MEDICINE BEFORE SCIENCE This book offers an introduction to the history of university-trained physicians from the Middle Ages

to the eighteenth-century Enlightenment. These were the el ite, in reputation and rewards, and they were successful. Yet we can form little idea of their clinical effectiveness, and to modern eyes their theory and pract ice often seem bizarre. But the historical evidence is that they were judged on other criteria, and the argument of this book is that these physicians helped to construct the expectations of society and met them accordingly. The main focus is on the European Latin tradition of medicine, reconstructed from ancient sourc es and relying heavily on natural philosophy for its explanatory power. This phi losophy collapsed in the scienti c revolution, and left the learned and rational doc tor in crisis. The book concludes with an examination of how this crisis was met or avoided in different parts of Europe during the Enlightenment. Historiograph ically, the book is directed at how the technical content of traditional medicin e can inform its social functions. ro g e r f re n c h was Lecturer in the Depar tment of History and Philosophy of Science, University of Cambridge, and a Fello w of Clare Hall. He taught in the universities of Leicester, Aberdeen and Cambri dge, and for twenty years was Director of the Wellcome Unit for the History of M edicine at Cambridge. His publications include William Harveys Natural Philosophy (1994), Ancient Natural History (1994) and Gentile da Foligno and Scholasticism (2001).

MEDICINE BEFORE SCIENCE The Business of Medicine from the Middle Ages to the Enlightenment ROGER FRENCH

Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, So Edinburgh Building, Cambridge , United Kingdom Published in the United States of Amer ica by Cambridge University Press, New York www.cambridge.org Information on thi s title: www.cambridge.org/9780521809771 The estate of the late Roger French 200 3 This book is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may ta ke place without the written permission of Cambridge University Press. First pub lished in print format 2003 - Cambridge University Press has no responsibility for the persistence or accuracy of s for external or third-party internet websites referred to in this book, and d oes not guarantee that any content on such websites is, or will remain, accurate or appropriate.

Contents Introduction part i: s o u rc e s 1 Hippocrates and the philosophers 2 Galen par t ii: t h e l at i n t r a d i t i o n 3 Medieval schools 4 Scholastic medicine 5 The weakening of the Latin tradition page 1 9 34 59 88 127 part iii: t h e c r i s i s 6 The crisis of theory 7 Resolutions 8 Enlightenment , systems and science Select bibliography Index 157 185 222 260 270 The publisher wishes to acknowledge the valuable assistance given by Dr Corneliu s OBoyle in preparing this book for publication, following the death of Dr Roger French in May 2002. v

Introduction This book presents an argument rather than a narrative survey. The premiss of th e argument is that from the high Middle Ages onwards, physicians built up their trade into an elaborate professional stucture, endowed it with an even more elab orate theory, and contrived to present it with great authority. Some physicians became rich, others famous and powerful, as teachers and practitioners. Great ho useholds retained physicians as part of the family and towns sought out university -trained physicians for contractbased employment.1 Many physicians were, then, s uccessful. We have no way of measuring their clinical success, for that would be to ask modern questions and expect modern answers from inappropriate historical material. Moreover, our instinct is to believe that old medicine was less effec tive than our own, which is so conspicuously scienti c. Indeed, from a modern view point pre-scienti c medicine can look ridiculous in its theory and bizarre and dis gusting in its remedies. How, then, did physicians in the past meet the expectat ions of their society, and so succeed?2 The argument of this book is that they d id so partly by helping to create those expectations, which were accordingly eas ier to satisfy. The fully trained university doctor had two main methods of cult ivating his image as a capable medical man, his reason and his learning. These t wo characteristics will often be capitalised in this book to show that they are technical terms in a historical sense. The Learned and Rational Doctor was 1 2 See for example Michael R. McVaugh, Medicine before the Plague. Practitioners an d their Patients in the Crown of Aragon 12851345, Cambridge (Cambridge University Press), 1993; and Luis Garca-Ballesters introduction to Luis Garca-Ballester, Roge r French, Jon Arrizabalaga and Andrew Cunningham, eds., Practical Medicine from Salerno to the Black Death, Cambridge (Cambridge University Press), 1994. As Nan cy Siraisi observes, a doctors success in the Middle Ages consisted of prolixity of authorship, fame and senior teaching positions. Success in attracting students into the studium was a nancial bene t to the town, and on this basis, for example, Taddeo Alderotti received privileges from the civic authorities in Bologna. See Siraisis Medical scholasticism and the historian and Two models of medical culture, Pietro dAbano and Taddeo Alderotti, in Nancy Siraisi, Medicine and the Italian Uni versities 12501600, Leiden (Brill), 2001, pp. 14056 and 7999, respectively. 1

2 Medicine before Science learned in a sense that we do not now recognise as valid in any medical or practic al sense, for it was largely a question of acquiring the knowledge of the ancien ts. He was rational not in a sense of reaching the truth, but in the simpler sense of using arguments, which were largely dialectical and philosophical, also of a ncient origin and not necessarily valid to us.3 Whatever we think about the vali dity of these attributes of the universitytrained physician, or of his clinical practice, we should note that it took about as long to train a doctor in the hig h Middle Ages as it does now. He therefore had a great deal of knowledge and man y modes of handling it, which he could use in persuading an audience that he was an effective practitioner. He used it primarily in constructing a story about h is kind of practitioner, a Good Story (also sometimes capitalised here) that he could tell his patients, his pupils, the powerful and the legislators about the effectiveness of his medicine and about his right to practise it. We need not su ppose that such a physician was always coldly cynical about telling the Story an d developing his image. Professional attitudes and medical ethics tended to deve lop along lines that had the effect of bene ting the profession, but this was not always recognised by the individual: properly professional or ethical ways of be having are rarely absorbed as part of a rationalist training. Although not a nar rative survey, this account of medicine before it became scienti c is based on a c hronology that runs from the high Middle Ages to the Enlightenment. There are a number of reasons that make this a self-contained story to tell. One of them is that although much of the medicine in this period was based on ancient doctrines , there is a much greater cultural link between us and the Middle Ages than betw een the Middle Ages and antiquity. Indeed, much of the development of medicine i n the period was due to the slow and dif cult business of recovering and trying to understand ancient medicine; while between us and the men who did this there wa s no cultural hiatus, no second Dark Age. This means that although a good deal is said here about ancient medicine, it is not as a background or early history of the topic, but as the material out of which later physicians constructed their o wn medicine. That is, the attempt has 3 It also needs to be said that rational is not used here to mean the opposite of sup erstitious, for superstition is simply someone elses belief. If that belief includ es gods or demons that cause disease, then it is rational to do what is necessar y to placate them. Rational is also sometimes used to mean natural (as with Greek id eas about the causation of disease) as opposed to supernatural (as in Egypt). No s uch opposition is implied here. See James Longrigg, Medicine in the classical wor ld, in Irvine Loudon, ed., Western Medicine. An Illustrated History, Oxford (Oxfo rd University Press), 1997, pp. 2539. See also Longriggs Greek Rational Medicine. Philosophy and Medicine from Alcmaeon to the Alexandrians, London (Routledge), 1 993.

Introduction 3 been made to look at ancient medicine through the eyes of the medieval doctors, or at least to emphasise what they found important in it. A word should be said too about the terminus ad quem of this account of medical history. Some historia ns would argue that science began in the seventeenth century and others that it wa s a product of the nineteenth; the reasons for choosing the Enlightenment, a del iberately vague term, are given below. A related question asks when medicine its elf became scienti c. A possible, although rather extreme answer is not until the l ast years of the nineteenth century when the science of bacteriology gave medicin e a demonstrable power of curing certain infectious diseases. Certainly this pow er of medicine gave the doctor a new authority, and one that he used in examinin g the nature of the history of medicine: it was his subject, after all, he was t he master of it, and it seemed natural that he should know best how it came to a rrive at its present state. This has been the prevailing historiography in the h istory of medicine as a discipline until comparatively recently, and it is still present in a virulent form in the sub-discipline of retrospective diagnoses. Th is book is an attempt to abandon the presentcentredness of much of medical histo ry, which is why the story ends in the eighteenth century. Indeed, it is equally arguable that some features of science were present in medical research in the eighteenth century. The medical experiment, recognised as part of the ancient me dical tradition by anatomists in the sixteenth century, was central to the gener ation of new medical knowledge in the seventeenth century, and was adopted by th e natural philosophers of the time.4 By the eighteenth century, systematic exper imentation (largely on animals), statistical methods and clinical trials were re cognised procedures for the validation of medical knowledge. But a good story is de ned not by its boundaries, but by its content. The story of this book is about the relationship of medicine to natural philosophy Aristotelian natural philoso phy. Aristotelian natural philosophy was known to and used extensively by Galen, the Greek physician to Marcus Aurelius and Commodus in Rome, and formed the bas is of university natural philosophy from the early years of the thirteenth centu ry in Oxford and from the middle of the century in Paris.5 It retained its 4 5 On the medical experiment see Roger French, William Harveys Natural Philosophy, C ambridge (Cambridge University Press), 1994, esp. ch. 10. The Parisian statutes can be found in H. Deni e and E. Chatelain, eds., Chartularium Universitatis Paris iensis, 4 vols., Paris, 188997. Student notes of natural philosophy lectures can be found in a number of manuscripts of the Aristotelian corpus vetustius, which were annotated in an English hand in Oxford. See especially London, British Libr ary, MS Royal 12 G II.

4 Medicine before Science place as the university mans means of understanding the natural world until the s eventeenth century in Protestant countries, and longer in some Catholic countrie s. The Learned and Rational Physician had based his Good Story almost wholly on traditional natural philosophy. Philosophy was the basis of the theory of medici ne. It supplied the doctor with a series of unassailable axioms about how the na tural world and the body worked. It offered a method of extending these principl es down to the particulars of medicine and its practice. The logic employed in n atural philosophy not only demonstrated the solidity of these principles but pro vided the doctor with a means of convincing other people that the philosophical doctors philosophical medicine was the best possible. When and where traditional natural philosophy collapsed under the attack of the new philosophers the Learne d and Rational Doctor was at a crisis. The ways in which doctors reacted to this crisis combine to form the thread that links together the narratives of this bo ok. It is a thread by which we may link the internal details of the physicians sc heme of things the concern of traditional intellectual history to the social use s (as well as therapeutic applications) of that knowledge. Historiographically, then, this is not an internal history of medical ideas nor can it claim to be an exte rnal history of the profession; rather, it attempts to show that we can read the technical detail of medical literature and listen for the effect that it would hav e had on the intended audience. However subtle the arguments of the rational doc tor and however detailed his learning, we must not slip into the error of believ ing that both were sterile, for every word could have an effect on his listeners or readers, generally an effect that re ected well on the doctor. Medical history has its traditional heroes, from Vesalius to Harvey and Boerhaave, and although these too are linked by the thread, it is not the intention here to retell well -known accounts of such men. There are other gures who perhaps better illustrate the theme of this book because they were less heroic and more ordinary or more t ypical of some group. In what follows we shall proceed partly by gures who are ex amples and we shall look at them in a little more detail than would be usual in a survey of this size.6 This approach means too that the modus tractandi here is not 6 This book is aimed at a readership of senior students and is not therefore a narro w research monograph. I have, however, included a research component in reading th e texts of the men I have chosen as examples. Critics will doubtless point out t hat these are not important examples. But important here is an attribute of tradit ional evolutionary history, and carries little meaning in the kind of story I am trying to tell.

Introduction 5 a magisterial survey of the secondary literature, most of which has been concern ed with medical progress. Such men as are used for examples here have often been ignored because of a perceived lack of a contribution to the development of medic ine, and tend nowadays to be left to the obscurity of their Latin treatises. Ind eed, an alternative way of presenting the argument of this book is that it deals with the Latin tradition of European medicine. Everyone agreed that the Father of Medicine was the Greek Hippocrates, but Greek was a language essentially lost to Western Europe after the fall of Rome. A Latin tradition might have started with the Greek Galen, who taught in imperial Rome and became physician to the em peror at a time when educated Romans increasingly learned Greek; or a few years earlier with Celsus, who wrote in a widely admired style of Latin. But the bulk of Galens work was not recovered until the high Middle Ages and Celsus was unknow n until the early fteenth century. It was from a Latin translation of Hippocrates and Galen that the Western doctors put together their medical tradition and it was the Latin tradition that came to an end in the Enlightenment with the collap se of traditional natural philosophy and Galenic theory and the replacement of L atin as a medium of education with the vernaculars. Looked at in this way contin uities are as important as novelties. When publishers of the early sixteenth cen tury printed huge commentaries that had been written two centuries before, they were making a very sizeable investment which could be recouped only in the marke t which fed the enduring programme of the schools. The same can be said of Galen ic texts published a century after Harvey had convinced some doctors that Galeni c theory was untenable. Even the editions of Hippocrates and Galen by Littr e and K hn in the nineteenth century indicate that classical learning was still u a wo rthwhile attribute for the gentlemanly (and pre-germ-theory) doctor. The forces of conservatism were considerable and varied from place to place and in differen t groups of doctors. It is a rash historian who attempts to cover as wide a chro nological period as this, where many specialists have spent careers on parts of it. Inevitably this book contains shortcomings. As Goldsmith says in introducing The Vicar of Wake eld, There are an hundred faults in this thing, and an hundred t hings might be said to prove them beauties. But he proceeds robustly, But it is ne edless. To adapt his defence, a book may claim to tell an interesting if imperfec t story, or it may be very dull without a single absurdity. Goldsmith is not wholl y without relevance here, for he had

6 Medicine before Science been, among many other things, a student at the famous medical school at Edinbur gh, with which this book effectively ends. It was a school on which he bestowed no lustre whatever; and of his brief excursion into medical practice his biograp hers note only that he once prescribed a medicine of such horri c strength that th e apothecary refused to make it up. Here is an allegory of the lost authority of the doctor.

part i Sources

chapter 1 Hippocrates and the philosophers medical wisdom When the medieval doctor looked into the past for the beginnings of his own profession, what he found was the gure of Hippocrates, the Father of M edicine in the medical tradition from the Middle Ages to the Enlightenment. Mode rn scholarship has not revealed much about the historical Hippocrates or which o f the Hippocratic works were written by him,1 but the medieval doctor felt more se cure in his knowledge. The Hippocratic works gave him a number of things. There was technical advice in a practical subject, which told him what to do and what to expect. For instance, the corpus includes works that explain how to reduce di slocations and how to bandage wounds.2 The Hippocratic works were also valuable because they were Hippocratic, that is, ancient and authoritative in an age that revered antiquity. These rst two chapters are not directly concerned with the rst of these aspects of antiquity, the technical content of Greek medicine and phil osophy. They are not, that is, a background to or an early history of a professi onal activity developed during the Middle Ages and beyond. Rather, they present an image of the medieval and later perception of antiquity, a construction (howe ver false in our historical terms) within the 1 2 Hippocrates was mentioned by Aristotle and Plato who says (Protagoras 311b) that he taught medicine for a fee. In the Phaedrus (270a) the Platonic Socrates argu es that rhetoric is like medicine, for they de ne the nature of the soul and the b ody respectively; Hippocrates the Asclepiad is credited with the declaration that the body can be understood only as a whole. Biographies of Hippocrates were writ ten by Soranus and Suidas. Tradition has it that he was born in 460 bc . Most of the works attributed to Hippocrates were written between 430 and 330 bc , and s ome later. See G. E. R. Lloyd, ed., Hippocratic Writings, Harmondsworth (Pelican Classics), 1978, p. 9 and W. H. S. Jones general introduction in vol. 1 of the L oeb Library series (see note 2 below). For a recent account of the historical Hi ppocrates and the corpus, see Jacques Jouanna, Hippocrates, trans. M. B. DeBevoi se, Baltimore (The Johns Hopkins University Press), 1999 ( rst published as Hippoc rate in 1992). The Greek text of the Hippocratic works, with an English translat ion by W. H. S. Jones and E. T. Withington, may be found conveniently in the Loe b Library series: Hippocrates (vols. IIV), London (Heinemann) and Cambridge, Mass . (Harvard University Press), 19628. 9

10 Sources Latin tradition and on which the later Western doctors based their actions. It i s not a story of beginnings but of resources. What the medieval doctor found in Hippocrates was primarily medical wisdom. This was the rst kind of medical learni ng used by the Rational and Learned Doctor in the West; we shall meet the other forms below. It went hand in hand with a useful knowledge of what natural things were good for this or that disease, or part of the body. Hippocratic medical wi sdom was found primarily in the text called the Aphorisms. This had probably con tinued in circulation during the earlier Middle Ages, and was certainly translat ed into Latin as the Eastern Empire tried to regain control of Italy.3 The medic al wisdom of the Aphorisms is of a particular kind. It is imparted with great co n dence and authority and appears to be the distillation of long experience by a r etentive and perceptive mind. Indeed, the rst aphorism of them all declares that the art of medicine requires much time to acquire and that, in comparison, life is short. It was generally agreed later on in the West that such had been the cl arity of Hippocrates mind that he had achieved this medical wisdom without the ai d of other arts such as dialectic and philosophy, which had not then been invent ed and which later came to be such a prerequisite of learning medicine. In our t erms this air of original authority of the Hippocratic writings may well be beca use they include some of the earliest written medical material.4 No doubt they r e ect an earlier oral tradition, but there were no earlier books to be used as an authority or as a basis of discussion, which became important features of the la ter Western tradition. Possibly the Hippocratic corpus is a collection of early Greek medical writings made and named by a librarian, possibly in Alexandria; po ssibly the collection is itself the remains of a medical library.5 At all events , literate doctors from the middle of the fth century were discussing the nature of medicine and using rhetoric to persuade their readers of the superiority of t heir own medicine in a competitive situation. Public lectures could also be used ,6 but it is clear that they felt that the 3 4 5 6 See A. Beccaria, I Codici di Medicina del Periodo Presalernitano, Rome (Storia e Letteratura), 1956, esp. p. 6. On literacy, see I. M. Lonie, Literacy and the de velopment of Hippocratic medicine, in Formes de Pense dans la Collection Hippocrat ique. Actes du IV e Colloque International Hippocratique (Lausanne e 2126 Septemb re 1981), ed. F. Lasserre and P. Mudry, Geneva (Libraire Droz), 1983, 14561. The r st prose book in medicine seems to date from the middle of the sixth century, an d the doctors were the rst to create a distinct body of technical literature. As suggested by Jones in the Loeb Library series, vol. 1. For example, the Hippocra tic Nature of Man opens with a reference to public debates on medical topics, fr om which a victor emerged. The context is whether man could be reduced to the few elements of the philosophers or the few humours of some physicians. (Loeb Librar y series, vol. 4.)

Hippocrates and the philosophers 11 written word offered the possibility of a wider audience, and an enhanced author ity.7 Medical aphorisms, as wisdom, share features with other forms of expression . Like proverbs and the words of oracles, they speak with their own authority wi thout supporting reasons and are open to the implication that this authority dep ends on either long experience or some kind of revealed knowledge. It can be arg ued that transmitting knowledge in this way is characteristic of pre-literate so cieties. Oral transmission in a complex business like farming has to be precise and not subject to accumulated errors. Structured oral expression helps here: th e verse of Homer was famously committed to memory, and terse and expressive prov erbs and aphorisms are memorable and useful. Pliny in imperial Rome reports some agricultural aphorisms of this kind. One of them was to have pruned the vines b efore the rst cuckoo is heard (leave it too late and the vines bleed alarmingly. Pliny says that the farmer who did leave it too late might be embarrassed by his neighbours making jeering cuckoo noises at him).8 Proverbs also often have a rh ymed structure to give them memorability. Sell in May and go away used to be a sto ck-market proverb reminding the broker of the slack summer season. Oak before ash and well have a splash; ash before oak and well have a soak is a rustic proverb of prediction based on the bursting of the buds. (It is also an English joke, beca use the rain will come anyway.) p re d i c t i o n Thus an important feature of proverbs, aphorisms and oracles is that many of them are predictive. When sleep p uts an end to delirium, it is a good sign is a predictive aphorism. The third aph orism of the collection is both paradoxical and predictive when it says (at rst s ight) that good health in athletes is dangerous because it can only change for t he worse. In medical terms prediction was very important. The doctor gained a go od reputation by being able to predict the outcome of a case, and he avoided a b ad one by refusing to take on a case where the patient was clearly going to die. The Hippocratic corpus contains a text devoted to medical prediction, Prognosis . The Greek author was quite explicit about the bene ts to ones reputation from cor rect prognosis, but the medieval version read by aspiring doctors down to the si xteenth century was much more so. It opens directly by 7 8 See John Vallance, Doctors in the library: the strange tale of Apollonius the boo kworm and other stories, in Roy MacLeod, ed., The Library of Alexandria. Centre o f Learning in the Ancient World, London and New York (I. B. Tauris), 2000, pp. 9 5113, at p. 99. Historia Naturalis XVIII. 66.

12 Sources advising the doctor who wants glory and lots of friends to be careful in prognosis.9 These are important words, for we are looking at the gure of Hippocrates through the eyes of later Western doctors as they tried to recover ancient medicine. Th e Greek text does not have these words. Possibly they were introduced into the t ext when it was paraphrased in Arabic or when the Arabic was translated into Lat in.10 At all events they provided authoritative justi cation for medieval doctors to seek monetary rewards from their practice of medicine. It was a message reinf orced by Decorum, where the rewards of proper ethical behaviour are said to includ e glory.11 Prognosis goes on to explain that medical foresight is more than predic ting an outcome and includes giving an account also of the patients present sympt oms and those that he has suffered in the past. It is very helpful, the text say s, if the doctor can describe past symptoms that the patient himself has forgott en about or not mentioned to the doctor. It was all good advertising for the doc tors skills, and Prognosis is quite clear that the purpose is to impress the pati ent. An impressed patient trusts his doctor, gives himself more readily into his hands, and obeys him.12 In other words, the doctor has persuaded the patient th at he knows about the kind of thing the patient is suffering from and can guide him through it: he has told the patient what in this book we shall call the Good Story. Prognosis then dwells on the uncertainty of the outcome in acute cases. Perhaps the patient has delayed too long before calling the doctor. Perhaps the disease is severe, and the patient will not last the day. It was vitally importa nt to foresee death because in predicting it, the text says, the doctor will esc ape blame. For this purpose there follows the famous facies Hippocratica, the ap pearance of the face of a dying person, with its sunken eyes and sharp nose. As with the Aphorisms, the descriptions in Prognosis are brief pieces of medical wi sdom, seeming to derive from long experience. 9 10 11 12 Omnis qui medicine artis studio seu gloriam seu delectibilem amicorum consequi d esiderat copiam: adeo prudentum regulis rationem suam muniat. Videtur mihi ut si t ex melioribus rebus ut medicus utatur previsione. See the Articella, Venice, 1 483, f. 47r. They are not included in the new translations from the Greek by Cor narius and Copus. See Hippocratis Coi Medicorum longe Principis, Opera quae ad n os extant Omnia, trans. I. Cornarius, Basel, 1557, p. 617; Hippocratis Coi Medic orum Omnium longe Principis, Opera, Basel (Cratander), 1526, p. 355. On the Arab ic paraphrase, see C. OBoyle, The Art of Medicine. Medical Teaching at the Univer sity of Paris, 12501400, Leiden (Brill), 1998, p. 90. See also V. Nutton, Beyond t he Hippocratic Oath, in Doctors and Ethics: The Earlier Historical Setting of Pro fessional Ethics, ed. A. Wear, J. Geyer-Kordesch and R. French, Amsterdam (Rodop i), 1993, pp. 1037. [E]st dignus ut de eo credatur quod est potens scire res egro rum ita ut illud provocet in rmos: vel sit ducia ad con dendum: et committendum se in manibus medici. Articella, Venice (H. Liechtenstein), 1483, f. 47r.

