible for minor repairs and not major, high-risk operations. Instead, most day-to-day business involved: blood-letting, lancing boils, dressing abrasions, pulling teeth, and treating skin ulcers. Fatality rates were therefore low as surgeons understood their limits, and internal problems were handled by medicines and not major surgery (especially before anesthetics and antiseptic procedures). There is in fact no record of a mother surviving a caesarian in Britain prior to the end of the 18 th century. Some improvements and new techniques were developed in the treatment of bladder stones (extracting the stone through the urethra), as well as treating cataracts by removing the hardened lens from the eye. War, and especially the growth of the British Navy and colonial expansion, created a demand for junior surgeons. By 1713, in the entire British fleet had 247 vessels each of which carried a surgeon and mate. By the late 18 th century (first in France, and later in Britain [Scotland]), surgery became a key subject in medical education. In England, the most famous surgeon was John Hunter who not only trained dozens of leading surgeons, but also amassed a huge collection of anatomical and biological specimens that became the core of the collection of the Museum of the Royal College of Surgeons (surgery therefore part of the “public’s” growing scientific appetite.) Amputation Surgery in the Early 1700s [Above]; & Museum at the Royal College of Surgeons in London, Early 1800s [Below]

20. The Golden Age of Quacks & Quackery The 18 th century witnessed the golden age of quackery, and while most of continental Europe (particularly France) attempted to control the excesses of this ‘branch of medicine’, in Britain, the free-market maxim of caveat emptor (‘buyer beware’) was the rule and as a result thousands of unqualified practitioners milked the population. There was a great variety amongst the quacks as some claimed that they could bring long life and sexual rejuvenation to their patients, while others simply tried to peddle tonics and elixirs that relieved pain and minor ailments (this was likely true as the main ingredient was often alcohol). Some of the more ambitious quacks claimed that both they and their recipes came from far-off exotic locals such as Turkey, or even the Indians of North America. The trade in patent medicines was a boom industry during this period and filled a need in society—claiming to cure illness that regular physicians could not, or providing a relatively cheap alternative to people who could not afford the care of a private physician. One of the most famous quacks of the period was Franz Anton Mesmer (1734-1815) of Vienna. Mesmer claimed that people could be treated by ‘animal magnetism’, and after fleeing Austria, he conducted fashionable séances in Paris, where he placed patients in a tub and then applied iron rods to their bodies. A commission by King Louis XVI forced Mesmer to flee again, this time to London where he practiced his brand of ‘medicine’ unhindered. British Quackery, Early 1800s

21. Medicine on the Periphery: Edinburgh’s Scottish Docs Edinburgh emerged as the leading medical school in Britain during the 18 th century. Its founding dates to the appointment of Alexander Monro I in 1726 as professor of anatomy. Monro was followed by his son and grandson, and thus the family controlled this chair of anatomy for 120 years. The school also boasted famous instructors in chemistry, practical medicine (surgery and anatomy), as well as philosophy and human sciences. By the late 1700s more than 200 students enrolled every year at Edinburgh, and by 1820 the number had grown to 400. Edinburgh also pioneered infirmary-based teaching, however only 1/3 of its students registered in clinical lectures and rounds. Although famous for anatomical studies, the school was always short on bodies and this resulted in the famous Burke and Hare murder scandal of the early 1800s. Elements of 18 th Century Scottish Medical Education: 1) Scotland’s reputation as centre of advanced learning during the Enlightenment 2) No religious barriers to study (as opposed to Oxford, or Trinity College in Dublin) 3) Use of English for instruction, not Latin 4) Wide range of courses, including emphasis on basic general sciences 5) Courses were non-residential, therefore reduced costs; take whatever courses you wanted 6) Bedside learning over book learning 7) Hospitals were attached to the medical schools to ensure that practical clinical experience was tied to classroom theory Three Generations of Edinburgh’s Alexander Monroes (1697-1859) Alexander Monro I (1697-1767)

22. The Growth of Early ‘Modern’ Hospitals In England during the Georgian period, there was an explosion in the founding of new hospitals. While prior to 1700, London could boast of only St. Thomas’s, St. Bartholomew’s and Bethlem Hospital, during the early 18 th century five new major general hospitals were constructed (the two most famous being Guy’s [1724] and London [1740]). Similar growth occurred in outlying regions with the cities of Edinburgh, York, Bristol, Bath and other centres also founding general hospitals. By 1800 a total of 28 British cities had a general, secular hospital to serve its poorer citizens. Many cities (Manchester, Liverpool and York) also had philanthropically supported lunatic asylums, and in London the Lock Hospital was established to treat venereal diseases. Another creation of this period was the ‘lying-in’, or maternity hospital that provided a few days rest to poor women. By 1800, London’s hospitals were treating over 20,000 patients a year. Improvements to Hospitals in the 18 th Century: 1) Floor-to-ceiling windows for ventilation 2) Daily washing of wards to cleanse the air 3) Regular whitewashing of walls 4) Tiled floors to assist in cleaning 5) Human waste disposed of outside the wards St. Bartholomew’s Hospital in Smithfield, [Above] and St. Thomas Hospital, Southmark [Below]