Hippocrates and the philosophers 13 Like oracles, medical aphorisms and prognostic advice were often expressed in te rse and even obscure language. Ambiguity in an oracle left room for interpretati on after the prediction had or had not come true, without destroying the credibi lity of oracles in general. The practising doctor had to be more direct, but gen erally left himself some room for manoeuvre after the event. What was important in this case, and in the terse language, was interpretation. Sometimes an aphori sm omits a verb, or uses a pronoun in place of a noun, so that we are left to gu ess who he is. Medical teachers found that aphorisms had to be explained, all the more so when they had to be translated out of old-fashioned Greek into Latin. Bu t the most important form of interpretation that aphorisms seemed to need was th e giving of reasons behind the situation so curtly described. How do winds from the south make people deaf? Why do acute diseases come to a crisis in fourteen d ays? Why was it that those whose bowels were loose in youth became constipated i n age? Every age that followed the Hippocratic period had its own preferred reas ons for the truth of the aphorisms (and explaining an aphorism was part of medic al graduation down to the eighteenth century). In an important sense aphorisms w ere not rational statements, but declarations of medical wisdom. They were not o f course irrational in our sense, but were conspicuously without arguments.13 Th e rational doctor, in the sense we are using in this book, supplied his own argu ments to the aphorisms to show why they were true or what must have been in the mind of Hippocrates when he wrote them. We shall see below that the most importa nt of the rational interpreters of Hippocrates was Galen, the Greek doctor in im perial Rome. g ro u p s o f d o c to r s In these ways, medical knowledge wisdom could be used directly to treat a patient and less directly to enhance the repu tation of the doctor. It is often remarked that there was no system of licensing doctors in the ancient world, and therefore the doctors reputation and that of h is teacher were very important.14 There was competition in the medical marketpla ce. If, like Hippocrates, the Greek doctor taught medicine for money, then poten tially at least, he competed with other teachers to attract pupils. Naturally, a 13 14 Lloyd calls the Aphorisms one of the scrapbooks or notebooks of the Hippocratic co llection. Lloyd, Hippocratic Writings, p. 11. The reputation of his school was a lso important for an aspiring city physician; Alexandria came to be important in this respect. See O. Temkin, Hippocrates in a World of Pagans and Christians, B altimore and London (The Johns Hopkins University Press), 1991, p. 20.

14 Sources good reputation always helped. Practice among fee-paying patients held out great er rewards and some Greek doctors became very rich, whether as physicians to the rich and powerful or to the Greek city-states.15 Democedes of Croton earned ove r thirty times as much as the average skilled worker.16 Such men were clearly su ccessful, and when Democedes moved from Aegina to Athens his salary increased, n o doubt in line with his reputation. But not all doctors agreed on what kind of business they were in, how patients should be treated or how reputations should be maintained. There is abundant evidence that Greek doctors belonged to differe nt schools, whether schools of thought, cliques or confraternities, and articulate d their differences. One particular aspect of this is especially important as we unravel the process by which medieval doctors tried to reconstruct and emulate the medicine of the ancients. Like-minded members of a group naturally believe t hat their common beliefs and practices are superior to those of a rival group, p articularly if the groups are competing in a calling such as medicine. It can ea sily follow that a rival groups success can be seen as being achieved by dubious means. In the case of medicine it would equally have followed that their medicin e, being of the wrong kind, was incapable of being practised ethically, because it damaged the patient. In fact, the Hippocratic collection of texts contains some that deal with the ethics of medical practice and teaching. There are two ways of reading such texts. The traditional internal reading of the texts rests on th e (not unreasonable) assumption that there are some general or absolute ethics i n the relationship between people. In Renaissance editions of the Hippocratic co rpus, the ethical works were often placed rst, as though they formed an introduct ion setting out the moral basis of the practice of medicine.17 But it is also po ssible to read these texts externally by considering who they were directed at and what they were designed to achieve. Let us take as a rst example the text called Precepts.18 It is addressed to the brothers of a family of physicians, that is, to a self-de ned group. Part of the motivation of the group was altruistic, for where there is love of man, there is also love of the art,19 but it would not be unduly cynical to guess that the physician also loved his fee. The author advises agai nst negotiating the fee when rst meeting the patient, for worry about providing i t and the 15 17 16 Lloyd, Hippocratic Writings, p. 19. Public physicians were chosen by a panel of laymen. See, for example, Cratanders edition. A similar sequence was mai ntained into the eighteenth century, the end of the period considered in this bo ok. See, for example, Magnus Hippocrates Cous Prosperi Martiani Medici Romani No tationibus Explicatus, Padua, 1719. The ethical works drew the attention of medi eval doctors at a comparatively late date. They were not discussed by Parisian m asters, for example, until about 1400, and they appear in the Articella only in the late and printed versions. 19 Ibid ., p. 318. Loeb Library series, vol. 1, p . 312. 18

Hippocrates and the philosophers 15 possible departure of the physician will make him worse: better to press for the fee when the patient has recovered. Indeed, forgoing the fee from a poor patien t is recommended for brothers of the art because the gain in reputation will be gr eater than the nancial reward. Although a personal choice, the brothers of the sa me fraternity would have gained from such a reputation. The most important of th e ethical works is the Oath.20 It has been treated as an expression of high ethi cal ideals, on a level that gives it a timeless validity, and for this reason ha s often been revived. It was an oath sworn by a new doctor at graduation down to the time when medicine became scienti c.21 But it is also clearly the product of a group of doctors with a particular kind of medicine, one that was atypical of ancient medicine in general.22 It is in fact a document of entry. The candidate or new recruit who swore the oath was agreeing to a set of rules that governed t he group he was joining. The rules of such a group are its ethics, and while som e of the rules may well be designed to bene t others outside the group, the effect of the ethical rules of a group is the survival of the group. The individual, a fter all, joins the group to enjoy the privileges it can secure by being an orga nised group; this may entail some sacri ce, but collaboration with fellow-workers generally brings bene ts. The long-term bene ciary of such ethics is the group itsel f.23 The medical man who swore the Hippocratic Oath did so by appeal to Apollo a nd Aesculapius, so probably he was joining a fraternity that was partly religiou s; perhaps the members believed that medicine was originally a gift from the god s. He swore to treat his teacher as a father and to teach his teachers sons as he would his own. This seems to re ect a father-to-son type of education, and the ne w doctor was entering an arrangement where the ethics of family responsibility w ere added to those of religion. He swore to teach other incomers, provided that they followed the rules, that is, became 20 21 22 23 See L. Edelstein, Ancient Medicine, Baltimore (The Johns Hopkins University Pres s), 1967, which includes earlier papers, especially that of 1943 on the Oath. Th us the Oath is a deathless gem for Jacques Jouanna: The birth of Western medical ar t, in M. D. Grmek, ed., Western Medical Thought from Antiquity to the Middle Ages , trans. A. Shugaar, Cambridge, Mass. and London (Harvard University Press), 199 8, pp. 2271, at p. 63. Edelstein argues that the Oath is Pythagorean in origin; D arrel W. Amundsen, Medicine, Society and Faith in the Ancient and Medieval World s, Baltimore and London (The Johns Hopkins University Press), 1996, p. 41 points out that it was little known in the ancient world before the coming of Christia nity. Again, this is not to deny personal or corporate altruism, but what is pro minent in the historical records is the physicians advice to each other on how to maintain a reputation. Many, if not most, of the ethical principles expressed in the medical literature were motivated by the physicians concern for his reputati on: see Amundsen, Medicine, Society and Faith, p. 35.

16 Sources members of the family. He also swore not to give to patients substances that cou ld be used by them to commit suicide or procure abortions. Was this a lofty expr ession of eternal ethical values? Some historians have treated it as such, but w e have to remember that there have been times and places when suicide, abortion and even infanticide have been acceptable and thus not ethically problematic. Su icide in particular was rarely censured in the ancient world.24 Whatever the int ention of the author of the Oath, we can see that the external effect of these p rohibitions might have been to enhance the reputation of the group of doctors wh o swore to obey them. An abortion might leave an aggrieved father, denied his le gal right to his child. The family of a suicide victim might feel the tragedy ha d been avoidable. These were the people who might, or might not, call in medical help again, and the doctors needed a xed code of behaviour. Some doctors were it inerant: they needed guidance on the properties and diseases of different locati ons (supplied in the text Airs, Waters and Places),25 and they needed to leave b ehind a good image so that the itinerant doctors who followed them would also be ne t from the high esteem in which Hippocratic doctors were generally held. The co nverse of ethics seen in this light is the Greek doctors need to recognise hopele ss cases, so that he could avoid them.26 This looks timelessly unethical to us, but it meant that the doctor could avoid being linked to failure, that is, death . Greek prognosis was not only a matter of predicting an outcome; it also involv ed diagnosis in the sense of persuading the patient that the doctor knew about t he condition itself. In describing the symptoms to the patient, perhaps symptoms that the patient had forgotten to mention, the doctor could make a display of h is technical knowledge that would impress the patient and family. This knowledge was valuable. Indeed, it was a stock-in-trade that the doctor used in two ways: to treat his patients and to maintain the reputation of the group to which he b elonged. Some groups were aware of this to the extent of keeping their medical k nowledge secret. The father-to-son education of the Oath and the strict rules ab out who could be taught imply that medical knowledge was a family secret. The Hi ppocratic text called Law suggests that medicine was originally a gift of the go ds and that knowledge of it had to be protected from the profane. A 24 26 25 See Lloyd, Hippocratic Writings, p. 15. Amundsen, Medicine, Society and Faith, p. 38. See The Art, in vol. 2 of the Loeb edition of Hippocrates, ed. W. H. S. Jones, London (Heineman), 1923, pp. 185217, chs. 3 and 8. This is another polemical text, against an unknown critic. The identi cation of hopeless cases was an important characteristic of the authors kind of medicine, and his refusal to tackle them was an important criticism. In Cratanders edition of the Hippocratic corpus, The Art stands in rst place, as if de ning what Hippocratic medicine was.

Hippocrates and the philosophers 17 number of the ethical works carry the message holy things should be given only to holy men. Professional secrecy, the refusal to take on hopeless cases and the ma nagement of prognosis for professional gain were all devices to enhance the repu tation of the doctors and to form the expectations of the public. We can usefull y glance at another of the Hippocratic ethical works, Decorum.27 This sets out w hat is decent for the good doctor to do. He must, for example, dress modestly an d not be too elegant or conspicuous. It was an article of ethics that came to be copied in the Renaissance in a fairly uncomplicated way, simply on the authorit y of Hippocrates. Later doctors may have seen the utility of modesty for creatin g an image or reputation, but we must for once go beyond later perceptions of th e Hippocratics to the circumstances of the Greek text. It soon becomes clear on reading Decorum that it is a partisan document. The tract is aimed against anoth er group of medical men, who profess and practise another kind of medicine. Nece ssarily the two groups had different ethics in the sense in which we are using t he term. To our author the other group seemed obviously not ethical or decorous. F rom his attacks on this other group we can learn a little about its characterist ics. That the members of the group wore ostentatious clothing means most likely th at they dressed with studied elegance. From other complaints by our author we ca n conclude that they also had great powers of persuasion. Perhaps this was evide nt in the public disputations that the Greeks used to arrange in order to judge between speakers. At all events, this is the nub of the matter: the two groups w ere in competition. Decorum says that the other doctors appealed especially to t he young, which might imply that pupils were being poached by the other group. T hey are sophists, says Decorum, giving them the no doubt gratuitous image of cla iming to be able to teach anything for a fee (and so teaching nothing properly). ph i lo s o ph y So far we have seen some of the uses to which medical wisdom c ould be put, particularly the authoritative and experiential wisdom of aphorisms . We can distinguish this from the technical medical knowledge, perhaps of divin e origin, that was a stock-in-trade. Both were kinds of medical learning that ch aracterised our Learned Doctor, and both were used by later European 27 O. Temkin dates the text to the rst century a d: Hippocrates in a World of Pagans and Christians, Baltimore and London (The Johns Hopkins University Press), 1991 , p. 25.

18 Sources doctors in trying to re-establish ancient medicine. But our Learned Doctor was a lso Rational in the sense indicated above, and he drew this too from the ancient world. The use of argument in medicine in the high Middle Ages was taken direct ly or indirectly from Aristotle, a circumstance we examine next. For the medical man, Aristotles style of argument was most interesting in the context of natural philosophy, and the theory of medicine was to become almost wholly Aristotelian in its principles. But the situation was very different for the early Greek doc tor. Returning to Decorum, it nally becomes clear that the enemy were doctors who based their medicine on natural philosophy. They invoked grand principles of ch ange, common to the macrocosm and microcosm; they denied the role of the gods; t hey held that all physical change was wholly natural and intelligible; and they claimed that the number of principles or causes of change were few. This was all very different from the medicine of texts such as Decorum and Ancient Medicine and other works ascribed to Hippocrates. We have seen that the Aphorisms and Pro gnosis do not deal with physical causes at all and are implicitly based on the a ccumulation of human experience. The author of Ancient Medicine likewise accepte d the superiority of long experience over a few imagined physical causes, and as serted that far from being godless, medicine had originally been born with divin e help. Ancient medicine was primarily dietetic and had begun with a study of the diet of the ill and grew, indeed was still growing, with the accumulated experie nce of the dif cult business of how different foods affected different people. The art indeed was long, life was short and judgement dif cult. In contrast, the phys ical principles of the new philosophy were of but recent origin. It is absurd, s ays the author of Ancient Medicine, to explain medicine and indeed the whole wor ld on the basis of the four elementary qualities, the Hot, Cold, Dry and Wet. Th ese were the few physical principles of the philosophers, the active powers that governed the four elements, Earth, Air, Fire and Water.28 For the author of Anc ient Medicine the world was a much more complex place. It was the many and subtl e qualities of foods, like the bitter, salt and acid, which affected the body fo r good or evil; the elementary qualities were not causal, for a fever patient ma y feel hot but shiver with cold; a cold bath makes the patient glow with heat on being dried; frostbite is like a burn and only becomes apparent when the patien t is warm again. In a complex world, medical experience was everything, for 28 Regimen I for example is a philosophical-medical text that, having announced the general principle that to be an effective doctor one must know the basic compon ents of the body, bases the body and soul of man on two elements, re and water, w hich between them supply the four qualities (Loeb Library series, vol. 4, p. 230 ).

Hippocrates and the philosophers 19 foods, patients and circumstances varied, and medicine was still being enriched by accumulated experience. Wisdom gained over time could not be replaced by the simplistic qualities of the philosophers or the false precision implied by their use of numbers.29 In traditional historiography, Greek medicine of the Asclepia d kind was rational in a modernist sense, in considering the natural world and the case history of the patient, eschewing divine causes.30 It may be that writing historia as in medical case histories, the Hippocratic physician was rational in t his sense, but it should be emphasised again that in this book rationalism is to do with arguments, not with naturalness. Nevertheless, despite the antagonism b etween old medicine and the new philosophy, some con ation was possible between natur e and reason in medicine, and in late antiquity medicine and philosophy soon came t o be regarded as sisters: philosophia et medicina duae sorores sunt, said the Al exandrians, attributing the doctrine to Aristotle.31 When medieval and later phy sicians tried to emulate Greek medicine they thus had two rather different model s within the medical literature. The in-family method of education treated medicin e as a lifetime art that depended on accumulated experience and may have had div ine origins. It was a valuable commercial asset and was often treated as secret, to be revealed only to the properly initiated. We may suppose that in these cir cumstances the composition of medical knowledge varied according to the school or f amily concerned. On the other hand, the philosophical doctors made a virtue of th e openness of their teaching (causing their opponents to make sour remarks about their verbosity). The reason for this may have been that the early Greek natura l philosophers often constructed their theories with an agenda in mind. A not un common aim was to enable man to reach a stability of mind. This could be done by accepting that all the dif culties of life were in some sense inevitable and had to be accepted. Certainly all were natural, and if one understood the laws of na ture then it was easier to bear the misfortunes of 29 30 31 Ancient Medicine, in vol. 1 of the Loeb edition of Hippocrates, ed. Jones, pp. 16 4, chs. 12, 14, 1617 and 20. Jouanna, Hippocrates, especially p. 56 and ch. 8. The Aristotelian locus was probably in De Sensus et Sensato, where Aristotle says t hat the natural culmination of natural philosophy would be the study of man and his health. See Cornelius OBoyle, Discussions of the nature of medicine at the uni versity of Paris, ca. 1300, in John van Engen, ed., Learning Institutionalized . Teaching in the Medieval University, Notre Dame, Indiana (University of Notre Da me Press), 2000, pp. 197227. That medicine was the philosophy of the body and phi losophy the medicine of the soul was a doctrine eagerly taken up by the later ra tional and learned doctor, as we shall see. See also Temkin, Hippocrates, p. 8, who derives the opinion from Aristotles observation that the philosopher nishes wh ere the philosopher begins.

20 Sources life. An important freedom that this aim helped to foster was freedom from fear of the gods. Some philosophers held that there were no gods, others that the god s were incapable of interfering with human and natural affairs. It was not Zeus who threw thunderbolts, said the philosophers, but a hot vapour arising from the earth, or the clouds exploding, or something of that sort. Ordinary Greeks worr ied about suffering from wilful gods not only in life but perpetually after deat h in some kind of quasi-material afterlife. The philosophers told them not to wo rry: death was so complete and nal and nothing could happen afterwards. Not all G reek philosophers argued in this kind of way. It was the young Socrates who desp aired of nding satisfactory answers to physical and natural questions and turned instead to human matters. His pupil, Plato, followed him, but also wrote two wor ks of great interest to later doctors and natural philosophers. One of them was the Republic, which explained the workings of an ideal city-state. The state in fact worked rather like the human body, with a threefold hierarchy. Controlling the city were the philosopher guardians, who alone had the wisdom to govern; its counterpart in the body was the rational soul, drawn down from the heavens into the head and possessing at least the rudiments of true knowledge. Below the hea d was the heart, the seat of the vital soul, the source of motion. Its place in the city was taken by the army, brave and vigorous but needing the direction of the guardians. In the lowest place in the body was the liver and its nutritive f aculty, corresponding to the workers and kitchens of the city. Plato described t his body in the second text, the Timaeus, which contains an account or a parable of the creation of the world by a deity, the demiurge. Like the Aphorisms of Hi ppocrates, this text and the commentary on it by Calcidius were remembered in th e West after the fall of Rome. No doubt this was because the Christian church co uld sympathise with the doctrine of a soul with divine origins that returned to its celestial home after the death of the body. And the Timaeus, unlike the work s of Aristotle, dealt with a creator god, as did the Old Testament. To all appea rance, Plato had been struggling to reach a Christian truth, hampered principall y by being unable to receive revealed knowledge. The doctrine of a wise and crea tive deity was taken up by Galen, as we shall see, and this gave it double autho rity with the later Christian doctors of the West. Because the body was the micr ocosm of the world at large, the doctor found it to be of advantage to have spec ialist knowledge of both, of nature as a whole. Nature was physis, which covered t he natural world and Aristotles nature-of-a-thing (as explained later). The docto r full of natural knowledge became in the Latin

Hippocrates and the philosophers 21 tradition a physicus, which could mean natural philosopher or medical man and which ultimately gave rise to the term physician.32 d e m o c r i t u s physicus When th e medical man of the Middle Ages and Renaissance looked back at the beginnings o f his subject he also saw a literature that has been treated as problematic by h istorians of the classical period. This includes letters attributed to Hippocrat es in early medieval medical collections, and the story of Democritus the Philos opher. This too was a story of medicine meets philosophy, and it was remembered do wn to the time when traditional natural philosophy met its crisis in the sevente enth century. It concerns Democritus the natural philosopher, who preferred to s pend his time in a retreat in the woods dissecting animals rather than live in h is native city. His fellow citizens thought him mad and called in the great Hipp ocrates to examine him. Hippocrates duly came, interviewed Democritus, and decla red him saner than the citizens. Not only that but, as if to symbolise the close relationship between medicine and philosophy, Democritus showed Hippocrates tha t he had discovered the physical cause of madness in animals. Democritus physicu s was a philosopher with a great reputation, the details of whose philosophy cou ld not easily be found by the men of later centuries. This was not inconvenient if, for example, an alternative to Aristotle had to be found. Democritus was eve n more ancient than Aristotle and the hints he left as to the nature of the worl d could be readily adapted to some later system. Democritean philosophy in later a ges only sometimes meant atomic and often referred to the pragmatic sylvan dissect or. a r i s tot l e a n d n at u r a l ph i lo s o ph y As with the case of Hipp ocrates, it is not the intention of this chapter to give a chronological or anal ytical account of a historical gure and his works. Rather we need to know what it was that the medieval and later doctors chose to pick upon as they sought to re construct the medicine and philosophy of the ancient world. We can conveniently begin with those philosophers whom Aristotle sometimes calls his predecessors. T here are two cautions to be observed 32 We shall see in later chapters that it became convenient to use physica for philo sophy where the latter term had pejorative connotations. See also, J. Bylebyl, The medical meaning of physica, Osiris, 2nd series, 6 (1990), 1641.

22 Sources here. First, Aristotle often began his physical treatises with a refutation of o ther mens theories on the topic under discussion. This was partly a dialectical e xercise, giving greater credibility to his own doctrines by the destruction of o thers. This meant that it was to Aristotles advantage to make it appear as if ear lier philosophers were engaged in the same kind of exercise as he was himself, b ut not so successfully. It would have been of no use to refute popular fables or the poets, and Aristotle occasionally points to the very different nature of th ese other forms of Greek thought.33 But we have only fragments of the works of t he early philosophers and cannot tell what their agenda was; before Socrates it seems unlikely that there was a succession of philosophers with any common program me. Second, the physical works of Aristotle were rst explored in the later West, like the medical works, partly in the form of Arabic paraphrases. The process of abbreviation was selective, and certain kinds of materials were left out.34 Occ asionally pieces of additional matter were added, as we saw at the beginning of Prognosis. This meant that, at rst, later Western scholars did not have a very go od idea of what Aristotle had written. For our purposes this does not matter. We are not concerned with any process of transmission of the text of Aristotle in which the criterion of success was a faithful delivery of an accurate text, but with what later doctors made of Aristotles texts, in whatever form they existed. We saw that the Hippocratically decorous doctors, who found rivals in philosophica lly inclined medical men, objected strongly to the doctrine that the fundamental principles of the world were the four elements and their paired qualities (each element had two qualities so that water, for instance, was Cold and Wet). This was a doctrine much developed by Aristotle, and it may be that the encounters de scribed in Decorum (which is dif cult to date) took place after Aristotles time. To understand Aristotles undertaking, however, it is necessary to glance back at hi s predecessors. It is well known that the pre-Socratic philosophers were interested in questions of nature and the physical world, and we saw above that they wanted to keep the gods out of their answers to their questions. As we have seen, trad itionally it was the young Socrates who despaired of nding answers to natural que stions and turned instead to questions dealing with men. There was a true succes sion, of master and pupil, between Socrates and Plato, and Plato and Aristotle. Aristotle, the son of a doctor, returned to an enquiry into nature. He agreed th at the gods had no place in the motions 33 34 Meteorologica 357a2428. See Roger French, Teaching meteorology in thirteenth-centu ry Oxford. The Arabic paraphrase, Physis, 36 (1999), n.s., fasc. 1, 99129.

Hippocrates and the philosophers 23 and changes of the physical world, but held that earlier philosophers had been t oo materialist in asserting that the natures of things arose from the characterist ics of the matter of which they were composed. The necessity involved in this se emed too rigid to Aristotle, who wanted to put purpose into the world. He could not accept the rational and creative demiurge who, Plato had taught, created the world, and Aristotle made nature a local principle of action. Every natural thing , and especially those living, had its own nature and purpose, that of achieving the full potentiality of its form.35 First, we must note some of Aristotles circ umstances. He taught in his own school, the Lyceum. He and his colleagues taught a wide range of subjects, of which we have space here only for those concerned with the natural world. The cycle of lectures seems to have been repeated often and the content modi ed, no doubt after discussion. Probably no fully edited and p olished lectures were produced, for Aristotles text is sometimes loosely organise d and even appears as notes. But those on the natural world are an organic whole . Aristotle began with the fundamental principles of natural change, or motion in the text called the Physics. He then went on to explain how these principles ope rated in increasingly physical circumstances. He developed his doctrines of the structure of the world and of the actions of the four elements and their qualiti es in his text On the Heavens and the Earth, and in his work On Meteorology. As the cycle progressed, Aristotle often recalls the original undertaking nothing les s than an explanation of the natural world and refers backwards and forwards to other topics in the series.36 The cycle took him through more and more elaborate forms of natural action, including those of animals. As we have seen, these wer e the natural objects that best exempli ed his general doctrine of the nature-of-t he-thing, and it is important from our point of view to note some details of Ari stotles procedure. First, he placed much more emphasis than Plato did on the role of the senses in generating knowledge (Plato held that the senses distracted th e soul from uncovering the reality of its ideas). Aristotle liked empirical know ledge. In the Lyceum they kept written accounts of the winners of the games, map s and itineraries, and accounts of the constitutions of different city-states.37 With animals Aristotle adopted what we might call a historical approach. For the Greeks, a historia was a report on an event 35 36 37 See Roger French, Ancient Natural History. Histories of Nature, London (Routledg e), 1994, ch. 1. See, for example, the Meteorologica 339a8 and 390b21. The Oxfor d Classical Dictionary, ed. Simon Hornblower and Anthony Spawforth, 3rd edn, Oxf ord (Oxford University Press), 1996, p. 166.

24 Sources given by a man who had done his best to visit and interview those with rsthand kn owledge of it. The report was factual and modest in language, very different fro m other forms of Greek literature. Aristotle adopted it for philosophy. He and h is colleagues sought historiae about animals from people professionally involved with them. That on elephants (and the amount they drink, in Macedonian measures ) seems to have come from India. Aristotles History of Animals is a selection of these reports, written in historical language, while the Parts of Animals presents generalisations, rst principles and conclusions about causes. These books contai n a famous passage in which Aristotle, having dissected many animals, praises th e knowledge to be gained from the inside of animals, however disgusting these ar e at rst sight. It is natural knowledge, worthy of a philosopher, he says, becaus e it is more certain than that of distant things like the heavens. This empirica l side of Aristotles method led him to promise a work on plants to match those on animals, and to deal with the most complex of all natural motions, that of the human soul. He declared that the natural end to the cycle of teaching, from the simplest to the most complex of motions, was a study of man. In addition to the soul, he meant medicine. The maxim Where the philosopher nishes the physician begi ns, which was adopted so eagerly in the Middle Ages, is Aristotelian. But Aristot le did not teach medicine. It was, after all, a productive art. Aristotle knew t hat doctors traded in a marketplace and sold health, or at least treatment, for money. The philosophers business was to teach people to handle knowledge, not how to make and sell things. He taught those who had the leisure to come and hear h im and he gave them a liberal education. Indeed, the term liberal arts, so importa nt in the Middle Ages, had its origins in Greece, and in both it meant studies s uitable for the free man. Liberal studies owed something of their status to the fa ct that in comparison to the productive arts they were quite useless: only the m an with free time and ability could acquire them. re a s o n i n g We have now g lanced at Hippocratic medical wisdom and seen how it could be used to win over p atients and perhaps pupils, and to defend its practitioners from the rivalry of s ophistical philosopher-physicians. The other great characteristic of the Rational and Learned Doctor whose historical career we are inspecting was his rationalit y, that is, his use of arguments. They were very largely Aristotelian. We need t o explore this a little to see what kind of arguments were used in philosophy.

Hippocrates and the philosophers 25 Plato often strengthened his own position by allowing others to talk themselves into an untenable position. Since this is a characteristic of the dialogue forma t, we can broadly call it dialectical. Aristotle used a form of it in rejecting the views of his predecessors, but of course they were dead and could not reply in the manner of the circle round Socrates. But Aristotle in addition used, inde ed almost invented, logic. In a sense this too was an observational business, ob serving, naming and classifying the ways in which people argued. It was also a t heoretical business, which did not need Socratic conversation. A basic form was the syllogism, which the medievals seized on with such enthusiasm. Syllogisms ca me in many forms and could be inductive or deductive. Inductive syllogisms relie d on repeated instances of the characteristics of a group, and a famous example is the link between rumination in animals and the possession of horns. Discover that the cow is a ruminant and it becomes known that it has horns. It is of cour se philosophically imperfect, for a perfect inductive syllogism would involve ob servation of all ruminants and all cows (the medievals found a way around this o bstacle). There is a good sense in which Aristotle was doing this kind of exerci se in the Parts of Animals. He was looking for correlations between parts and be haviour of animals, for example between diet, dentition and the number of stomac hs. Such features could remain constantly linked in different groups of animals, as repeated observation the historiae showed. The point about the linkage of th ese features was that they were co-ordinated for the bene t of the animal. This wa s not a rational or conscious plan of a creative demiurge, but was the product o f the nature-of-the-animal striving to achieve its full expression during the de velopment of the animal. It was of course a purposeful action, and, as we have s een, Aristotle had wanted to put purpose back into nature. So Aristotle was usin g logic in looking at animals and making inductions. But there was also a deeper sense in which his natural philosophy involved logic. His insistence on the pur pose of nature led him to what he considered the most valid form of knowledge. W e can recall that he criticised earlier philosophers for ascribing the features of natural things to the matter from which they were made. This was a very parti al explanation in Aristotles view. Certainly, matter had irreducible characterist ics which Aristotle called the material cause of an object. But it also had shape or Form, and Aristotle systematised the position by adding to the Material and F ormal cause the Ef cient, generally the agent that brought it into being: a table might be made of wood, have a at top and a number of legs, and be made by a carpe nter. By far and away the most important of the four causes listed by

26 Sources Aristotle was the last one, the Final. This was the purpose of the object, wheth er man-made or natural. Aristotle argued that full knowledge of a thing came fro m an awareness of what it was for, whether it was a tooth, a horn or a stomach. In the more strictly logical works Aristotle worked at a related theme. The prac tical limitations of induction meant that it could not produce philosophically c ertain knowledge. Aristotle also wanted to produce deductive knowledge, from rst principles to observed instances. This he called demonstrative, knowledge that a t hing could not be otherwise. It related to Final Causes, knowledge of which was the best path to knowledge of a thing. To the medievals Aristotles texts on logic , such as the Posterior Analytics, looked like a programme that could generate p roper knowledge of the natural world that was displayed in the physical works. T he attractions of logic were great. Knowledge of syllogisms could prove an oppon ent wrong or prove that he had framed his premisses badly. This touched on rheto ric and public speaking, whether political or medical, which we perhaps saw in t he case of Decorum. To produce demonstrative knowledge of the physical world in an irrefutable way with an elaborate apparatus of learning was a huge asset to t he medical man, who could argue that the human body was the most important part of the physical world and that Aristotle had said it was the natural end-point o f all natural philosophy. When he nally obtained Aristotles philosophical and logi cal works, the Learned Doctor also became Rational. a n ato m y We have seen fro m the different works that Hippocratic medicine was a distillation of long exper ience, partly based on knowledge revealed by the gods, somewhat oracular in its aphorisms and prognosis, and largely concerned with diet. Such anatomy as it con tained was incidental rather than fundamental. For Aristotle, on the other hand, anatomy was fundamental, for true knowledge of the parts of animals was gained through a knowledge of their function, which their shape indicated. The organs c ould not be otherwise in order to perform their function. We saw that Aristotle made dissections and vivisections to study form and function. But Aristotles inte rest was philosophical, not medical. His subjects were animals, not men. The ins ide of the human body remained for him, as he said, one of the most unknown of a ll things.38 38 Historia Animalium 494b2124.

Hippocrates and the philosophers 27 Yet Aristotles treatment of animals was immensely important for later rationalisi ng doctors. They adopted it for the human body and it became a major part of the ir argument about the superiority of rational and learned medicine. We can call it anatomical rationality. But this adoption was not a straightforward business. It meant claiming to know the inside of the human body, and we shall see that t his led ultimately to human dissection, which in turn meant the overturning of a ncient and widespread taboos about mutilating the dead body. Many societies, inc luding that of ancient Greece,39 believed in a quasi-material afterlife, and the real punishment of judicial mutilation lopping noses or the hands of criminals was the fear of eternal dis gurement. Somehow European doctors overcame these tabo os, practised human dissection and animal vivisection, and brought Aristotles phi losophical anatomy into their medicine. They might never have done so had it not been for certain events in Alexandria, a few years after Aristotles death. We ha ve already met Alexandria in the third and fourth centuries BC where, probably, librarians were arranging early Greek medical works under the name of Hippocrate s, thus causing immense trouble for later scholars. But in another quarter of to wn something much more sinister was going on, at least according to a persistent rumour. This story said that two Greek doctors, Herophilus (c. 330260 BC) and Er asistratus (c. 315240 BC), had not only broken the taboo against mutilating the b ody, but were performing vivisections on human beings. Historians have thrown do ubt on whether in fact these men were in Alexandria at the same time,40 but of c ourse what is important from our point of view is that later European doctors be lieved the story and that belief affected their actions. The context of their be lief included some pieces of circumstantial evidence in favour of the rumour. Th e rst is that Aristotles view of the philosophical utility of dissection and vivis ection may well have been known, together with his view that medicine followed n aturally upon natural philosophy. Medical men would have seen that knowledge of internal human form and function would improve medicine, and the rumour asserts that Herophilus and Erasistratus were indeed in icting great pain upon their subje cts for the greater bene t of later generations. Second, it was believed that the vivisectionists subjects were condemned criminals who had forfeited their right t o live, which seemed to be some justi cation 39 40 See H. Von Staden, Herophilus. The Art of Medicine in Early Alexandria, Cambridg e (Cambridge University Press), 1989, p. 141. For a discussion on this point see Von Staden, Herophilus, p. 37; see also Vallance, Doctors in the library, p. 97.

28 Sources for the manner of their death. Moreover, the rumour added that the exercise was carried out at the wishes of the ruling Ptolemy, a patron of learning.41 Third, Greek philosophers did not put much faith in an afterlife. Plato held that the i mportant thing was the soul, which returned to the heavens at death, leaving its prison, the wholly corporeal body, on earth. Aristotle held that the most activ e part of the soul was indestructible, and the way in which he said the body and soul interacted in life could hardly be extended to a quasi-material afterlife. The Stoics and atomists said that death was absolute. In none of these cases wa s what happened to the body after death important. If our two Greek doctors were learned in philosophy, as seems likely, then they probably did not think they w ere in icting eternal punishments on their subjects. There are also some circumsta nces which suggest that the rumour was not true. These are also of interest to u s for if they kept a false rumour alive they equally helped to form peoples belie fs and actions. The rst is that in form the rumour resembles the late-antique par adoxes. These constituted a genre of literature that presented stories of marvel lous things and events. It may have grown out of the very sober Greek historiae which, as we have seen, were reports, as original as possible, on important thin gs and events. Important events were interesting, and so were marvellous events, and so perhaps the form of the historia was extended to cover paradoxes. Alexande r the Great enters the story here. Not only did he found the city of Alexandria in Egypt (in 331 b c) and several other cities of the same name in territories h e conquered, but he took with him surveyors to assess the resources of these ter ritories, and learned men to send home accounts of things done and found. Perhap s in being retold, these accounts became exaggerated, emphasising both the glory and abilities of Alexander as a general and conqueror, and the strangeness and richness of the distant countries now under Macedonian control. These stories we re part of the Alexander literature that survived through the Middle Ages. Impossi bly strange races of men and animals found, for example, on medieval world maps derive from such forms of paradoxology that originated either from the Alexander literature or from the similar circumstances of Roman military expansion and fo und in Pliny. 41 Ptolemy Soter reigned from 323 b c to 283 b c and Ptolemy Philadelphus from 283 to 246. The latter thought that it would be possible to build a universal librar y, containing all the books in the world; and he tried to acquire Aristotles libr ary. See Luciano Canfora, The Vanished Library, London (Vintage), 1991, p. 20. F or a criticism of Canfora and a discussion of the destruction of the library in Alexandria, see Robert Barnes, Cloistered bookworms in the chicken coop of the mu ses: the ancient library of Alexandria, in MacLeod, ed., The Library of Alexandri a, pp. 6177, at p. 74.

Hippocrates and the philosophers 29 Alexander was in essence sending home ready-made historiae. Some of them were co ncerned with animals. It was generally believed, after the event, that Alexander had sent specimens of animals back to his old tutor, Aristotle. This has been d iscounted by modern historians because it looks like a story constructed round t he relationship between the greatest philosopher and the greatest general of anc ient times. But as we have seen, there was certainly a Macedonian source for Ari stotles knowledge of elephants and there seems no reason to doubt that when Arist otle and his colleagues in the Lyceum set out to solicit historiae they could ma ke use of Alexanders lines of communication. Late classical and medieval interest in stories about cannibals and the dismemberment of ones parents was similar to the interest shown in the Alexandrian rumour about two Greek doctors vivisecting prisoners.42 It was an unforgettable paradox, doctors killing rather than curin g; the great cruelty, set against the bene t to future generations; the royal sanc tion that partly absolved the doctors, and the criminality of the victims who as condemned men were judicially dead before they reached the hands of the vivisec tors, who thereby received a further degree of absolution. These issues also mad e the topic a useful one in rhetoric, which may be another reason for its surviv al. The story reached the Middle Ages in a number of ways. It was given by the R oman medical writer Celsus in the rst century a d who remarked on the advantages of vivisection for medical progress, but repudiated it for its cruelty. Celsus wo rk was not recovered until late in the Middle Ages, but he quickly became a mode l of medical Latinity. The story was retold by the Christian writer Tertullian i n about a d 200. Tertullian condemned vivisection in strong language, possibly t o illustrate the greater barbarity of pagans compared to Christians; but his sou rce was a medical man, Soranus.43 Galen (a contemporary of Tertullians in Rome), who was in favour of vivisecting animals and, if he got the chance, of dissectin g dead human bodies, reported directly that Herophilus dissected people.44 An im portant aspect of the affair of the Alexandrine rumour was that the people who h eard it and repeated it recognised as an arguable opinion the idea that the body could be investigated physically, that its parts and actions could be understoo d rationally. While there is nothing to suggest this in the experiential, partly divine and largely dietetic medicine of the Hippocratic texts we have looked at , it forms the underlying assumption 42 43 John Block Friedman, The Monstrous Races in Medieval Art and Thought, Cambridge, Mass. (Harvard University Press), 1981, p. 10, quoting Pliny. 44 In De Uteri Di ssectione : Von Staden, Herophilus, p. 143. Von Staden, Herophilus, p. 142.

30 Sources in Aristotles works on animals. Aristotles procedure was one of generating knowled ge, from historiae and dissection to physical correspondences and causes: it was a method that could be developed. Likewise in the Alexandrine rumour the prize, bene t to future generations, clearly depended on new knowledge being produced fr om vivisectional procedures. Indeed, the two Greek doctors may have discovered s omething quite unexpected, the central nervous system. co n t ro l l i n g c e n t re s The Greek notion of the superiority of thought over intractable matter i s a commonplace of histories of philosophy. In the case of the human body it was associated with the belief that there must be a special entity that gave life t o and directed the body. At different times different philosophers held that the re were souls or spirits providing the body with one or more of the features of life. The terms psyche, pneuma and thymos were variously used to denote somethin g that gave physical life, mental life and even life after death. Sometimes they represented a respired spirit, drawn from the life-giving air; often there were two or more of these principles in the body. Aristotle used psyche for soul and h eld that it interacted with the body by a quasi-material pneuma (which was innat e, not respired). The philosophers also placed these principles in different par ts of the body. There was a tradition that linked the life-giving breath to the heart, which was connected to the rest of the body by its ramifying system of ve ssels. The notion that somehow air reached the heart remained characteristic of Greek and medieval medicine. Aristotle placed all faculties of the psyche in the heart, grouping them into three, the faculties of simple vitality, shared with plants; sentience and motion, common to all animals; and rationality, possessed by man alone. Plato had three separate souls, each broadly similar to Aristotles categories of faculty, but located in the liver, heart and head respectively. Th is drew on another tradition, which recognised the importance of the brain as a controlling centre of the body. Those who worked with animals must have known ab out the vulnerability of the brain, and philosophers as early as Alcmaeon had pl aced the soul in the brain. What seems to have happened in Alexandria was that v ivisection not only con rmed that the brain was the seat of many soul-faculties, b ut that the effects of these faculties reached the body by means of the nerves. The Greeks had no word for nerve and used neuron, bre in a specialised way,

Hippocrates and the philosophers 31 just as the Romans came to use nervus. Nerves are not large or obvious structure s in the dissected body, and communication within the body was taken to be effec ted by the blood vessels. But nerves would be very obvious in the living body, w here disturbance of the motor nerves would cause muscular spasms or convulsions, and paralysis when cut through. Stimulating or cutting nerves close to their or igin in the brain or spinal cord reveals their distribution as these effects are seen in different parts of the body. It would be a guess to say that Herophilus was trying to resolve the philosophers difference on the seat of the soul by viv isection. But we know something of his work on anatomy which shows him to have b een particularly interested in the brain and nerves. He distinguished between mo tor and sensory nerves and gave a formal enumeration to the cranial nerves. The presumption would be that he was at rst an Aristotelian, for to be a philosopher in Alexandria almost meant to be an Aristotelian.45 But Aristotle was in our ter ms conspicuously ignorant of nerves, believing that the function of the brain wa s to cool the heart. Aristotle was also ignorant of muscle as the organ of motio n, and talked instead of the connate pneuma as moving the body. With the ever-pr esent possibility of confusion with the term neuron it cannot be quite certain t hat Herophilus recognised brous muscle in the modern sense. Perhaps he shared an earlier Greek view that animal motion was performed by the brous structures at th e joints. He certainly held that the nerves worked by transmitting a humour or s pirit of some kind, a belief from an older Greek tradition.46 We know that Herop hilus was taught by Praxagoras of Cos and we know the name of one of his own pup ils.47 That is, there was almost certainly a school around him, whether or not c onnected with the Museum in Alexandria. It seems likely that what was rst discove red accidentally, as in vivisection, was then taught systematically in a manner appropriate to the classroom. Classrooms are important groupings of people, with their own rules and ethics as outlined above, and we shall frequently meet such g roupings later in this book. It is notable that Celsus hints that there was a st andard list of things to be looked for in performing a vivisection, a formal rot e of observables systematised for a class. These are the position, shape, colour , size, arrangement, hardness, softness, smoothness, relation, processes and dep ressions of each organ, and whether one organ was inserted 45 46 47 Von Staden, Herophilus, pp. 39, 97. See also Friedrich Solmsen, Greek philosophy and the discovery of the nerves, Museum Helveticum, 18 (1961), 15097. Von Staden, Herophilus, p. 41.

32 Sources into another.48 Arrangement is ordo, which might be disposition of, for example, s erial structures such as the vertebrae, or the sequence of organs revealed in th e process of dissection. Celsus says that the advantage of following this sequen ce of observations was that the doctor would be able to locate pain in his patie nt and that when he saw interior parts in accidental wounds he would know whethe r they were in a morbid or natural condition; that is, by making comparisons wit h vivisected parts. Celsus account not only hints at formal teaching in a group w ith shared technical knowledge and procedures, but also at the opposition the gr oup encountered from outside, from those who believed that not much could be lea rned from dissection or vivisection. We shall look at these outsiders in the nex t chapter, and here we can note that, as in the case of the dietetic Hippocratic doctors and the philosopher-physicians, an encounter between two different grou ps often reveals interesting things about the nature of the groups. Finally, we should note that the library itself at Alexandria gave status to medicine. Medic al texts were treated as literature and the rst commentaries on Hippocrates were written in Alexandria. Doctors talked to scholars and librarians and wondered, f or example, how Hippocrates use of terms differed from that of Homer. The Ptolemi es continued to patronise learning after the time of Herophilus and saw librarie s as desirable. Galen, in the second century AD, tells the story of ships arrivi ng in Alexandria being obliged to surrender any books they were carrying so that the library could be enlarged; the owners had to be content with a copy. In com menting on Hippocrates the Alexandrian scholars were effectively placing him at the head of a tradition which suddenly acquired the dignity of age. The Alexandr ian doctors argued for their medicine as a rational activity, and so effective w as their rhetoric and intellectualism that the historian Polybius complained tha t they were called on by people who were not even ill.49 co n c lu s i o n This chapter has presented some of the features of Greek medicine and natural philoso phy known to the men of the Middle Ages and Renaissance. They were in fact build ing up their own tradition of medicine by choosing their heroes and doctrines. T hey were of course ignorant of what only 48 49 [P]ositum, colorem, guram, magnitudinem, ordinem, duritiem, millitiem, levorem, c ontactum, processus deinde singulorum et recessus, et sive quid inseritur alteri . See the Loeb Library edition: Celsus de Medicina with an English Translation b y W. G. Spencer, vol. 1, London (Heinemann) and Cambridge, Mass. (Harvard Univer sity Press), 1971, p. 14. Vallance, Doctors in the library, p. 104.

Hippocrates and the philosophers 33 modern scholarship and there has been a mass of it has revealed, and it must aga in be emphasised here that this chapter is not a history of Greek medicine in a chronological and inclusive sense. Medieval doctors knew of Herophilus and Erasi stratus by reputation only, but it was a potent one. They knew Aristotle at rst p artly in incomplete versions of his works that had passed through perhaps three languages. The more oracular Hippocratic writings needed constant interpretation . We shall see in later chapters that it took centuries to recover Galens works. And while this was going on, the doctor of medieval and post-medieval times was building up an image of the origin and lineage of doctors to which he felt he be longed. In this tradition the work of the Alexandrians was very important. The f act that physical structures, the nerves, con rmed the old notion that the brain w as a controlling centre of the body, gave them enormous importance in the study of the origin and distribution of the causes of motion and sensitivity. Part of the Learned and Rational Doctors rationality was now an anatomical rationality.

chapter 2 Galen i n t ro d u c t i o n Galen was, in the words of a number of Renaissance titlepages, the Prince of Physicians, second only to Hippocrates.1 For those who founde d and followed the Latin medical tradition of the West, what was the relationshi p between the Father of Medicine and the great Galen, physician to emperors? Wha t did medieval and Renaissance man nd in Galen as he found medical wisdom in Hipp ocrates? The answer in brief is that he found rationality and learning in a rich er measure and partly of a new kind. Galen was a potent image of the Learned and Rational Doctor who had a Good Story to tell to his patients. We can best demon strate this by following Galens life. Galen wrote voluminously and often very per sonally, quite unlike the impersonal historia-like reports, case-histories and a phorisms of the Hippocratic writings. It was partly a question of time and place : Galen was born in about a d 129, some ve hundred years after the earlier of the Hippocratic works had been written. His home town was Pergamon, an important He llenistic city, but the political centre of his world was imperial Rome where, h e decided, his medical career was to be. Galen was the son of a prosperous archi tect called Nikon and as a young man had received an extensive education in phil osophy. He seems to have had a particular interest in problems of proof, or demo nstration. But Galens father, guided by a dream (we might call it non-medical pro gnostication) sent his sixteen-year-old son to learn medicine. Galens particular interest was anatomy, and he pursued the famous teachers of the time particularl y Numesianus the anatomist at Smyrna, Corinth and Alexandria, where a human skel eton was on show. However, it appears he was not given much opportunity to disse ct human 1 See, for example, the address by Fabius Paulinus to the Venetian College of Phys icians in the rst volume of the Giunta edition of Galen of 1625: Galeni Opera ex nona Iuntarum Editione, Venice (Giunta) 1625. 34

Galen 35 bodies. Galen returned to Pergamon where, at the age of thirty, he was appointed physician to the gladiators. It is worth noting that although temples to Asclep ius were being built in Galens time he does not discuss the kind of medicine asso ciated with them; for us the doctors or priests of the temples did not form a gr oup of practitioners comparable to the followers of the sects, discussed below. m e d i c a l co m pe t i t i o n i n ro m e Galen arrived in Rome in 162, the y ear after Marcus Aurelius became emperor. It was a city full of tensions for som eone in Galens position. Certainly, this city at the centre of the world, with so me 1 million inhabitants, held great opportunities but also many dangers. First, there were cultural dif culties. Galen in language and training was Greek, but wa s seeking a career at the centre of the Roman Empire. Romans were ambivalent abo ut Greeks. On the one hand, as the empire absorbed Hellenistic towns like Pergam on, educated Romans began to admire the language and culture of Greece. Some Rom ans came to think of Greek as their primary means of expression, even though the y had never, perhaps, left Italy.2 On the other hand, the self-image of other Ro mans, perhaps sharpened by this Hellenisation, was that of a sturdy and self-rel iant agricultural and military race, full of grave moral virtues. They distruste d Greeks as overly loquacious, full of theory, smooth and untrustworthy. Galen s aid that the view such Romans took of the subtleties and minutiae of Greek philo sophy was that it was as useful as drilling holes in millet seeds.3 Greek medici ne seemed particularly suspicious, for there was nothing like its elaborate theo ry in Roman medicine, which was practical at the veterinary level. Nothing was w orse to Romans of the old school than smooth Greek doctors with a plausible line in patter, with unpleasant remedies like letting blood. There was no more licen sing of doctors in Rome than there was in Greece, and patriotic authors like Pli ny were inclined to believe that Greek doctors were deliberately killing Romans close to the centre of imperial power.4 There were many immigrant doctors in Rom e, almost all of them Greek, and Galen faced stern competition. Professional riv alry was another source of tension and at times Galen feared for his life.5 2 3 4 5 An example is Aelian, born in Galens lifetime. See Roger French, Ancient Natural History: Histories of Nature, London (Routledge), 1994, p. 262. See Vivian Nutto n, ed., Galen on Prognosis, Berlin (Corpus Medicorum Graecorum), 1979, p. 74. Se e, for example, the beginning of Book XXIX of Plinys Natural History. Nutton, Gal en on Prognosis, p. 93.

36 Sources Yet Galen triumphed, becoming physician to the young Commodus, son of Marcus Aur elius. He may, of course, have been simply the best doctor in Rome, but as has a lready been observed, there are no historical criteria on which we can judge cli nical effectiveness. We have to rely on hints as to the strategies employed by d octors to become successful in professional, social and monetary terms, and Gale n left many such hints. We shall consider these later on in the categories alrea dy established, rationality and learning. First we need to know a little more ab out the nature of medicine in Rome. m e d i c a l g ro u p s Again it is useful to look at medical groupings. It is clear from Galens writings that some practiti oners in Rome adopted the name and the beliefs of a great teacher. Galen was soo n at loggerheads with the followers of Erasistratus, whose view on the contents and pathology of the blood vessels differed from Galens. It was an enduring group , to judge by the fact that Erasistratus had died roughly four centuries earlier . Galen also distinguishes as a kind those doctors who owed their success to bei ng obsequious to the rich. Galen (not unusually) uses sneering language, but wha t he seems to be referring to was the formal relationship between patron and cli ent. The patron was generally a rich and powerful gure who supported and often at e meals with a number of clients. The patron gained status from the number of hi s clients, whom he protected. The clients were in turn supporters of the patron, sometimes in a political sense; if they were doctors, their services were avail able to the patron and they were essentially retained by him. This was in some w ays an ideal mode of medical practice, and one which doctors afterwards also sou ght. Client doctors must have felt even more protected since in Rome no action a t law could be prosecuted between patron and client. The clientpatron relationshi p effectively removed the practitioners from the competition in the medical mark etplace; Galen does not say whether they had special beliefs or practices, which doctors in the marketplace were so often strident about. g a l e n a n d t h e d e m i u rg e : r at i o n a l i t y o f t h e b o d y Galen reports fully on t he medical sects of imperial Rome. These competed with each other and with him, and form the context in which his strategies for advancing his career were playe d out. The sects were not ancient. They seem to have arisen from an increasing u se of philosophy in medicine. We have glanced at the anatagonism felt by some Hi ppocratic doctors

Galen 37 for the new and logical philosophical medicine, expressed in texts which are dif c ult to date. We are on rmer ground with the two vivisectors, Herophilus and Erasi stratus. Herophilus at least seems to have been mindful of Aristotles natural phi losophy and the group of pupils and followers around him formed a school6 that con cerned itself with logical medicine, by which we should probably understand the pr oduction of knowledge about the body by reasoning, from a few rst physical princi ples. It has been convincingly argued7 that in reaction to this, from about 225 to 50 b c, there developed a group of doctors who emphasised the empirical side of medicine the long experience and accumulated wisdom that we met in Ancient Me dicine. By this time the Hippocratic corpus had been collected together and the new empiricists found support for their views in the empirical works of the coll ection, particularly those, such as Ancient Medicine, that were rhetorical in de fence of empiricism.8 In doing so they were inventing a medical tradition for th emselves and choosing Hippocrates as its founder. Not everyone at the time thoug ht of Hippocrates as the Father of Medicine, and the new empirics were the rst to write commentaries on the empirical Hippocratic works.9 That is, experience was now not only a question of personal observation, but the experience of others, which could be read in books. This was a question of historia, which we met in t he previous chapter, and knowledge gained from books came to have a privileged s tatus.10 Naturally the rationalist physician reacted in turn and became more rat ionalist. Their opponents called them dogmatists and in the rst centuries b c and a d two new forms of rationalist medicine appeared. One was that of Asclepiades, who drew on atomism for his natural philosophy and supplied the material for the sect known to Galen as the Methodists. The second was the Pneumatist sect, whic h drew on humoral theory and Stoic logic, and which also practised in Galens Rome . Thus, in Rome, Galen faced four sects the Empiricists, Rationalists, Pneumatis ts and Methodists. He regarded himself as separate from them, for his philosophi cal training told him that both empiricism and rationalism were valuable in thei r own way; and at the same time he used some doctrines that had found favour wit h the Pneumatists. He regarded himself as a follower of Hippocrates, 6 7 9 10 Herophilus and his house was a near-contemporary expression. See Wesley D. Smith, The Hippocratic Tradition, Ithaca and London (Cornell University Press), 1979, p . 194. 8 Ibid., p. 209. Ibid., p. 178. See also John Vallance, Doctors in the lib rary: the strange tale of Apollonius the bookworm and other stories, in Roy MacLe od, ed., The Library of Alexandria. Centre of Learning in the Ancient World, Lon don and New York (I. B. Tauris), 2000, pp. 95113, at p. 105. Vallance, Doctors in the library, p. 107.

38 Sources and as his battles with his opponents in Rome moved him further towards a ration alist position he claimed Hippocrates as the rst Rationalist, with an excellent k nowledge of anatomy. It seems to be generally true in the history of medicine th at those authors who are defending a position against attack, or setting up a ne w one, are given to constructing a history or lineage for it, preferably with a revered Father. Thus, while Herophilus and Erasistratus did not recognise rival schools,11 and Erasistratus apparently ignored Hippocrates, in the competitive s ituation in Rome both Empiricists and the rationalising Galen (ultimately though t of as the arch-Rationalist) could choose Hippocrates as the Father of their di fferent systems. The main opposition was between the Rationalists and the Empiri cists. Importantly for our story a central issue between them was anatomy. The E mpiricists refused to make the assumption that the body was intelligible: if it were, they said, then men would understand it and agree about it, while in fact the Rationalists disagree greatly, and philosophers cure no one. Celsus account o f the dispute between the two sects recalls the defence of dietetic medicine aga inst the invasion of philosophical principles, which we met in chapter 1. But no w the issues were enormously in ated by the human vivisections attributed to Herop hilus and Erasistratus.12 The Empiricists dwelt on the cruelty of vivisection an d the paradox that it should be done by doctors, whose calling was the preservat ion of health. Not only cruel, they said, but useless: the colour and physical c haracteristics (listed formally at vivisection) of the parts change so much in a dying man that nothing can be inferred from them. Moreover, penetration of the diaphragm or chest kills a man instantly and so the heart and lungs can never be seen in their living condition. The Rationalist position was that, in principle , medicine would be improved by the knowledge provided by dissection and vivisec tion. A large part of this claim was that future generations would bene t. As the other arm of the paradox about present cruelty it was, of course, hypothetical. The vivisectors and the Rationalists who followed them were philosophers and hel d that the body was intelligible and that knowledge about it was valuable in its elf. Moreover, this knowledge included that of the nervous system and could be d emonstrated dramatically: there were many situations in which this knowledge cou ld be used professionally, quite apart from the future. 11 12 Nor did Meno, a student of Aristotles, discuss sects in his history of medicine. Smith, The Hippocratic Tradition, p. 182. Celsus De Medicina, trans. W. G. Spenc er, 3 vols., Cambridge, Mass. (Harvard University Press, Loeb Library series), 1 9358, vol. 1, p. 22.

Galen g a l e n s d e m o n s t r at i o n s 39 Galens early interest in anatomy was surely inspired by the story of Herophilus a nd Erasistratus. Anatomy was not, of course, simple morphology but in a philosophi cal way included function. Galen would have been aware of the Aristotelian doctr ine that knowledge of a part is primarily what the part is for, its action or us e. Moreover, he believed that the body had been put together by a deity very lik e the demiurge of Plato, who created the world of the Timaeus. Unlike Aristotles n ature, this was a creator god who put the body together rationally, using reason to do the best possible job with the materials available. In dissection Galen wa s looking for anatomical rationality and his prime example was how the body was controlled by the brain, spinal cord and nerves. The link with Herophilus and Er asistratus was fairly direct. Their work had been revived and examined by the an atomist Marinus, who dissected apes. One of Galens earliest works was an abstract of Marinus Anatomy.13 With this background Galen made an important discovery. He cites three cases in which the patient, undergoing surgery in the neck, became wholly or partially dumb. Perhaps Galen was there at the operation or came to kn ow of it quickly, for he says that everyone was surprised, because the larynx an d windpipe were undamaged. But to Galen it looked like loss of nervous control. The implication is that the cases prompted him to do experiments in which he dis covered that the voice is controlled by the recurrent laryngeal nerve, which arise s in the brain, loops round a blood vessel in the thorax and rises again to the organs of speech in the throat.14 When he made this discovery, early in his rst s pell in Rome, or even while still in Pergamon, Galen had a sophisticated knowled ge of the mechanics of respiration, which we may guess had been a topic of inter est to Herophilus and his followers. Certainly Galens teacher Pelops understood t he function of the diaphragm, and Galen came to see the action of the intercosta l muscles.15 13 14 15 Smith, The Hippocratic Tradition, pp. 65, 74. Galens description is partly in De Locis Affectis. The standard edition is that by C. G. K hn, u Galeni Opera Omnia, 22 vols., Leipzig (C. Knobloch), 182133; vol. v i i i, p. 53. There is an Englis h translation by Rudolph E. Siegel, Galen on the Affected Parts, Basel (S. Karge r), 1976; see pp. 367. It is an implication because while Galen pointedly claims the discovery of the nerve as his own, he presents the three cases as examples o f the nerves operation, not as circumstances of its discovery, which he does not give. Perhaps he glosses over this in order to present himself as knowledgeable about the nerve when explaining the matter to the puzzled observers. Smith, The Hippocratic Tradition, p. 85.

40 Sources Galen made great use of his knowledge of the nervous control of respiration and the voice. In the summer of 163, a year after arriving in Rome for the rst time, Galen was asked by Flavius Boethus (whom we shall meet again) to perform vivisec tions to demonstrate his opinions.16 The performance was from the start a public display, designed to convince. Boethus had assembled a crowd of Stoics, Aristot elians, other philosophers and medical men, with whom Galen disputed. Here would have been discussed the issues between the different kinds of philosophers. Ver y likely the Aristotelians believed that the voice came from the heart, which th ey preferred to think of, with Aristotle, as the controlling centre of the body. If they had heard about nerves, they would probably have argued that they arose in the heart, as did Aristotelians in the Middle Ages and Renaissance, citing A ristotles description of brous structures within the heart.17 The vivisections the n formed a sort of physical argument to demonstrate the cranial origin of the ne rves, and hence voice, and prove Galen right. On Galens advice Boethus had arrang ed for a supply of pigs and young goats, rather than apes. Perhaps apes would ha ve made a better spectacle because (as Galen said) they resemble man, but pigs h ave louder voices. Clearly Galen intended to stage-manage the demonstration care fully. But it nearly went wrong. It was arranged that Galen, the doctor, would d emonstrate the structure (of the nerves and larynx) while the philosopher Alexan der of Damascus would guide the crowd to the conclusions. Alexander was Boethus t utor and it was probably expected that, like other Aristotelians in Rome, he wou ld support Galen. But Alexander was also familiar with Platos philosophy, in whic h the senses were held to be a distraction from the souls search for truth within itself. Perhaps for this reason Alexander began prematurely by asking whether t hey all agreed that they would accept the evidence of the senses. Merely to rais e the question was to throw doubt on the essence of Galens demonstration, and he angrily walked out. The debate continued and Alexander was silenced. A bigger de monstration was arranged and over several days Galen demonstrated the nervous co ntrol of the actions of muscles in respiration and production of the voice. It m ust have been a convincing moment when Galen silenced the 16 17 Nutton, Galen on Prognosis, p. 95. See, for example, Pietro dAbano, Conciliator C ontroversiarum, quae inter Philosophos et Medicos Versantur, Venice (Giunta), 15 65, f. 62v. Pietro in the early fourteenth century could nd support for the idea in the truncated paraphrase of Galens De Usu Partium that circulated widely under the title De Juvamentis Membrorum. See Roger French, De Juvamentis Membrorum and the reception of Galenic physiological anatomy, Isis, 70 (1979) 96109.

Galen 41 squealing pig, as he had promised, by compressing its recurrent laryngeal nerve. He was demonstrating, that is, not only that he had knowledge of how the body w orked, but that he had control of it. It was a demonstration of rationalism and Galen was the Rational Doctor: the body was capable of being understood and resp onded to intervention.18 It is worthwhile spending a little more time on the rec urrent laryngeal nerve because it illustrates a number of other features of Gale ns rationalism. The three surgical cases he describes are in the text On Affected Places, which deals with signs and causes of disease. It is partly anti-empiric al in tone and Galen makes a great deal of the fact that in diseases involving t he nerves the causes often occur in places that an Empiricist would not expect. The point of the three surgical cases was not only that the practitioner did not know of the nerve, but that he was puzzled that the non-functioning organ was n ot damaged. Galen also recalls the case of a man who had lost all feeling, but n ot motion, from three ngers. His own doctor applied various remedies to the ngers, to no avail. When he was called in, Galen discovered that the patient had damag ed his neck in a fall from his carriage, and Galens knowledge of anatomy told him that the cause of the complaint was located at the cervical origin of the nerve s serving the ngers. In a similar case a blow to the back paralysed the intercost al muscles and the legs so that the patient could not walk or talk. Galen again stopped the (rather empirical) applications of remedies to the larynx and legs a nd treated the in ammation of the spine. The recurrent laryngeal nerve also receiv es attention in Galens work On the Use of the Parts. This too is a rationalist te xt, in emphasising that the body is intelligible because it was created by a rat ional divinity, the demiurge (Galen uses the term interchangeably with nature, phy sis). The rational anatomist can understand, and must admire, the reasoning of t he demiurge: Galen has many passages of natural theology. A good example is the question Galen has to answer: why does the recurrent nerve run down to the thora x and then back up to the larynx?19 Galens answer is in several parts. First, he believed that all motor nerves enter their destination muscle at its head, that is, the end opposite to the motion it produces Galen supposed that some form of traction was exerted by the nerve itself. 18 19 The story is given in the text called De Praecognitione in the 1625 edition of t he collected works: Galeni Librorum Quarta Classis, Venice (Giunta), 1625, p. 21 6 (the pagination is false, 215 following 224). Galen, De Usu Partium Corporis H umani, K hn, vol. i i i, p. 570. There is an English translation by u M. T. May, Galen on the Usefulness of the Parts of the Body, 2 vols., Ithaca (Cornell Unive rsity Press), 1968, p. 362.

42 Sources This meant that the muscles closing the larynx were obliged to be innervated fro m below. But, of course, nerves begin in the brain, and so nature in constructin g the body sent the recurrent nerve down into the thorax, bent it round a blood vessel and directed it straight to the larynx. Galen believed that this once mor e defeated the Aristotelians (for if the heart were indeed the origin of the ner ves, they could reach the larynx in a straight line). More to the point in this text is that the arrangement shows that the rationality of the demiurge consists partly in overcoming the dif culties of matter. Galen held that sensory nerves ha d to be soft for functional reasons, but that some, like that to the mouth of th e stomach, where hunger is felt, had to reach across long distances from the bra in. This made them vulnerable to damage from motion, and nature consequently rei nforced them at intervals with ganglia. The blood vessel round which the recurre nt nerve turned not only acted in this way but also behaved as a glossocomion, a device in which a capstan on a single shaft pulls different parts of an object in different directions. Fractures of the bones of the leg were reduced with suc h a device. Thus the traction exerted by the recurrent nerve was reversed in dir ection. In this case, natures rationality is close to human not only in being int elligible to man, but in resembling human rationality in machines. Galen in ates t he natural theology of the situtation. I want you now to pay me closer attention than you would if you were being initi ated into the mysteries of Eleusis or Samothrace or some other sacred rite and w ere wholly absorbed in the acts and works of the hierophants. You should conside r that this mystery is in no way inferior to those and no less able to show fort h the wisdom, foresight and power of the Creator of animals, and in particular y ou should realize that I was the very rst to discover this mystery which I now pr actise . . . x your mind now on holier things, make yourself a listener worthy of what is to be said, and follow closely my discourse as it explains the wonderfu l mysteries of Nature.20 g a l e n s g o o d s to ry : p ro g n o s i s Boethus arranged Galens demonstrati on by vivisection in order to promote him. He was in fact one of a small circle of friends who were of considerable assistance to Galen when he rst arrived in Ro me. This part of the story of Galens life in Rome begins with Eudemus, an Aristot elian philosopher 20 May, Usefulness of the Parts, p. 367.

Galen 43 who had once been Galens teacher.21 Eudemus accordingly thought that philosophy w as more important to Galen than medicine, but it was natural that he should call in Galen when he felt ill; perhaps knowing of Nikons dream for Galens future help ed. When Galen arrived, he told his patient that he had a quartan fever a fever with crises at four-day intervals. Galen continued his treatment during Eudemus f ever, inspecting his urine from time to time. He was, that is, making prediction s about the outcome of the fever, both from correctly identifying it and from th e appearance of the urine. Galen was proved correct, for Eudemus recovered. Duri ng the illness, two important things happened. First, Eudemus was visited by Boe thus, who had heard about Galens skill in anatomy and was anxious to set up the viv isectional demonstrations.22 Like Eudemus, Boethus was an Aristotelian; moreover , as he had been a consul, he was a person of importance. He was accompanied by Sergius Paulus (shortly to become a prefect) who having talked to Boethus was al so keen on seeing the demonstrations. Galen adds to this list the uncle of the e mperor Lucius and another Aristotelian, Severus. When at the end of the case Gal ens prediction was shown to be true, his reputation in the higher social and inte llectual circles was enhanced. The second event was that, while still ill, Eudem us demanded an explanation for Galens prognosis. He was after all an Aristotelian and would only have been satis ed with a philosophically rigorous reply, which in Aristotelian terms would have been the discovery of natural causes. Galens expla nation rested easily on Aristotelian natural philosophy. He explained that fever was a localised excess of the elementary quality heat, which reached the heart and was disseminated through the arteries. Eudemus would have known, of course, of the four elements and their qualities and could make connections with the spe cial medical knowledge being expounded by Galen. Galen explained the periodicity of the crises by describing how the body concocted the corrupt humour at the root of the trouble, making it, if possible, less damaging and then ejecting it. Thi s was the effort of nature within the body, explained Galen, and again Eudemus wou ld have found connections with the Aristotelian doctrine of the nature-of-the-th ing, although Galens medical interpretation owed something also to Hippocrates. G alen also took Eudemus pulse and explained that he was testing the ability of the faculty of the soul that 21 22 Nutton, Galen on Prognosis, pp. 75, 83. Galen begins the De Anatomicis Administr ationibus with a brief autobiographical section, and calls Boethus a keen anatom ist (K hn, Galeni Opera Omnia, vol. i i, p. 215). There is an English translation u (somewhat cavalier in parts) by Charles Singer: Galen on Anatomical Procedure s, London (Oxford University Press), 1956, p. 1.

44 Sources resided in the heart to expel the concocted humour at the end of the given perio d, that is, at a crisis. If nature were strong, the patient survived; if the dis ease were stronger, the patient died. In other words, Galen was full of the doct ors sickroom patter, in this case appropriate to an Aristotelian philosopher. The patient in fact already possessed some knowledge of the medical principle of th e expulsion of morbid matter, and asked particularly what Galen meant by nature an d concoction. In both cases, in fact, Galen had drawn his doctrine from Hippocrate s, and since in a sense his whole medical programme was to nd Aristotelian ration ality under Hippocratic medical wisdom, he was in a position to explain Eudemus q uartan on the very fundamentals of the Aristotelian world picture. He was, in sh ort, telling Eudemus the Good Story of the Rational and Learned Doctor: I am the doctor, I have specialist knowledge of what it is you are suffering from, I can predict the outcome because of my knowledge and medical rst principles, and I ca n trace your very symptoms back to the axiomatic rst principles of the natural wo rld. Eudemus had asked for all the details, and he got them. He said (it is, of course, Galen reporting) that he followed Galens arguments better than those of o ther doctors, and that he admired Galens logic.23 Galen made sure he told his Goo d Story to men of position and understanding: it is striking that he had no inte rest in the very young as patients.24 He needed patients he could talk to. In fa ct, Galen had not realised when he went to Rome that the doctors there did not p rognosticate. Galen thought of himself as a Hippocratic and was aware of the adv antages of it expressed in the Hippocratic text Prognosis. Galen thought that th e reason the Roman doctors did not prognosticate was that they toadied to the ric h he means the patronclient relationship, discussed above. Secure in that position , says Galen with Hippocratic disapproval, they dress in an ostentatious way and attract many pupils by claiming that medicine can be taught quickly. Galen adds signi cantly that being followed by a large number of pupils increased the in uence of such doctors in the city. Nor did the followers of Erasistratus prognosticat e, and when one of them, Martianus, heard Galens prediction in Eudemus case, he sa id it was like divination from the ight of birds or horoscopes. Galen was in a di f cult position. His reputation among doctors was not enhanced by prognostication. Is it your own idea, they asked him, or do you 23 24 Nutton, Galen on Prognosis, p. 87. See Danielle Gourevitch, The paths of knowledg e: medicine in the Roman world, in M. D. Grmek, ed., Western Medical Thought from Antiquity to the Middle Ages, trans. A. Shugaar, Cambridge, Mass. and London (H arvard University Press), 1998, pp. 104138, at p. 135.

Galen 45 follow some master? Rather than being thought a sorcerer, Galen at rst kept his a ttachment to Hippocrates a secret. He was teased by Martianus, who had found a d enial of prognostication in the second book of the Hippocratic Prorrhetics. Its s purious, said Galen. Moreover, to make predictions about the emperor was a capit al offence; and the medical marketplace in Rome was dangerously competitive. Eud emus took Galens aside and explained that things in Rome were not as they were ba ck home in Pergamon, for in our own country the doctors did not have the vices of the metropolis.25 Most of Galens enemies in Rome, added Eudemus, were also from p rovincial cities and often poor or ignorant; they wanted to make money quickly a nd to return home as soon as possible. They were accordingly savage in their ght for success, and Eudemus warned Galen to beware of plots to poison him, recallin g the death of a young doctor and his two servants some ten years earlier. Galen was clearly worried and wanted to go home; but there was trouble too in Pergamo n and Galen decided to remain and face his problems. He did so by insisting on t he Hippocratic nature of his medicine. He not only made prognosis acceptable but successfully promoted the letting of blood, which he took to be fundamental to Hippocratic medicine. There could perhaps be no more striking example of the pow er of a doctor to use his learning and reasoning to promote his own kind of prac tice and his own career. Galen was in an almost murderously competitive situatio n. The other doctors in Rome did not practise venesection and their patients wer e unused to it. Imagine that you are a Roman citizen, sturdy, grave and stoical, but with a pain in your side. It gets worse, and you nally agree to the calling of a doctor who, you suspect, will be Greek. It is Galen. He carries a sharp kni fe and wants to make a hole in your arm. Not a prick, but a hole large enough fo r lots of blood to come out. Do you let him do it? The answer for many Romans wa s often enough yes. What powers of persuasion did Galen have? The opponents of ven esection, after all, had a good case.26 It was a nuisance to have to open the bl ood vessel, and to make sure that it was a vein and not an artery, which would b e dangerous. Some patients died from fear even before the vessel had been cut wh ile others fainted during the operation and never recovered. In others it was di f cult or impossible to stop the bleeding, and in those where it could be controll ed, how was the doctor to know how much blood to take? Moreover, the Erasistrate ans, 25 26 Nutton, Galen on Prognosis, p. 93. Galen himself lists the apparent disadvantage s of venesection. See Peter Brain, Galen on Bloodletting. A Study of the Origins , Development and Validity of his Opinions, with a Translation of the Three Work s, Cambridge (Cambridge University Press), 1986, p. 18.

46 Sources Galens enemies who held that the arteries contained not blood but pnuema, argued that removing blood from a vein would cause the pathological entry of pneuma fro m the arteries, with disastrous results. Galen may have had an uphill struggle t o make his case, but in such cases he was a mountaineer. He demonstrated in expe riments with ligatures that the arteries do contain blood and that no Erasistrat ean pathology would occur. He quoted passages from Hippocrates to give authority for letting blood. He cited medical cases known to himself and his opponents.27 In one of them he was present with the Erasistrateans who agreed that the patie nt had a dangerous plethora of blood. Their method of reducing it was starvation , for it was generally admitted that blood was produced from food. Galen asserte d that this was far too slow and that many patients had been killed by Erasistra tus and his followers. The patient in the case had a spontaneous nosebleed and r ecovered. Galen seized his chance and proclaimed that this was natures own venese ction and that physicians could do no better than follow nature. It was a useful tactic, for he was in a position again to employ the whole of the philosophy of nature in explaining an actual medical case.28 Another strategy Galen used was the public disputation. At that time the custom had somehow sprung up of speaking in public each day on any questions that were put forward, recalled Galen.29 Thi s was a Roman continuation of the Hellenistic habit of giving public lectures fo r the bene t of the citizens, but they had now become debates, perhaps at a recogn ised meeting place of doctors, that could be used to challenge opponents.30 Prec eding the dispute Galen was about to recount was the case of spontaneous noseble ed, in which Galen had argued with the Erasistrateans. While they were saying thi s, however, a certain Teuthras, a fellow citizen and schoolfellow of mine he was exceedingly frank in his ways said: You will never in uence these men; they are to o stupid to remember the patients who were killed by Erasistratus. For a moment T euthras was centre stage. He rolled off a list of all the patients he said had b een killed, made a rude gesture with his hand and dragged Galen away from the me eting.31 The following 27 28 29 30 31 Multiple consultation was usual. See Nutton, Galen on Prognosis, p. 160. The pat ient was female and had suffered a suppression of menstruation, natures routine e vacuation of blood. Galen describes how she leapt from her bed and rushed shriek ing outside before the nosebleed, which removed all symptoms. Galen leads rhetor ically to this climax and re ects sententiously on the doctor following nature. Br ain, Galen on Bloodletting, p. 40. Ibid., p. 41. Nutton, Galen on Prognosis, p. 187. At Ephesus there were formal contests between doctors, with a list of winne rs displayed publicly. Brain, Galen on Bloodletting, p. 41.

Galen 47 day Teuthras went to the public meeting with the works of Erasistratus, hoping t o provoke a dispute with the older doctors, but they refused to engage with some one so young. But by chance or design (perhaps Galen had planted Teuthras in the audience) at a later meeting someone raised the question of whether Erasistratus was right in not letting blood. Galen was fully prepared with a speech, which he and Teuthras had arranged to be written down from Galens dictation. Galen claime d that as a result of his speech and the leaking of the dictated text all the Er asistrateans changed their minds and adopted venesection. The written word was a nother useful means of persuading people. Teuthras wanted Galens words dictated b ecause he was shortly going on a journey and presumably had a use for them in co nnection with it. Boethus sent experts in shorthand to capture what Galen said w hen demonstrating the nervous and muscular control of respiration in the living animal.32 Galen himself wrote voluminously, promoting his own doctrines, rejecti ng those of others and defending the memory of what he had written or done long before, and he continued to write during the rest of his career. The troubles in Pergamon came to an end just as Boethus was making moves to recommend Galen to the emperor (Galen had just cured Boethus wife of a watery swelling) and Galen lo st no time in slipping hastily home, eager to avoid the dangers of Rome and anxi ous in case the emperor should prevent him from leaving. But when the imperial c all came three years later he had to return. Galen records that he was recommend ed to the emperor Lucius on the basis of his philosophy as well as medicine in o ur terms as a Rational Doctor but Lucius died and was succeeded by Marcus Aureli us. Famously the Stoic emperor, Marcus Aurelius was probably sympathetic to the place given to nature by the philosophers, and to Galens basing medicine on natural principles. Galen impressed the emperor with his skill at prognosis and analysi s of the imperial pulse. Galens recruitment to the palace may have been part of t he preparation for the German wars, but Galen did not want to go to war. He knew that in wartime more opportunities arose for human dissection than in Rome, but that was not enticement enough. He asked to stay in Rome and look after Commodu s, son of Marcus Aurelius. He lived close to Commodus in the palace partly for h is own safety. Galen wrote many works during the German wars. One of them was On Crises33 which, Galen said, makes the theory of prognosis available to anyone t rained in geometry and dialectic that is, our Rational Doctor. 32 33 Nutton, Galen on Prognosis, p. 104. Galen recounts a similar story at the beginn ing of the Anatomical Procedures, which he says grew out of the notes given to B oethus. Nutton, Galen on Prognosis, p. 121.

48 Sources Others were Critical Days and The Difference of Fevers: all were designed to sho w that the theory of medical prediction comes out of Hippocrates. r at i o n a l i s i n g h i p p o c r at e s Galen held throughout his life that proper medic ine was Hippocratic, and devoted his later years to commentaries on the Hippocra tic works. His purpose was to interpret Hippocrates and show why Hippocrates had been right. It was partly that some of the Hippocratic works were 500600 years o ld and needed to be rendered into modern Greek. But much more it was that the pi thy words of works such as Aphorisms and Prognosis abounded in wisdom but did no t engage in argument or learning, in the sense we are using in this book. Galen saw his principal duty to be to explain Hippocrates by pointing out the reasons and learning that must underlie the medical wisdom of Hippocrates: Hippocrates n eeds interpretation, said Galen.34 A good and simple example is the pearl of wis dom from Breaths: Opposites cure opposites. In the Middle Ages this became known a s the Law of Hippocrates and was used axiomatically as the premiss of syllogisms . This was because of the interpretation put on it by Galen, who assumed that opp osites were the opposing elementary qualities of Aristotelian natural philosophy. Indeed, Galen attributed the four-element theory itself to Hippocrates.35 This gave Galen and subsequent doctors the whole range of peripatetic doctrines and a rguments to construct a rational Hippocrates. In fact Galen the phlebotomist and prognosticator was reconstructing Hippocrates in his own image. Hippocrates gav e him ancient authority: Galen knew that the common people admired physicians wh o knew their history, believing that it gave these doctors an added knowledge of the theory of medicine.36 Historical medical learning was, in other words, usef ul in the medical marketplace. Hippocrates was also called on to ght Galens battle s. When Galen disagreed with Martialius, an Erasistratean and anatomist, Hippocr ates in Galens eyes became a great anatomist; he must have known all about anatom y, Galen reasoned, but did not express it because it was kept as a secret in the family.37 One of the main purposes of Galens vivisections was to demonstrate tha t the controlling centre of the body was in the brain and not the heart as Arist otle had said. There were works in the Hippocratic corpus that seemed to support this, and Galen 34 35 36 See Smith, The Hippocratic Tradition, p. 72. In The Elements according to Hippoc rates. See Smith, The Hippocratic Tradition, p. 88. 37 Ibid., pp. 789, 105. Smith , The Hippocratic Tradition, p. 163.

Galen 49 knew too that Plato had located the highest soul in the brain. This meant to Gal en that Plato was a follower of Hippocrates, and he wrote On the Opinions of Pla to and Hippocrates dedicated to Boethus to demonstrate it. He adapted the work to serve as the philosophical prolegomenon of his system generally.38 It is notable too that Galen dedicated the rst book of his great anatomical text On the Use of the Parts to Boethus. Both works were begun early in Galens rst period in Rome an d the dedications look like a tactic to secure the patronage of an important man . Here was another external use of technical knowledge. Perhaps the clearest examp le of Galens rationalisation of Hippocrates was his treatment of the aphorisms. W e have already noticed that these are condensed pieces of medical wisdom, someti mes brief to the point of obscurity but with a con dent authority that seemed to b e the product of long experience. They always seemed to need a little explanatio n and every subsequent generation of doctors interpreted them in its own way, in dicating what they surely had meant in antiquity in terms accessible to the cont emporary world. Let us look at how Galen treats the rst aphorism of them all, whi ch famously begins with remarks on the shortness of life and the length of the a rt of medicine. It then adds a little on the doctor, the patient and external ci rcumstances. Galen opens his commentary by saying that whether this is a single aphorism or several, all commentators are agreed that it is like a proemium to t he whole work. This indicates two important things to us. First, that the Aphori sms had already attracted commentary. Second, it shows that Galen (and by implic ation the earlier commentators) were seeking an argument through the work as a who le. It is the purpose of introductory material to set out the rationality of wha t follows and Galen was clearly examining the rst aphorism in this light. But as we have seen, the Aphorisms is not rational in this way, and Galen, although alw ays ready to nd the arguments behind the aphorisms, doubted whether Hippocrates h ad intended the rst aphorism as an introduction.39 Galens resolution of this doubt begins as soon as he has expressed the above in a couple of sentences. Let us a nalyse the words of the aphorism, he says, to discover what Hippocrates intention was. To see what Galen does, we can start with the aphorism itself. Its economy of language is partly achieved by omitting verbs, which adds to its oracular na ture. 38 39 Ibid., p. 99. Lists of things, like aphorisms or case-histories, can always be a dded to, particularly when in the possession of a school of physicians, but reader s often sought threads of rationality running through them.

50 Sources Life short, art long, opportunity eeting, experience deceptive, judgement dif cult. It is necessary for him to make appropriate himself, the patient, the assistant s and the circumstances. When we have supplied the verbs and guessed, as Galen guessed, that him is the doc tor, it is still a rather obscure expression of wisdom. Any explanation that Gal en made would necessarily draw on his own experience and reading, and since his purpose was to make the aphorism clear to his contemporaries he had to express h imself in terms that they too would understand. The art is long, explains Galen, because the time in which the doctor has to do individual things seems short. W hat may have been in Galens mind, but what could not have been in Hippocrates, was the Aristotelian doctrine that particulars of experience build up over time to form more general statements, by induction.40 When Galen now says that two thing s are needed to bring any art to actual practice namely, experience and reason h e is clearly thinking of the RationalistEmpiricist dichotomy of the Rome of his t ime. We have seen that this did not have a long history and would have been unkn own to Hippocrates. Galen makes the deceptive experience of the aphorism the busines s of the Empiricists and the dif cult judgement a Rationalist affair; and it is reas on that judges the thing to be proved. He rejects those who asserted that it was a dif cult experiential judgement. Galens discussion is a philosophical one, drawi ng on issues that had been important to him throughout his educated life and whi ch derive partly from Aristotles distinction between observed and theoretical kno wledge. Galen concludes his analysis of the rst part of the rst aphorism with the unambiguous statement that Hippocrates, in all the aphorisms, was a Rationalist. 41 A major tool of Galens for expounding Hippocrates was that as a Rationalist Hi ppocrates must have known the physical principles behind the appearances. The fo urteenth aphorism says Those who are growing have much innate heat and therefore need much food. If the y do not get it, the body wastes. Old men have little heat and accordingly need little nourishment, and much of it destroys the heat of the food. For this reaso n too fevers are not so acute in old men, for their bodies are cold. This somewhat homely piece of medical wisdom called out to Galen for rational ex planation. Without preliminaries he returned to his own book on 40 41 Artem longam: quia tempus in quo particulariter est operandum strictum videtur a tque parvum: quam siquis velit capere longis exercitiis et longo usu capi est ne cesse. Articella, Venice, 1483, f. 9r. Following the translation of Leoniceno in the 1625 Giunta, who uses dogmatic.

Galen 51 complexions and its theoretical discussions. Complexion was fundamental to Galen ic medicine, for it was a mixture of the elementary qualities which determined h ow the parts of the body worked and reacted to external things. Bad complexion w as illness, and evacuation of offending humours and their elementary qualities w as a central technique of practical medicine. But how much was much innate heat? H ow does one measure a quality? In De Complexionibus Galen rehearsed the argument s of doctors who had discussed whether infants or youths were hotter. This invol ved the distinction between more heat and sharper or stronger heat.42 Galen begins h is dialectical treatment by saying that sometimes the word hot is applied to the q uality, while at other times it is the name of a hot body, particularly in old w ritings. There is then more heat in a larger hot body than in a smaller. If two vessels of different sizes are lled with warm water, the larger vessel contains m ore heat. The underlying problem was Aristotles assertion that quality and quanti ty are separate categories and that qualities cannot be quanti ed. Galen also rati onalised Hippocratic prognosis. Here Galen was in a dif cult situation. It seems t o have been some sort of prediction from the pulse that secured his appointment to the emperor, but as we have seen, it was a dangerous business making predicti ons about the emperor. While Galen had successfully promoted his own techniques of prognostication, it was another matter when he had to explain the words of Hi ppocrates, as he did in his commentary on Prognosis, written late in life. The p roblem was partly that Hippocrates talked less precisely than Galen would have w ished about foretelling the future. Like the Aphorisms, the Hippocratic text on prognosis is not a reasoned argument but a description of signs that bode ill or well. This was uncomfortably close to the soothsayers practice of seeking signs in entrails or the ight of birds, particularly since both practices were based on a knowledge of what was normal, in order to identify the abnormal. No doubt Gal en remembered being called a soothsayer when he rst made a prognostication in Rom e. He now urgently needed to rationalise Hippocratic prognosis to distance it fr om soothsaying. Part of ancient soothsaying was predicting what was going to hap pen by the will of the gods, which was not at all a philosophical thing to do. W e have seen that many Greek philosophers wanted to keep the gods out of nature, and although Galen believed in a creative demiurge, he held that it was above al l a rational creator. Prognosis too had to be rational. But Hippocrates had used words that seemed to allow for forms of prediction 42 Articella (1483), f. 12r: abundantius and acutior et fortior.

52 Sources other than the rational, and Galen had to deal with this. The problem was perhap s a common one in the Greek and Latin tradition and even those that followed. We use the term divination for seeing the future or other dif cult things, as if by ap peal to the gods. Providence is some principle that guides us into the future, per haps the Deity, although literally it is seeing before, seeing something before it happens. Galen was faced with similar problems when interpreting Hippocrates. T his is no place for a discussion of Greek etymology, but we must look brie y at Ga lens commentary, for it was an important text in the Latin tradition of Western m edicine. Indeed, the Latin tradition characteristically takes on a life of its o wn, raising matters not in the conversation between Galen and Hippocrates. While Galen had recognised the political and philosophical dangers of predicting the future, these became largely religious problems in the Middle Ages. Predicting t he future seemed to deny mans free will and usurp the authority of God.43 But med ically prognostication was very important. We have already seen that the medieva l version of the Hippocratic text emphasised the utility of prognosis in enhanci ng the reputation of the practitioner, and perhaps no other text is quite so blu nt about marketplace strategy. The predicting doctor is nobler than divine prophe ts, says the medieval text.44 Galen begins by saying that originally Hippocrates had not used the word for prediction that appeared in the text Galen was comment ing on. He believed that Hippocrates the rationalist had used, or at least meant prognosis rather than a simpler and non-rational term that meant seeing into the f uture previsio in the Latin as used by the poets Homer and Euripides.45 It was cl early an important matter for Galen, who invokes Solon and the usage of the rhet ors to explain previsio. He also mentions philosophers who talk of previsio as t he bene cial governance of the world by a creator our providence. Galen can accept t his usage of the term, for his demiurge was rational: previsio, he says, is a na me that is derived from a thing that is reasoned about before it comes into bein g.46 What he could not accept was foresight in a world governed only by chance. Prognosis, then, was rational previsio that rested on the natures of things and the signs they gave. It was an ordered body of knowledge, a scientia; it rationa lly prepared the doctor for what was to come, and generated in the patient a tru st which made the doctors task easier. He had to defend this scientia against oth er doctors who thought the job of the physician 43 44 46 See pp. rgo f. Roger French, Astrology in medical practice, in Garca-Ballester et al. (1994), 3059. 45 Articella (1483), f. 47rv. Articella (1483), f. 47r. Manifestus est e quod nomen derivatur a re que ratiocinatur ante esse suum. Articella (1483), 47v.

Galen 53 was to maintain and restore health and that trying to look into the future was d ivination. These seem to have been doctors who also had commented on Hippocrates , and Galen has to deal with the troublesome Hippocratic opinion that there was something divine in acute diseases.47 Galen was well aware of the power of progn osis to impress. He tells the story of meeting the philosopher Glaucon, who taxe d Galen with making prognoses that were closer to soothsaying than medicine.48 T o test Galens medicine, Glaucon led him to the sickroom of a patient whom Galen h ad not previously visited. Galen snatched a glance at the patients excreta as the y were being carried away, and he stole another at the medicine containers near the bed; Glaucon did not notice these glances and when Galen made the correct pr ognosis after taking the pulse was astonished that so much could be told from th e pulse alone. The patient, moreover, was a doctor himself, and said little to G alen. From the nature of the discharge and from the hyssop in water and honey, G alen concluded that the patient-doctor thought himself to be suffering from pleu risy: Galen guided the patients hand to where he knew it would hurt when the pati ent took a deep breath or coughed. So Galen had in an intelligent and rather sly manner used adventitious information and the patients own professional knowledge to produce a result that startled Glaucon and the patient into admiration. Gale n was grati ed but remained silent: the moral of the story, he tells the reader, i s to use cleverly such pieces of luck as come your way in order to gain a great reputation. c re at i o n a n d o m n i p ot e n c e We have seen, then, that th e whole purpose of Galens treatment of Hippocrates was to supply the physical rea sons that lay behind the great mans medical wisdom. Galen took little on trust, a nd we can recall that one of his earliest philosophical interests was in demonst ration, the rational proof of argument. Nature was also rational: Galen uses phy sis and demiurgos, which both emerged in the Latin tradition as natura. As we ha ve seen, the demiurge was Platonic and rationally and with foresight created the world and the human body. Galens admiration for the demiurge reaches a 47 48 Some translators made these Hippocratic commentators Empirics and Methodists and so reconstructed Galens circumstances in Rome: for example, Laurentius Laurentia nus in the 1625 Giunta edition. Note that Galens comment is much longer here than in the Articella (which includes a long quotation from Hunain). Galen reports G laucon as using the word mantike, which came into the Latin as divinatio. K hn, u Galeni Opera Omnia, vol. v i i i, p. 362 (De Locis Affectis).

54 Sources level of natural theology in De Usu Partium and the essence of his wonder is the rationality with which the demiurge handled matter. Teeth had to be hard, but t he hardest substances were brittle and would not serve; sensory nerves had to be soft, which made them liable to damage when extended over long distances (such as those to the stomach), so the demiurge took special steps to protect them: th e demiurge took all things into consideration and achieved the best possible com promise. It was the demiurges foresight that made the eyelashes remain the same l ength, for if they were shorter they would not serve their purpose of protecting the eyes and if they were longer they would be cumbersome and impede vision. Wh at was it that kept the eyelashes at a certain length (while the remaining hair on the head grew continuously)? Galen argues that the demiurge endowed them with the necessary feeling. It is not the case, he continues, that the eyelashes liv e in fear of the creator, subject to his direct order: is this the way that Mose s argues? Galen here is on the edge of another world. He lived until almost the end of the second Christian century and knew of the Christians and perhaps more about the Jews. But he could have no sympathy with the doctrine of omnipotence. The intractibility and pre-existence of matter was fundamental to most Greek phi losophy, inherent in the doctrines of Plato and Aristotle, and absolutely basic to Galens view of the demiurge. Creation ex nihilo by a Creator who could, if he wished, make water dry, was profoundly unphilosophical to Galen.49 To accept suc h a Creator on the basis of faith rather than reasoned demonstration was as bad. Yet ultimately and slowly the Christian Middle Ages, a wholly different climate and one in which the highest truth was undemonstrated revealed knowledge, adopt ed Galens medicine. celsus and pliny To complete this account of the ancient sour ces employed by the later Latin tradition of medicine, we should take note of tw o authors, Pliny and Celsus. Both were Roman and wrote in Latin, not Greek. They lived over a century before Galen and so we have to jump back in time a little, but they lead the narrative a little more naturally than Galen into the Middle Ages. We have seen that Celsus reported the story of Alexandrian vivisection: it was part of his De Medicina, sometimes called a medical encyclopaedia and 49 It is not decent, said Galen, to observe laws not properly demonstrated by reaso n as in the school of Moses and Christ. K hn, Galeni Opera Omnia, vol. v i i i, p. 579. See also Mays translation, u p. 533.

Galen 55 thought to be part of a bigger collection of works on the other arts.50 Pliny re fers to Celsus, who is, then, one of the comparatively few Latin writers that Pl iny uses. But Celsus medicine is not the traditional simple Roman affair that hea ds of households often knew, but draws heavily from Greek sources. Indeed, his p roemium is partly a history of medicine, which begins with the Greeks. It is her e that he discusses Alexandrian vivisection and the medical sects of the time. S cholars in the past have wondered whether or not Celsus book is an adaptation of a Greek original, and whether he was an active practitioner; but these are not q uestions that need detain us, for what is important in this story is that his te xt is a model of Latinity that could be put to a particular use when it was nally rediscovered. Pliny is quite different. The Latin of the Historia Naturalis is often terse and compressed as he tries to cover his multitude of facts. Like Cel sus he depends primarily on Greek sources, but sometimes resents it. His objecti ve was to do what no Greek had ever done to report fully on the natural world an d its contents. Part of that world was medicine and it is here that his dislike of Greeks is most pronounced. He knew that early and worthy Latin writers had ex pressed the Roman ideal of a sturdy race full of gravitas and not afraid of hard work, with a simple medicine to match. But the new Greek doctors had theory: it was overly sophisticated, persuasive but unreliable. Modern urban degeneracy of the Romans gave them diseases which opened the way for plausible Greeks to esta blish their medicine at the very heart of the empire: Pliny even suspected that Greek doctors were secretly killing important Roman citizens who were their pati ents. Greek doctors were greedy, said Pliny, and there was no remedy at law if t reatment went wrong.51 Unlike the text of Celsus, that of Pliny was known in the Middle Ages and abstracts were made of it; one was a collection of medical reme dies, the Medicina Plinii.52 The number of times the Historia Naturalis was prin ted suggests that it was a very popular work and Plinys criticism of doctors may well have shaped later attacks on doctors, which we will meet below. 50 51 52 Celsus De Medicina, vol. 1, p. vii. Celsus may have been born in 25 bc. See Vivi an Nutton, The perils of patriotism: Pliny and Roman medicine, in Roger French and Frank Greenaway, Science in the Early Roman Empire: Pliny the Elder, his Source s and In uence, London (Croom Helm), 1986, pp. 3058. See Roger French, Pliny and Ren aissance medicine, in French and Greenaway, Science in the Early Roman Empire, pp . 25281. On Pliny in his time, see also Mary Beagon, Roman Nature. The Thought of Pliny the Elder, Oxford (Clarendon Press), 1992. The recent Pliny the Elder on Science and Technology, by John F. Healy, Oxford (Oxford University Press), 1999 unfortunately omits medicine (and is a rather whiggish account); a different vi ew is offered in my Ancient Natural History: Histories of Nature, London (Routle dge), 1994.

56 Sources co n c lu s i o n It is perhaps necessary to say again that these two chapters have not attempted to be a chronological history of Greek medicine, but rather to outline the sourc es from which the Latin medical tradition grew. But neither has it been an attem pt to register the translations and commentaries by which the Latin tradition ex cavated the mine of ancient medicine. Such a story would certainly be possible, but it would not necessarily help very much. The date of a translation, theoreti cally making a text available, says nothing about who read it or when, and these t wo chapters cover material that was clearly part of the formed Latin tradition.

part ii The Latin tradition

chapter 3 Medieval schools i n t ro d u c t i o n The Latin medical tradition was a long time in forming. M edicine remained Greek with Galen, and might have become Latin with Celsus, but the loss of the Western Empire a little over two centuries after Galens death mea nt the end of any elaborate form of Roman medicine.1 All of Celsus and most of G alen remained unknown until the Middle Ages. Learned and rational medicine survi ved in a Greek form in the Eastern Empire, which lasted a thousand years longer than the Western. The Eastern Empire tried to recover the Western by establishin g exarchates, for example in Italy, and it seems to have been in such places tha t some Greek medical works were translated into Latin.2 There were two main cent res of teaching in the east, Constantinople and Alexandria; there was an Alexand rian medical tradition in the Salerno area in the sixth and seventh centuries, a nd it is known that the Abbey of Montecassino received a copy of the Aphorisms a s a gift in the tenth century. In the mid-twelfth century there were schools in Salerno favoured by Jews; there were Greek monasteries in the area; and the poli tical and economic growth of Salerno also favoured its cultural development.3 Bu t in the seventh century Alexandria was taken over for a 1 2 3 Further south and east it was a different matter. St Augustine used Hippocratic medicine in discussing astrology (which he was tempted with but wanted to deny). He was a friend of the medical man Vindicianus, who may have informed him about Hippocratic medicine. See O. Temkin, Hippocrates in a World of Pagans and Chris tians, Baltimore and London (The Johns Hopkins University Press), 1991, pp. 1326. In general, philosophy and medicine were useful in Christian anthropology and the Christians recognised that these disciplines supplied many things of which they were ignorant. Bishop Nemesius Nature of Man was an anthropology and was paraphr ased into Latin by Archbishop Alfanus of Salerno when the medical school there w as growing in reputation. See Loren C. MacKinney, Early Medieval Medicine with s pecial reference to France and Chartres, Baltimore (The Johns Hopkins University Press), 1937. See also David C. Lindberg, The transmission of Greek and Arabic l earning to the West, in his Science in the Middle Ages, Chicago (University of Ch icago Press), 1978, pp. 5290. The pre-Salernitan summa (see below) seems to have originated in such translations of the fth to seventh centuries. See Patricia Ski nner, Health and Medicine in Early Medieval Southern Italy, Leiden (Brill), 1997 , pp. 128, 1303, 140. 59

60 The Latin tradition brief period by the Persians and then by the Islamic Arabs, who very rapidly swe pt through North Africa, up through Spain (beginning in 711) and into Occitania. Greek remained a working language in Arabic Alexandria, and some translations w ere made directly from Greek to Arabic.4 The Arabs also encountered the Greek-sp eaking cultures of the Eastern Mediterranean, whose mathematics, medicine and ph ilosophy they began to admire and translate. When the Western Christians became strong enough to begin to push the Arabs back to the south they thus had on eith er side of them two different cultures. The Arabs were alien in language and rel igion, but had some interesting ideas on astrology and the Greek material they h ad absorbed. The Christians of the Eastern Empire regarded the Westerners as bar barians who had usurped the position of the old emperor and who spoke a graceles s Latin in place of Greek, the old language of culture. Eastern Christianity als o differed, being centred on the emperor and not on the bishop of Rome. But thes e were chronic rather than acute antagonisms and the West had much time to inter act with the two cultures as it became slowly more prosperous and powerful. e a r ly s c h o o l s The institutional arrangements of medical teaching become an important part of our story. Traditionally there were schools of medicine in the a ncient world, such as that at Cnidus and another at Cos, associated directly wit h the name of Hippocrates. The same thing may be said of schools of philosophy, wi th Plato and the Academy and Aristotle and the Lyceum. These were schools in the sense that they centred on a famous teacher, who may even have owned the physic al building or its library.5 After the death of the famous teacher it was still possible to recognise academics or peripatetics by their doctrines: they constit uted a school of thought, like the Erasistrateans in Rome. We do not know how fo rmal the instruction was in such places, although as we have seen it is possible to recognise a cycle in Aristotles teaching in the Lyceum. However, in the Easte rn Empire there is good evidence of formal instruction, and vestiges of a detail ed curriculum of studies are plain.6 The works 4 5 6 See M. Ullmann, Islamic Medicine, Edinburgh (Edinburgh University Press), 1978, p. 8. There was no communication between Alexandria and Byzantium after 642. See W. Jaeger, Aristotle. Fundamentals of the History of his Development, 2nd edn, London (Oxford University Press), 1962, p. 315. See A. Z. Iskandar, An attempted reconstruction of the late Alexandrian medical curriculum, Medical History, 20 (1 976) 23558.

Medieval schools 61 of Galen were important here. As we have seen, Galen wrote diffusely and at grea t length, often re ning his works over the years and maintaining disputes with opp onents: he had no school and his writings were unsuitable for a xed-term curricul um. By the year 500 Galens works had been compressed to the Twenty Books, a canon t hat was studied in Alexandria and Ravenna.7 The Alexandrian curriculum was desig ned to allow a partial medical education for those who could not continue for ve ry long at the school, and there must have been, as in all formal schools, press ure on the teacher to select what was important and teach it in a short time. Th e full course was based on theory and began with the naturals the elements, comple xions, humours, faculties and so on which related the body to the world at large . The rst work to be studied in the Alexandrian curriculum was Galens De Sectis, t ogether with a commentary on it by John of Alexandria, who is thought to have li ved in the rst half of the seventh century. This may have been a standard comment ary, for another form of it is known and attributed to Agnellus of Ravenna.8 De Sectis was a good introductory text for it set out the different ways of doing m edicine that Galen had met in Rome. But while Galen had considerable sympathy wi th the methods of sensory observation used in Empirical medicine, the commentary by John moves rmly in the direction of the Rationalists. This was perhaps a natu ral tendency on the part of a classroom teacher. His business was with words, no t sensory perception. The constraints of time not only ruled this out for the ar t was long and life was short but favoured a medicine that could be drawn out of rst principles, which could be introduced quickly. Johns commentary shares a feat ure of later medieval commentaries, namely that in discussing Galens medicine it makes the circumstances of Galens medicine those of John and his medicine. Galens enemies were still there, as were the sects. John repeats the vivisection rumour naturally, Herophilus and Erasistratus were Rationalists and even discusses in the present tense those who vivisected animals in his day. Johns commentary conta ins a doctrine which became central to the medicine of the Middle Ages and later , an item of faith of the Learned and 7 8 See Vivian Nutton, God, Galen and the depaganization of ancient medicine, in Peter Biller and Joseph Ziegler, eds., Religion and Medicine in the Middle Ages, The University of York (York Medieval Press), 2001, pp. 1732, p. 25. See also Iskanda r, Alexandrian medical curriculum. Ravenna was the capital of the exarchate from 5 68 to 752: see Danielle Jacquart, Medical scholasticism, in M. D. Grmek, ed., West ern Medical Thought from Antiquity to the Middle Ages, trans. A. Shugaar, Cambri dge, Mass. and London (Harvard University Press), 1998, p. 200. See C. D. Pritch ett, ed., Iohannis Alexandrini Commentarium in Librum de Sectis Galeni, Leiden ( Brill), 1982; Agnellus of Ravenna, Lectures on Galens De Sectis, Buffalo, N.Y. (D epartment of Classics, State University of New York at Buffalo), 1981.

62 The Latin tradition Rational Doctor in the Latin tradition of medicine. It was that medicine and phi losophy are sisters, philosophia et medicine duae sorores sunt.9 Related to it w as the doctrine that medicine is the philosophy of the body and philosophy the me dicine of the soul, which also had an Alexandrian origin and was used by Agnellus of Ravenna.10 The schools of the Eastern Empire and the commentary on De Sectis are important because they helped shape later medicine, and not just by encoura ging a rationalist approach, the rationalism of the Rational and Learned Doctor. 11 The constraints of the classroom led to special ways of presenting and handli ng knowledge: learning and rationality were changed by the schools. Philosophy t oo was taught in schools, and since medieval medicine became highly philosophica l, we can glance at some features of the classroom. Aristotles philosophy in part icular was taught with the help of a classroom device called the accessus ad auc tores, literally a means of access to the authors, or how to understand them.12 The essence of the technique was that the teacher took his class through a routi ne set of questions when introducing a new text. The questions asked about the t itle of the work, its correct attribution to the author, the authors intentions i n writing, the mode of exposition he employed, and the part of philosophy to whi ch it belonged. The answers to these questions added to the pupils understanding of the text, whatever its technical content, which would be explained in a comme ntary. Treating all texts in a similar way gave a degree of uniformity to the cu rriculum and helped the teacher to cover a large number of texts in a comparativ ely short time. The commentary was another classroom device. We have seen that G alen wrote commentaries on the Aphorisms and Prognosis, with the aim of defendin g his interpretation of Hippocrates old medicine. But Galen had written freely, f or an educated public; by contrast, commentaries used for teaching in the classr oom were highly structured and, as in the accessus (which they often included), routine questions were repeatedly asked. John 9 10 11 12 See Cornelius OBoyle, Discussions of the nature of medicine at the university of P aris, ca. 1300, in John van Engen, ed., Learning Institutionalized. Teaching in t he Medieval University, Notre Dame, Indiana (University of Notre Dame Press), 20 00, pp. 197227. See O. Temkin, Galenism. Rise and Decline of a Medical Philosophy , Ithaca, N.Y., and London (Cornell University Press), 1973. Medicine and philoso phy are sisters, said John, in passing on a piece of Alexandrian wisdom to those who would read his book (such as Pietro dAbano in the late Middle Ages). See OBoyl e, Discussions of the nature of medicine. See E. A. Quain, The medieval accessus ad auctores, Traditio, 3 (1945) 21564. For medical examples of the accessus see also O. Temkin, Studies in late Alexandrian medicine. 1: Alexandrian commentaries on Galens De Sectis ad Introducendos, Bulletin of the History of Medicine, 3 (1935) 4 0530.

Medieval schools 63 of Alexandrias commentary on De Sectis shows some of these features. We have alre ady seen that of the kinds of medicine discussed in this text the rational kind was best suited to the classroom. Certainly John as a professional teacher would not have been sympathetic to the Methodists opinion that medicine was essentiall y simple and could be learned in a short time. John thought and taught that medi cine was dif cult, rational and needed time to be learned. He readily went back to Herophilus and Erasistratus as the rst Rationalists and argued that, except for its cruelty, human vivisection was the best way of learning about the body. We c an recall that when Celsus had discussed the same matter he listed a number of t hings that could be better seen in the opened living body than in a dead dissect ed one. John of Alexandria does something similar, telling his pupils that there are six things to be observed in an anatomical investigation into the body: for each organ, consider its position, shape, size, composition, number and connect ions. As a rote of questions to be asked of the organs in turn, this list is rel ated to the accessus to the authors, and indeed we might call it an accessus ad corpus, an access or introduction to the body.13 Clearly a classroom device in i nspiration, it became surprisingly widespread among later anatomists, who used i t to structure their texts. The point for us again is that the circumstances of the classroom changed rationality and learning, producing a sort of anatomical r ationality, or at least an accepted structure of knowledge. While classroom teac hing generated such devices as abbreviations of texts, the accessus, and particu lar structures of commentary, outside the classroom scholars had the opportunity to treat texts differently. We are concerned here primarily with the Arabs, who made determined efforts to nd and translate technical material from the Greek. P rime among them was Hunain ibn Ishaq (c. 80873), who worked directly from the Gre ek, but who was sometimes forced to use the intermediary Syriac or to make re-tr anslations where the task had been poorly done. The intention was to render the Greek as precisely as possible. It was then the business of other scholars to ma ke the medicine so uncovered suitable for the classroom, or to weld it together in great synthetic reference works. Much of medieval Western medicine came out o f the Arabic and the formation of the Latin tradition was a question of attempti ng to reconcile material from Arabic and from Greek sources. 13 See Roger French, A note on the anatomical accessus of the middle ages, Medical Hi story, 23 (1979) 4618.

64 The Latin tradition e a r ly t e x ts The way texts were handled thus depended on what they were used for. Medicine in the early Middle Ages was taught by individual masters, each of whom had a favo urite selection of texts. But they were not canonised or necessarily agreed upon by different masters, and the pupils of one master were expected to learn from the collected exemplar of their master. The more important a text seemed to be, the more it was rearranged, excerpted, added to and dismembered. The orilegia and textual fragments of the earlier period give no clear historical picture of the use of texts, but some generalisations are possible. The rst is that there is a striking absence of theoretical material. There is almost no anatomy; prognosis is reduced to lists of signs or divination; the action of the humours is describ ed in the simplest way; and pathology is descriptive rather than causal. Pharmac y and materia medica are prominent.14 This is medical learning of a kind, of cou rse, and perhaps similar in broad outline to that of many other cultures; but it was quite different from the medical learning of the Arabs and the Byzantines. Possibly theory was offensive to Christian clerks who must have been responsible for copying many of the manuscripts, and probably it was some Christian lter of th is kind that removed a reference to the divinity of the cosmos from Galens De Vic tus Ratione.15 Such an action is consistent with a view that a book is respected for its practical utility, not for the integrity of the words of an author. Ind eed, authors names were often lost as the material was reworked. Lists of remedie s constituted a large category of these early medical texts, and such things len t themselves naturally to rearrangement. A survey of manuscripts of the earlier part of the Middle Ages shows clusters of them round the topics of herbs and the names of Galen and Hippocrates.16 But this is a statistical grouping, rather li ke the preSalernitan summa which includes frequently occurring texts.17 But among all this the Hippocratic Aphorisms stands out as an early Latin translation rmly associated with the name of Hippocrates: we still have manuscripts 14 15 16 17 See Faith Wallis, Signs and senses: diagnosis and prognosis in early medieval pul se and urine texts, in Peregrine Horden and Emilie Savage-Smith, eds., The Year 1 000. Medical Practice at the end of the rst Millennium [Social History of Medicin e, 13, 2000], pp. 26578, at p. 266. See Faith Wallis, The experience of the book: manuscripts, texts and the role of epistomology in early medieval medicine, in Do n Bates, ed., Knowledge and the Scholarly Medical Traditions, Cambridge (Cambrid ge University Press), 1995, pp. 10126. Wallis, The experience of the book, p. 104. See A. Beccaria, I Codici di Medicina del periodo Presalernitano, Rome (Edizioni di Storia e Letteratura), 1956.

Medieval schools 65 of the Carolingian age,18 and we shall see later the importance of this text for the Rational and Learned Doctor. The economic recovery of the West was associat ed with the growth of towns and of trade, conditions that made possible schools and cultural interchange. This is also the background to the customary story of the rst of the great translators from the Arabic, and one of the fathers of the L atin tradition of medicine, Constantine the African (who died in 1087). Accordin g to this story, Constantine, an Arabic merchant from Muslim North Africa, arriv ed in the Bay of Salerno in southern Italy. His command of Latin was no more per haps than his trading required, but he was surprised to learn that the Latins ha d no medical books on prognostication from urine. Ultimately he settled at the m onastery of Montecassino and devoted himself to translating into Latin the medic al works that the Arabs had taken from the Greeks, and the big Arabic compendia. 19 Chief amongst them was the Pantegni of Haly Abbas, which begins with a discus sion of medical theory.20 Western doctors began to see that medicine could be ve ry theoretical, and if we can date the beginning of the Latin medical tradition to Constantine, doctors soon saw the advantages of a medicine that, in our terms , was rational. While Constantines material came from what is now Tunisia, later translators at Montecassino, such as Desiderius and Alfanus (archbishop of Saler no),21 made a concerted effort to nd Greek texts in southern Italy (where there w ere Greek-speaking areas, sometimes known as magna Graecia).22 to w h at pa rt o f ph i lo s o ph y d o e s i t b e lo n g ? Cathedrals had had schools since Ca rolingian times, but in the new and prosperous towns, schools expanded in their intake and subject matter. Often their popularity depended on a single teacher, a hero who could attract pupils from all over Europe. In the Renaissance of the twel fth century professional teachers gave attention to the whole range of human 18 19 20 21 22 See MacKinney, Early Medieval Medicine, p. 98. In fact the library at Montecassi no did contain at least one manuscript containing a tract on prognostication fro m urine. See Wallis, Signs and senses, p. 269. See Jacquart, Medical scholasticism, p. 204. See Paul O. Kristeller, Batholomaeus, Musandinus and Maurus of Salerno an d other early commentators of the Articella, with a tentative list of texts and manuscripts, Italia medioevale e umanistica, 19 (1976) 5787. See also Cornelius OBo yle, The Art of Medicine. Medical Teaching at the University of Paris 12501400, L eiden (Brill), 1998, pp. 88, 94. See also Danielle Jacquart, The in uence of Arabic medicine in the medieval West, in Encyclopedia of the History of Arabic Science, vol. 3, London (Routledge), 1996, pp. 96384, which contains a useful chronologic al table.

66 The Latin tradition knowledge. This was all philosophy, often de ned as knowledge of God and His works. The purpose of philosophy was to lead the good life, perfecting the soul as far as was possible on earth.23 Teachers argued that philosophy became necessary bec ause knowledge and the ability to hold it had been lost at the Fall.24 It was no longer possible to know God directly or read His word in the Bible with full un derstanding. It could be read literally for a surface meaning or spiritually for its deeper and often allegorical meaning, but a training in the arts was necess ary for both (said the teachers). Some urgency was felt in all this, for before the Second Coming Christian society, so the schoolmen argued, should be stable a nd extended as far as possible; the means of doing so was the recovery of prelap sarian knowledge according to the divisions of philosophy.25 Even the old pagan ph ilosophers were useful because of the detail in their work, which had proceeded some way along the path to true Christian knowledge. But too much attention to t he detail of natural philosophy, for example, seemed to churchmen to be curiosity, a sin that drew the observer away from revealed knowledge.26 Nevertheless, in t he twelfth century there was an optimism that one could learn more about God fro m the elements of the physical world and from mans body. Medicine was in a dif cult position here. The doctor who knew about the natural world and the human body d emonstrated that he was an expert and had medically useful knowledge.27 Undoubte dly doctors used their natural knowledge as a form of advertising, and a number of their patients recognised this. But Christians objected to the global and nat uralistic explanations of disease,28 which was part of the dangerous tendency of doctors to attribute power and autonomy to nature, thereby detracting from Gods omnipotence. They also objected to the doctors discussion about the soul, which, like nature, had been a topic in Greek philosophy 23 24 25 26 27 28 See, for example, Hugh of St Victors account of philosophy: Bro. Charles Henry Bu ttimer, ed., Hugonis de Sancto Victore Didascalicon. De Studio Legendi, Washingt on, DC (The Catholic University of America Press), 1939 (Hughs preface). See, for example, B. Smalley, The Study of the Bible in the Middle Ages, 3rd edn, Oxford (Clarendon Press), 1984, p. 26; G. R. Evans, The Language and Logic of the Bibl e, Cambridge (Cambridge University Press), 1984, p. 1. See R. W. Southern, Schol astic Humanism and the Uni cation of Europe, vol. 1 Foundations, Oxford (Blackwell ), 1995. See, for example, Vincent of Beauvais (Vincentius Burgundus), Bibliothe ca Mundi Speculum Quadruplex, Naturale, Doctrinale, Morale, Historiale, 4 vols., Douai, 1624: Doctrinale, I, 26, p. 23. Words derived from the Greek word for na ture, physis, generally hovered in meaning between nature (as in Aristotles Physics ) and medicine (as in our physician). See Brian Lawn, The Rise and Decline of the Sc holastic Quaestio Disputata, Leiden (Brill), 1993. See also J. Bylebyl, The medical meaning of physica, Osiris, 2nd series, 6 (1990) 1641. See Wallis, The experience of the book, p. 119. See also Wallis, Signs and senses, p. 266.

Medieval schools 67 and was inappropriate for the Christian tradition. Philosophy indeed was a major part of the problem. The church had need of philosophy only to defend and promo te itself and was traditionally cautious lest its disciples be led astray by the words of the philosophers. Medical men began to nd an interesting philosophy in the new medical works coming out of the Arabic, and the grammarian at Chartres, William of Conches (c. 1085aft. 1154), for example, was familiar with the Pantegn i, the medical reference work translated by Constantine the African.29 William t reated the story of the creation of Eve from Adams rib in a literal, or physical way (rather than spiritual), an attitude that brought down on his head from the church the severe rebuke that he thought like a heretic or, as bad, a philosophe r.30 Global and naturalistic explanations of disease were also clearly part of the doctors patter, the story they told to their patients. For John of Salisbury (c. 111580) a physicus was a man who, giving too much authority to nature and not en ough to God, studied natural signs about the future, that is, medical prognostic ation. Probably this now included uroscopy, which Constantine had been surprised to nd lacking among the Latins, but which thereafter became the symbol of the do ctor. As Daniel of Morley found with astrology, forecasting the future was theol ogically dangerous.31 John too disliked medical talk about the soul, the body an d its growth, death and resurrection, and the causes and cures of diseases. The soul was central, for it was here that the Christian doctrine of human immortali ty, derived from the scriptures and the Fathers, came face to face with Greek ph ilosophical teaching, including the nature of, and details of reproduction of an imals and plants. As for the causes and cures of disease, John objected in parti cular to talk of complexion, the mixture of elementary qualities in the body, whic h played such an important part in medical theory. Indeed, to the physicus the w hole action of the upper world, where rst principles 29 30 31 The major in uence was on Williams Dragmaticon (about 11449), but also on the earlie r Philosophia. It resulted in Williams rather odd corpuscular theory of the four elements. See Italo Ronca, The in uence of the Pantegni on William of Conches Dragma ticon, in Charles Burnett and Danielle Jacquart, eds., Constantine the African an d Al Ibn Al-Abb s Al-Mag s: The Pantegni and Related a u Texts, Leiden and New York ill), 1994, pp. 26685. On the economic background see B. Stock, Science, technolog y and economic progress in the early middle ages, in Lindberg, Science in the Mid dle Ages, pp. 151. His critic was William of St Thierry, who compared William of Conches with the condemned Abelard (who had also used the Pantegni) and the Albi gensian heretics; these were the rst major clashes between the church and revived ancient philosophy. See J. P. Migne, ed., Patrologiae Cursus Completus, (Latin series), 221 vols., Paris, 1866; vol. 180, cols. 33340. Daniels text is given by K. Sudhoff, Daniels von Morley Liber de Naturis Inferiororum et Superiorum, Archiv f r Geschichte der Naturwissenschaften und der Technik, 8 (1918) 140. See John u of Salisbury, Polycraticus, in Migne, Patrologiae Cursus Completus, vol. 199, pp. 41575 (Book II), at p. 475.

68 The Latin tradition lay, upon the lower was a complexioning, a physical action where the theologian sa w only the hand of God. When John complained of the doctors claim to be able to c ontrol disease, neutrality and health he is using three categories which are dis cussed in the Galenic text, the Tegni, which became important in medieval medica l education. Johns disapproval of doctors was shared by a signi cant gure. This was Alfred of Shareshill. He is signi cant because he was one of the rst to translate a nd comment on the physical works of Aristotle, which transformed the philosophy of the late twelfth century. We shall look at this below and here we must comple te our glance at twelfth-century perceptions of medicine and doctors. Alfred, as a translator of philosophy, called himself a philosopher, using the word physic us in one of its senses. He distanced himself from the medical men, who were mer e mercenary treaters of disease.32 Alfred shared the suspicions of the theologians that the medical men were too inclined to make nature an autonomous principle. He argued forcibly, for example, that what moved the heart was not nature, but t he soul.33 Part of his scorn for doctors was that they (unlike the philosophers) w ere still using pre-Aristotelian philosophy: plebei medicine professores, he cal ls them in his commentary on Aristotles Metheora.34 It was not only Alfred who th ought doctors mercenary. Churchmen saw that while medicine was praiseworthy (for Christ had been a healer) doctors were often greedy and deceitful. Even teachin g medicine for money could be seen as sinful. The various church decrees forbidd ing the religious to take up medicine were designed to prevent a loss of recruit ment into theology as able men were attracted to the monetary rewards of medical practice. Not only that, but medicine could be seen as a mere manual trade, a p roductive art that ranked well below the liberal arts, which were intellectual and had no physical end-product. The division of the sciences literature ranked theol ogy as the highest study with medicine below even law, another productive and lu crative art. The fact that the twelfth-century doctor could be attacked on the m oral grounds that he sold health for a fee reminds us that he was in a medical m arketplace. Attacked for excessive naturalism, for claiming to know the future, for being mercenary and for being intellectually vulgar, the doctor 32 33 34 See Carl Sigmund Barach, ed., Excerpta e libro Alfredi Anglici de Motu Cordis it em Costa-ben-Lucae de Differentia Animae et Spiritus, Innsbruck, 1878, p. 94. Al freds book on the motion of the heart, De Motu Cordis, dates from about 1200 and thus falls neatly between the twelfth-century philosophers of nature and the use of the new Aristotle in the universities. See Alfred of Sareshal, Commentary on the Metheora of Aristotle, ed. James K. Otte, Leiden and New York (Brill), 1987 , p. 42.

Medieval schools 69 was obliged to develop a line of patter, a Good Story, to convince his patients that they were in the hands of a capable man. When I hear them they seem to me to be able to raise the dead, thinking they are as good as Aesculapius, said John o f Salisbury.35 He added signi cantly that he was unable to give faith to the docto rs to believe their stories because they disagreed so much. Practitioners of an art who disagree about its principles or practice bring the art into disrepute a nd when doctors disagree the patient is disillusioned. But, as we shall see shor tly, the doctors soon found themselves with new weapons, including collaboration and agreement, in their attempts to persuade. i n co r p o r at i o n An import ant feature of the growth of towns in the West was the appearance of corporation s. The voluntary association of people with common interests was a way of promot ing those interests. Guilds were corporations and were formed by people making a nd selling things or people who traded abroad. Guilds had a major voice in the r unning of towns, which were themselves corporations. The biggest corporation, al beit of a special kind, was the church. In some places the cathedral schools, un der the guidance of the bishops chancellor, grew enormously, often under a charis matic or heroic teacher. Aristotles logic was a popular subject, for with it came t he power to argue convincingly and secure a career, perhaps in the court of a po tentate. But in the later twelfth century an important change took place. Some s chools were so big that they had a number of masters and in some places the mast ers realised that they could do better by collaborating rather than competing. I n short, they formed a guild of teachers; those in Paris called theirs a consort ium.36 A guild was a legal person: it could sue and be sued, it could hold land, write its own statutes, elect its own of cers, including those who represented it to other important corporations of persons, and possess a common seal. The only external condition was that its business had to be a genuine and lawful activit y.37 This has an important corollary for us. The rst schools taught the liberal a rts, but soon the teachers of medicine also formed masters guilds. The essential thing about them both 35 36 37 C. C. I. Webb, ed., Ioannis Saresberiensis Episcopi Carnotensis Policrati sive d e nugis curialium et vestigiis philosophorum, 2 vols., Oxford (Clarendon Press), 1909; vol. 1, p. 167. See H. Deni e, O. P., Chartularium Universitatis Parisiensi s, vol. 1, Paris, 1889. The principle was established by Innocent IV (d. 1254). See Antony Black, Guilds and Civil Society in European Political Thought from th e Twelfth Century to the Present, London (Methuen), 1984, p. 20.

70 The Latin tradition was that it was the masters of the guild who decided what their business was. Th e consortia of teachers drew up curricula, decided who the founders and heroes o f their subject were, and canonised the texts they chose. No one outside a guild of medical men had the authority to say what medicine was; and when princes utt ered decrees about medical training or licensing, it seems always to have been d one on the advice of a panel of doctors. Finally, a guild of teaching masters ta ught their pupils to a level where they became masters themselves: in doing this the guilds controlled the size of the group, that is, the number of teaching an d practising doctors. Part of the attraction of university-trained doctors was t hat they were not ten-a-penny. Control of the monopoly of the practice of intern al medicine was made possible by this control of numbers entering the profession , and it was made possible too by the fact that inception and the licence now co nstituted a medical quali cation in some nearly modern sense. t h e r at i o n a l i t y o f t h e d o c to r Half the story of the learned and rational doctor is how he acquired his rationality. At the root of it all was the syllogism, inven ted, or at least codi ed, by Aristotle. Up to the middle of the twelfth century th e medieval scholar had only the old logic of Aristotle, consisting mainly of his C ategories and Interpretation.38 Interpretation is concerned with logical proposi tions. Categories deals with the terms used in syllogisms and they are grouped u nder a number of heads: substance, quantity, quality, relation, place, time, pos ition, state, action and passion.39 For future reference there are two things we need to note about this list. The rst is that quantity and quality are different categories. In strict Aristotelian terms a quality had no characteristics of qu antity; but in medical theory a quality of, say, a medicine was the means by whi ch it had its effect, and it became desirable for Galen and much more for the me dieval doctors to give some numerical assessment of the activity or power of the medicine. The quanti cation of qualities was a major medieval undertaking. Second , the categories represent a list of attributes that could be sought in a variet y of circumstances, especially when Aristotelian logic became well known. It is argued below 38 39 For an introduction to the question of logic see Norman Kretzmann, Anthony Kenny and Jan Pinborg, The Cambridge History of Later Medieval Philosophy, Cambridge (Cambridge University Press), 1990, Introduction, p. 5. See D. P. Henry, Predicab les and categories, in The Cambridge History of Later Medieval Philosophy, pp. 12 842, at p. 129.

Medieval schools 71 that they could be sought in relation to the human body, in both textual and phy sical anatomies.40 In the second half of the twelfth century, thanks largely to the translations of James of Venice, the new logic became available. This made log ic much more powerful, and we can see the attractions for the teacher and studen t of the whole collection, called the Organon, the tool or instrument of argument. T he heroic teacher attracted students looking for careers in which the presentati on of facts and the arguing of cases were important. Aristotles Sophistical Refut ations (De Sophisticis Elenchis), for example, was one of the most important tex ts of the new logic and it taught the debater how to recognise apparent refutati ons of his arguments that were in fact based on fallacies (sophistical syllogism s).41 Finding these in ones opponents argument and avoiding them in ones own was a recipe for success in the man of affairs. Another important text in the new logi c was the Topica.42 Aristotle said that its purpose was to enable the reader to argue properly about any problem from generally accepted opinions. Again, in a c areer outside the university it was probable opinions that a diplomat or agent of a potentate was most likely to encounter. The arguments used were correctly syll ogistic in form, which gave the arguer the extra authority of Aristotles theoreti cal discussion of the syllogism in the Prior Analytics. The other book on analyti c Aristotles term for logic was the Posterior Analytics. This held out the offer o f certainty in knowledge: knowledge that could be demonstrated to be true. Comme ntators have wondered how far this text offers a programme for dealing with the natural world, of which Aristotle gave an account in the libri naturales, from t he general principles of natural motion up through the earth and heavens to text s such as the History of Animals. Could Greek historia become demonstrable knowl edge? The medieval doctors thought it could. Already in the possession of the Po sterior Analytics, when the physical works began to be translated in the late tw elfth century, scholars saw a huge opportunity to gain fully philosophical knowl edge of the natural world. The rationality of the learned doctor, developing ove r the thirteenth century, interpreted the natural world and the human body in a certain way. Logic was more than words, meanings and syllogisms: 40 41 42 See French, Anatomical accessus, p. 464. . . . arguments that appear to be refutati ons but are really fallacies, De Sophisticis Elenchis, 164a20, and see the Introd uction to E. S. Forster and D. J. Furley, Aristotle On Sophistical Refutations, On Coming-to-be and Passing-Away, On the Cosmos, Cambridge, Mass. (Harvard Unive rsity Press), 1992 (i.e., the third volume of the Loeb Library series of Aristot le), pp. 2, 11. We shall see below that it was these two texts, the Topics and t he Sophistical Refutations, that Bacon complained of doctors using too much.

72 The Latin tradition the world itself acted in a logical way. It had, after all, been created with di vine rationality, and it came to be accepted that God had put it together in an Aristotelian way. Logic was physical, in a sense we nd it dif cult to recapture.43 Thus there were many facets of the authority that the Rational and Learned Docto r used to introduce his subject into the new incorporated schools. s a l e r n o a n d t h e articella Tradition attributes great age to the medical school of Sal erno, but this has not been supported by recent scholarship.44 It is not clear h ow formal this school was in the twelfth century, but Salerno was clearly known as a good place to go to learn medicine; perhaps there was an assemblage of medi cal teachers there who had begun to collaborate rather than compete as heroes.45 Salerno is not far from Montecassino, where Constantine the African made his tr anslations from the Arabic, and again tradition gave these an important role in medical education in Salerno. It has even been suggested that Arabic institution s of learning were models for European teaching guilds, but the matter has not b een resolved.46 One circumstance that suggests a degree of formality about the s chool of Salerno was the appearance of a textbook. Textbooks imply a settled cur riculum, agreed among the teaching masters. In practice the textbook acted like the statutes of a guild, de ning what medicine was. If the Latin tradition in medi cine can be said to have begun with Constantines translations, then it was canoni sed with the fully developed textbook, known generically as the Articella. This s mall art of medicine was quite different from the individual selections of texts of the heroic medical teachers. There, practical 43 44 45 46 See Roger French, Canonical Medicine. Gentile da Foligno and Scholasticism, Leid en (Brill), 2001, pp. 11124. See Kristeller, Bartholomaeus. For a summary view see also Kristellers Philosophy and medicine in medieval and renaissance Italy, in Stua rt F. Spicker, ed., Organism, Medicine and Metaphysics, Dordrecht (Reidel), 1978 , pp. 2940. See the scholarly summary in Luis Garca-Ballesters introduc tion to Prac tical Medicine from Salerno to the Black Death, eds. Luis Garca-Ballester, Roger French, Jon Arrizabalaga and Andrew Cunningham, Cambridge (Cambridge University Press), 1994. Many universities have myths of very early origins in order to sec ure the authority of age. Many humanists ignored such myths because they were st ories of the early Middle Ages, not the classical period. See Walter R egg, Themes, in Walter R egg, general ed., A History of the University in Europe. Volume 1 u u Universities in the Middle Ages, ed. Hilde de Ridder-Symoens, Cambridge (Cambr idge University Press), 1992, pp. 334, at p. 7. Medicine at Salerno seems to have been vocational: see Danielle Jacquart, Theorica et practica e e dans lenseignment d e la mdecine a Salerne au xiie si cle, in her La Science mdicale Occidentale e en tre deux Renaissances, Aldershot (Variorum), 1997, item VII. See G. Makdisi, The Rise of Colleges, Edinburgh University Press, 1981; and his The scholastic metho d in medieval education: an enquiry into its origins in law and theology, Speculu m, 49 (1974) 64061.

Medieval schools 73 utility had been of the essence and authors names had little weight. Here, as be tt ed a canonical collection, it was important to know which of the founding father s of medicine had written the texts. Although in its early form the Articella wa s not very theoretical, it was a highly structured collection of knowledge about what medicine was and instructions about what to do. Most of those instructions related to prognosis, including uroscopy, which brings us back to Constantines s urprise that before him the Latins did not prognosticate in this way. In its rst form the Articella was known simply as The Art of Medicine, Ars Medicine, and it i s arguable that the collection was formed round a nucleus of the Hippocratic Aph orisms. We have already seen that this particular collection of medical wisdom w as important to Galen and that it was translated early in the Middle Ages into L atin (but the Ars Medicine version was another translation). We also saw that ma ny of the aphorisms are prognostic and one of the purposes of the Ars Medicine w as to enable the medieval doctor to judge when a case was going to turn out well or not. Indeed, the next most important component of the Ars Medicine was the H ippocratic Prognosis, which is almost a manual for detecting hopeless cases. The medieval form of Prognosis opens with much more emphasis than the original Gree k on the glory to be obtained from correct prognosis, and when students in the p hilosophy course read about the most glorious Hippocrates it was a reference to th is.47 The Ars Medicine also corrected the earlier Latin ignorance of uroscopy by including a short tract by the Byzantine Theophilus. This was matched by an inc omplete tract on prognostication from the pulse attributed to a Philaretus (abou t whom little is known). In short, almost the whole early collection of texts wa s prognostic in intent. Clearly, medieval doctors were aware of the rewards of g ood prognostication. A successful outcome of a case enhanced the practitioners re putation and a prediction of death avoided damaging it. The only theoretical com ponent of the Ars Medicine was the Isagoge of Joannitius, which always came in rs t place.48 This is a very short tract of a hundred sentences setting out the pri ncipal headings of the theory of medicine, mostly Galenic. It is so terse that i t could not be used in any fundamental way to explain the medical wisdom of the Hippocratic texts, but it introduced the Salernitans to a philosophy of nature t hat could be used 47 48 See London, British Library, Royal 12 G II, f. 358v: [ipocratis] gloriosissimi q uia inter omnes loquentes de medicina prognostica laudis debetur ypocrati. Also Royal 12 G V, f. 221v; London, British Library, Harleian 3487, f. 202v and Durha m Cathedral, C III 17, f. 381r. On the Isagoge see Danielle Jacquart, A laube de l a renaissance mdicale des xie xiie si cles: lIsagoge e e Johannitii et son traducteur, in her La Science mdicale Occidentale entre deux Renaissances, Aldershot e (Vari orum), 1997, item I.

74 The Latin tradition in conjunction with medical wisdom. We have already seen that twelfthcentury phy sicians could talk grandly about nature as a principle and about the action of t he upper world on the lower, but here at hand was an emerging philosophy that of Aristotle that looked more systematic, inclusive and convincing. The Salernitan s and medical teachers in other schools explored this possibility in two main wa ys. First, they sought to understand Hippocratic medical wisdom better by adding Galens commentaries to the textbook. In this way the Ars Medicine became the Ars Commentata, and much bigger. Between themselves physicians often referred to me dicine simply as the art in reference to the rst aphorism, and sometimes as the art of Hippocrates; Articella is a comparatively late Italian vernacular term meaning little art. As the Ars Commentata developed it increasingly took on the form of a Galenic rationalising explanation of Hippocratic medical wisdom, and a big new addition to the collection was the Tegni, thought to have been written by Galen in old age as a summary of medical principles. In some sense the heart of mediev al medical education was explaining the Aphorisms on the basis of the Tegni. It has also been argued that northern France was also a likely place for the new me dicine to have developed. The Ars Medicine was being glossed there in the twelft h century in the biblical manner; and the schools there were familiar with the n ew GreekLatin translations of Aristotles physical works. Masters at Chartres were also commenting on the texts of the Articella at the time of John of Salisbury ( d. 1180) and it has been argued that the Articella could have had a French origi n.49 With these schools were associated scholars such as Hugh of St Victor, John of Salisbury and Bernard Sylvestris; Norman political power linked the area wit h southern Italy, a natural place for translations from the Greek; and scholars such as William of Conches at Chartres were familiar with the Pantegni.50 a r i s tot l e a n d t h e l at i n t r a d i t i o n The second way in which the Sal ernitans explored the opportunities of the new rationalism was by using Aristotl es physical works directly. In the 49 50 For a summary of the literature see Francis Newton, Constantine the African and M ontecassino: new elements and the text of the Isagoge, in Burnett and Jacquart, C onstantine the African, pp. 1647, at p. 17. See OBoyle, The Art of Medicine, p. 99 ; Marie Thr se DAlverny, Translations and translators, ee in Renaissance and Renewal in the Twelfth Century, ed. Robert L. Benson and Giles Constable, Cambridge, Ma ss. (Harvard University Press), 1982, pp. 42162.

Medieval schools 75 1160s, when in other parts of Europe Aristotle was known principally as a logici an, the Salernitans were reading his physical works to give rationalist explanat ions to medical wisdom.51 This was an important change, and we need to look a li ttle at its context. Indeed, the rst use and then the canonisation of Aristotles p hysical works was a de ning moment in the intellectual history of the West. We nee d to note a few points about it. First, the importance of the Aristotelian works in an internal and external sense has encouraged historians to treat them as if they had a career of their own, and we often read that the works arrived or occur red in the West as a legacy. But this was not the case and what in fact happened i s important for the argument of this book. There was a contemporary parallel wit h astrology, an exciting art of prognostication that could be found in Arabic so urces. When they came to know this, would-be astrologers went and sought out the texts, which was sometimes an arduous business. What was new about Arabic astro logy was that it predicted the future with certainty and mathematical precision: it was not only exciting but commercially valuable.52 A second parallel was law . Part of the urban renewal was a new interest in Roman Law, which was different from the customary law that stretched over much of Europe. It had been the law of Rome, and some thought that Rome again ought to be a seat of the law. It had been, too, the law of emperors and was therefore of interest to the Holy Roman E mperor, who claimed the power of the Caesars. The emperor had become holy with the aid of the pope, and the pope became more powerful with the aid of the emperor; but it was never an easy alliance, and it was important to have authority when negotiating claims to political power. The great works on Roman Law were found a s a result of a deliberate search for them, and they were found perhaps it was n ot a coincidence in about 1070 in the monastery of Montecassino, where Constanti ne had translated the Pantegni. Indeed, books were now important in a new way. A uthority lay in books, as it did in the Bible. The bible of the doctors was rst t he Pantegni and then the huge Canon of Avicenna, translated by Gerard of Cremona (c. 111487) in Toledo, at the boundary of Muslim and Christian Spain. The bible of the lawyers was the Digest of Justinian, before the discovery of which, law, like medicine, had been a question of fragmentary ancient texts and abridgements set in a matrix of contemporary knowledge, but containing 51 52 See DAlverny, Translations and translators. See for example Roger French, Foretellin g the future. Arabic astrology and English medicine in the late twelfth century, Isis, 87 (1996) 45380.

76 The Latin tradition nothing re ective that could be described as theory.53 The importance of the new l aw texts was such that the earliest groups of scholars which we can recognise as having been in some sense incorporated were the legists of Bologna.54 To many h istorians the central event of the early history of Western medicine was the rece ption of texts, particularly Greek. This is a view partly conditioned by the conc erns of the classical scholar, for whom texts are classical and canonical. But m edical texts, like those of law and astrology, did not arrive: they were fetched . Accounts of the transmission of texts do not normally give much attention to t he motives of the translators but some of the circumstances are suggestive.55 Fi rst, the translations were often supported by men who we can assume had some int erest in the result. The model is the translation of religious materials. Robert of Chester (fl. 114150) was asked by Peter of Cluny to translate the Koran; Mark of Toledo (fl. 11911216) was supported by the archbishop of Toledo while he tran slated Islamic materials for use in the archbishops campaign against the Muslims. 56 Michael Scot, the early translator of Aristotle, was also supported by the ar chbishop. Rulers had a need for educated men and sometimes, like Roger, Frederic k II and Manfred (all kings of Sicily), funded translations. When Western transl ators such as Michael Scot and Alfred of Shareshill worked from Arabic with the help of Jewish translators, it was often possible because the Jews too had a nee d for the texts of astronomy, medicine and other technical subjects. Where we do not hear about patronage, as in the case of Daniel of Morley57 and Alfred of Sh areshill, it seems that the translators spent a great deal of money and time (pe rhaps at the risk of their careers) travelling to centres of translation. In add ition to religious materials, astrology and medicine are conspicuous in the tran slations of the eleventh and twelfth centuries. Both were valuable forms of know ledge, even in a commercial sense, and both were concerned with the important bu siness of prognostication.58 53 54 55 56 57 58 See Stephan Kuttner, The revival of jurisprudence, in Benson and Constable, eds., Renaissance and Renewal in the Twelfth Century, pp. 299323. Law students began fo rming nations in Bologna at the end of the twelfth century, and Bologna is gener ally regarded as the oldest university. R egg, Themes, p. 6. u A standard source fo r transmission is the detailed account given by D. C. Lindberg, The transmission of Greek and Arabic learning to the West, in D. C. Lindberg, Science in the Middle Ages, Chicago (University of Chicago Press), 1978, pp. 5290. Lindberg, Transmissio n, p. 66. On Daniel, see also R. W. Hunt, English learning in the late twelfth cen tury, in R. W. Southern, ed., Essays in Medieval History, London and New York (Ma cmillan), 1968, pp. 10628. Astronomy, long esteemed by historians of science as t he model science of the Middle Ages, can also be seen as the theoretical basis of the practice of astrology. See French, Foretelling the future.

Medieval schools t h e u n i ve r s i t i e s 77 The discovery and use of Aristotles physical works is a story that has to be told in conjunction with that of the universities. These studia play a central role in the story of the Rational and Learned Doctor, for they secured for his subjec t the autonomy of the guild; they provided him with the intellectual component o f his trade; and they were the institutional arena in which he secured the profe ssional standing he needed for it. There were two main models on which European universities were founded. In the south, particularly in Italy, the schools in w hich medicine was taught were associations of students, set up for the mutual pr otection and promotion of young men coming into a strange town.59 They elected t heir teachers and established the rules, at least at rst. They wanted a practical training, and read arts and medicine together. The Bolognese schools of medicin e appeared in about 1260 but the lawyers did not recognise it as a proper univer sity until 1316.60 The rst known medical degree was in 1268.61 In Montpellier the re had been unincorporated schools of medicine as early as 1135 (separate from t he earlier schools of law). Again, the pope took control (1220) with statutes th at gave the masters authority; what seems to have happened was that the college of doctors was absorbed into the student university. Montpellier, like the unive rsities of Spain and Portugal, was mixed, with the students electing their recto r.62 The northern model, of which Paris was the exemplar, was less vocational. I t grew out of the cathedral school, and the chancellor long claimed the right to control it. It was essentially an incorporation of masters, and we have seen th at the Parisian masters called it their consortium. We also noticed the populari ty of logic in the schools of the twelfth century, and now, thinking of Paris at the beginning of the thirteenth century, this was taught with grammar and rheto ric, all useful skills of communication for a later career. This trivium was tau ght early in the arts course (and so became known 59 60 61 62 In Bologna in 123040 the two universities, transmontane and cismontane, were clea rly distinct. The masters were often Bolognese and readily swore not to go elsew here; the rectors, elected by students, did not. Control was secular until the p ope took charge, for example by asserting in 1219 that the archdeacon of Bologna should award the licence. Law students in Bologna were generally adults and oft en high in social scale. See Jacques Verger, Patterns, in Ridder-Symoens, Universi ties in the Middle Ages, pp. 3568, at p. 49. Verger, Patterns, p. 50. See Nancy Sir aisi, The faculty of medicine, in Ridder-Symoens, Universities in the Middle Ages, pp. 36086, at p. 368. Verger, Patterns, pp. 39, 52; Siraisi, The faculty of medicin e, p. 367. There were new medical statutes in 1239, when Henry of Winchester ouris hed there: he wrote the earliest known medical text, a commentary on the Isagoge .

78 The Latin tradition pejoratively as trivial) and was followed by the four mathematical arts that compl eted the seven liberal arts: the quadrivium of astronomy, arithmetic, geometry a nd music. Comparatively few students went from the arts course to the higher fac ulties, and the greater number of masters of arts gave them much political power within the consortium. This pattern of teaching was greatly changed when the ph ysical works of Aristotle began to circulate.63 The masters began to teach natur al philosophy, generally known simply as philosophy unless there was need to disti nguish it from Aristotles moral philosophy. But the church was ambivalent about phi losophy. The principal problem was that Aristotle, keeping the divine out of nat ure, had said that the world was eternal, not created. As with the case of Willi am of Conches, Aristotle could lead one into curiosity or a literal reading of the natural world. In Paris there was an outbreak of heresy that could be attribute d to reading too much Aristotle, and the general feeling was that Aristotle wrot e too much about creation (the natural world) and not enough about the Creator. Consequently, reading the physical works was prohibited in Paris in 1210 and aga in in 1215. On the other hand, there was a heresy of a different kind in Langued oc which the church thought could be suppressed by using the physical works, and the masters of Toulouse wrote to other schools, urging masters to come and defe nd the faith, with the added freedom of reading Aristotle. The Cathar heretics i n and around Albi and Toulouse argued that the world was so obviously an evil pl ace that it must have been created by an evil God, whom the good God had created but could not control. The Catholics were horri ed and insisted that God was the omnipotent and good Creator, who had, however, given his created angels free wil l to choose good or evil. The heretics retorted that in that case God as omnisci ent must have known that one of his angels would choose evil. When the arguments from the scriptures ran out, the discussion turned to causes and effects. Inten ded to demonstrate the relation between Creator, angels and evil, this argument was taken from philosophy. The Dominicans, the order of friars formed with the s ole intention of destroying the heresy, at once found that the physical works of Aristotle could be used to demonstrate that the natural world was in fact a goo d place. It was good in the realisation of potential, in the ful lment of purpose that Aristotle saw in the expression of the nature-of-the-thing, and which the C atholics saw as the purpose of the Creator.64 63 64 See also Gordon Leff, The trivium and the three philosophies, in Ridder-Symeons, U niversities in the Middle Ages, pp. 30736. See Roger French and Andrew Cunningham , Before Science. The Invention of the Friars Natural Philosophy, Aldershot (Scol ar Press), 1996.

Medieval schools 79 When the church had crushed most of the heresy with a military crusade and burne d most of the heretics, the Dominicans, for the purpose of re-education, set up schools of natural philosophy to train the brothers. It was Aristotelian and Chr istian together and the pinnacle of its expression was Aquinas Summa Theologica. In other words, their theology was philosophical, and where it was taught it nee ded a philosophical arts course, just as the older theology needed the seven lib eral arts. Toulouse became a full studium generale that taught not only (as we h ave seen) Aristotelian natural philosophy but also Galenic medicine. The Dominic ans spread over Europe, wherever heresy was suspected and wherever they could re cruit. This made university towns a natural target, and the Dominicans with the help of the pope secured dominance in the teaching of theology, with the results for philosophy that we noted above. There is some suggestion that when dialecti cal natural philosophy reached Italian medicine, it was by the mediation of the friars.65 The different circumstances of Oxford meant that the masters and stude nts there too were free to read Aristotle, which they seem to have done since Al fred of Shareshill made his translations in the last years of the twelfth centur y. We know of teachers such as Adam of Buck eld who made extensive commentaries on the physical works, and traditionally it was the English Oxonian Roger Bacon wh o in the 1240s took philosophy to Paris when the prohibitions had ceased to be e ffective. It was the English Nation in Paris that set up the rst statute that rel ated to the reading of the physical works, and very soon (in the middle of the t hirteenth century) a very complete set of decrees was in force, setting out how the physical works were to be read. It was partly a political matter, for the ma sters of arts were in dispute with the friars, the theologians and sometimes wit h the pope. They took to philosophy as their own, and in the second half of the arts course made knowledge of it a condition of becoming a master. This much has been necessary to explain how Aristotles rationality became available to the med ical man, our Rational and Learned Doctor. While in the Italian universities nat ural philosophy came to the arts-andmedicine course rather later than in the nor th,66 Aristotle came to dominate the medieval university, and Aquinas great theol ogical work shows 65 66 It was not only the Dominicans who used Aristotle, for the Franciscans of Santia go de Compostella in north-west Spain were using all the libri naturales of Aris totle by 1222. See Luis Garca-Ballester, The construction of a new form of learnin g and practising medicine in medieval Europe, Science in Context, 8 (1995) 75112, at p. 85. See Nancy Siraisi, Taddeo Alderotti and his Pupils. Two Generations of Italian Medical Learning, Princeton (Princeton University Press), 1981, pp. 10, 147.

80 The Latin tradition how even central Christian dogma could be seen through Aristotelian eyes. By mea ns of philosophy too the doctor, so often seen as avaricious and duplicitous, co uld make the lowly and manual craft of medicine part of a properly instituted st udium generale. Indeed, in the north, he made it a higher faculty, along with la w and theology. We shall look at the Medical Faculty in the next chapter, and mu st end this one with a glance at how medicine related to philosophy when the lat ter was being taught in its new statutory form. Let us return brie y to Oxford. Ad am of Buck eld had completed his commentaries on the physical works of Aristotle b y the 1240s, while they were still banned and under investigation in Paris67 and before the Oxford medical faculty ourished. His purpose was to lay out the intel lectual morphology of the text so that students could nd their way in it.68 He do es not mention medicine where we might expect it, for example in commenting on t he text On the Difference between the Soul and the Spirit, which discusses matte rs of interest to both medical men and philosophers.69 In contrast, two or three decades later, the Oxford masters had agreed a common gloss on the physical wor ks, also called the libri naturales, a term that seems to have given rise to the philosophy teachers name for themselves, the naturales. This common gloss contai ns more reference to medicine than we might expect, and would have furnished the medical man with a powerful argument for regarding medicine as a subject proper for a studium generale. The central textual basis for this argument is in the A ristotelian text On Perception and the Perceived (De Sensu et Sensato) where Ari stotle says that the philosopher should acquaint himself with the rst principles of health and disease, because these occur only in living things. That is, Arist otle has now reached the point in the cycle of teaching at the Lyceum where the general physical principles have been set out and explained in circumstances of increasing complexity to the point where life itself became the centre of attent ion. The Parisian statutes of 1252 set out the libri naturales 67 68 69 In 1231 Gregory IX set up a committee to inspect the physical works of Aristotle , preserve what was useful to the faith and reject what was offensive. See Deni e, Chartularium Universitatis Parisiensis, vol. 1, p. 143. Strictly, he was an exp ositor rather than a commentator, who would have resolved problems with the text , pointed out parallel passages elsewhere, and so on. De Differentia Spiritus et Anime. See E. J. French, Adam of Buck eld and the Early Universities, PhD thesis, U niversity of London, 1998, pp. 13143. This text is the only one on the corpus vet ustius known not to be by Aristotle. The corpus vetustius, the older collection of Aristotles physical works, is a textbook in the sense of carrying the texts spec i ed by statutes in Paris and Oxford for the completion of the arts course togethe r with much space for the reception of students notes. It dates from the second h alf of the thirteenth century. It was, that is, a textbook in the same way as th e Articella was the textbook of medicine.

Medieval schools 81 in approximately the same sequence, and the Oxford gloss followed it too. This o pinion of Aristotle became codi ed as where the philosopher nishes, the physician be gins.70 This aphorism was picked up by Isidore,71 and was exactly what thirteenth -century doctors wanted everyone to think. It suited their purpose too that Aris totle had not descended to teaching the manual craft of medicine but had declare d that its principles were philosophical. Moreover, they believed that Aristotle had written a book on the principles of medicine, which had been lost.72 The es sence of this relationship between philosophy and medicine was subalternation, a nother Aristotelian doctrine. A subalternated discipline drew its rst principles from another discipline and did not set them up itself.73 Medicine, said the med ievals, was subalternated to philosophy and the principles it drew from it had t o be treated as unassailable axioms. The medical man could not question them and should not try to. Medical principles, they said in Oxford, were proximal.74 The medical man could thus argue that, yes, the physician begins where the philosoph er nishes in going further than the philosopher. This meant that philosophy was f undamental and had to be learned rst, but for that reason was also more basic, wh ile medicine in going further could be seen as a higher discipline. This re ects w hat happened in institutional terms when nally, in the fourteenth century,75 medi cine was represented in its own faculty and as a higher discipline in Oxford. Su balternation also crossed disciplinary boundaries in terms of text. The Oxford t eachers said that the chain of subalternation was that Aristotles work on the sou l, De Anima, was fundamental to De Sensu et Sensato which in turn was fundamenta l to the rst work in 70 71 72 73 74 75 quia ubi naturales terminant ibi incipiunt medici ut dicitur in libro de sensu e t sensato, as the Oxford masters said. Durham Cathedral, C III 17, f. 382r. Faye Getz, Medicine in the English Middle Ages, Princeton (Princeton University Pres s), 1998, p. 48. The aphorism was used by philosophers such as Albertus Magnus a t a time in the thirteenth century when not all doctors were using the Canon of Avicenna, and when boundaries were developing between philosophy and medicine. L ike other authors, Albertus derived the opinion from the Aristotelian De Sensu e t Sensato. See Nancy Sraisi, The medical learning of Albertus Magnus in her Medici ne and the Italian Universities 12501600, Leiden (Brill), 2001, pp. 1136. . . . sua medicina quam [ad hoc] non habemus. London, British Library, Royal 12 G V, f. 20 9v and London, British Library, Harleian 3487, f. 200v. For His [Aristotles] medic ine see also London, British Library, Royal 12 G II, f. 355v and Royal 12 G V, f. 209v as well as London, British Library, Harleian 3487, f. 200v. sicut illud quo d probatum est in scienta subalternante debet supponi in scientia subalternata. N uremberg, Cent. V 59, f. 221r. London, British Library, Royal 12 G III, f. 245r [ de medicina] idest ad proxima principia que sunt de consilio medici, et non cons iderant prima principia sanitatis et egritudinis de quibus tantum considerat nat uralis. Also Royal 12 G II, f. 382v. Getz, Medicine in the English Middle Ages, p . 17.

82 The Latin tradition the medieval textbook of medicine, the Isagoge of Joannitius.76 We have seen tha t this brief tract was the only theoretical piece in the early Articella and in a sense is an introduction to the whole of medieval medicine. This was the place where (the Oxford masters thought) all the unassailable axioms of philosophy pa ssed from one discipline and one textbook, the corpus vetustius, to another disc ipline, another textbook, and ultimately another incorporated group of men.77 Th e chain is even longer than this, for the Oxford masters selected a passage from the Isagoge where Joannitius names three states of the body, sickness, health a nd neutrality. This is a doctrine from the Tegni which, as we have seen, was add ed to the Articella as a summary of medicine, and for which, the medievals belie ved, Joannitius wrote the Isagoge as an introduction. The process of subalternat ion provided additional mechanisms for the Rational and Learned Doctor to trace his practice back to the fundamentals of the world picture. b e f o re t h e fac u lt i e s Medical men in Oxford took longer than those in other studia to set up their faculty, and no university-educated English doctor is known from the th irteenth century.78 It is dif cult to tell what the nature of pre-faculty medicine was, but it was a time when the doctors were adapting their medicine to the new circumstances. According to Roger Bacon, the doctors of the 1240s practised poo r medicine because they did not read the Arabic authors, particularly Avicennas C anon. He was familiar with Paris as well as Oxford and was speaking in general t erms;79 what he meant was that the doctors were insuf ciently learned. The Canon, a vast compilation from largely Galenic sources, had been translated and glossed by the other great medieval translator, Gerard of Cremona, but spread through t he European studia rather slowly, no doubt because of the dif culty and expense of copying it.80 Bacon has praise for earlier doctors who learned 76 77 78 79 80 Madrid, Escorial, F II 4, f. 181r [consequens est] scilicet in hoc libro et in qu ibusdam sequentibus libro de anima subalternatis aliquo modo. And [subiaceatur] id est supponantur in hoc libro et in relinquis sequentibus sicut determinata in su periori scientia. (See also Madrid, Escorial, III, f. 245r and II, f. 382v). The philosophical axioms were largely the nature of the elements and their qualities , which provides the foundations of the theory of complexion. We have seen how t his was objectionable to John of Salisbury, and now with the accessibility of th e libri naturales, it was a much more elaborate theory. Getz, Medicine in the En glish Middle Ages, p. 17. See the Opera hactenus Inedita Rogeri Baconi. Fasc. IX : De Retardatione Accidentium Senectutis, ed. A. G. Little and E. Withington, Ox ford (Clarendon Press), 1928. The Canon was becoming known by the 1190s and was used by some philosophers and physicians in the following century, but it was no t until the fourteenth century that it was used routinely by

Medieval schools 83 their medicine by experience which alone quali ed them and to whom, perhaps, he thou ght the Canon was not available. His criticism of contemporary doctors was not o nly that they ignored Arabic sources but that they enthusiastically engaged in d ialectical methods.81 He speaks of them giving themselves to disputations of in nit e questions and useless arguments instead of experience. He mentions the introduc tory topics of logic as taught in the universities and derides the accidental ques tions and the sophistical and dialectical arguments that surely speak of a unive rsity context.82 So it seems that the doctors were enthusiastically becoming rat ional in the Aristotelian way, the attractions of the Old Logic of the previous century now enhanced with the circulation of the New. The implication of Bacons v iew that experience alone used to con rm men as doctors is that they were now seek ing to do so by succeeding at academic logical exercises, that is, securing some sort of institutional validation of their medical worth. Something similar happ ened in the early thirteenth century in Sicily, where the doctors advised the ki ng, Frederick II, that a knowledge of logic should be a formal requirement for a nyone wishing to begin a study of medicine.83 He enacted that three years of log ic were necessary and that the medical course should be ve years. The result was that those who followed these rules then practised medicine by royal assent. Thi s took the form of a licence to practise, licentia practicandi, awarded after an examination by a panel including masters of the art. This was the term used only for doctors educated at Salerno, another Norman kingdom and where, after all, th ey knew what medicine was. The decree speci es the genuine books of Hippocrates and Galen which together with the three years of logic indicates the Salernitan mode l medical men, although it was not popular for example in Montpellier. See Daniell e Jacquart, La e rception du Canon dAvicenne: comparaison entre Montpellier et Pari s aux xiiie et xive si cles, e e ee in Histoire de lEcole Mdicale de Montpellier, A ctes du 110e Congr s National de Socits Savantes, e Montpellier, 1985, pp. 6977; an d Nancy Siraisi, Changing concepts of the organization of medical knowledge in th e Italian universities: fourteenth to sixteenth centuries, in La Diffusione delle Scienze Islamiche nel Medio Evo Europeo, Rome (Accademia nazionale dei Lincei), 1987, pp. 291321. There was an earlier parallel in the increasing use of dialect ic in theology: the re ective theology of the cloister became dialectical and syst ematic as it was used increasingly in urban situations. Law became increasingly dialectical. See Southern, Scholastic Humanism, and French and Cunningham, Befor e Science. esp. ch. 3. vulgus medicorum dat se disputationibus questionum in nitaru m et argumentorum inutilium, et non vacat experientie ut oportet. Ante 30 annos non vacabant nisi experientie, que sola certi cat; sed nunc per artem topicorum et elencorum multiplicant questiones accidentales in nitas, et argumenta dialectica et sophistica in nitiora, in quibus absorbentur ut semper querant et numquam inven iant veritatem. Inventio enim est per viam sensus memorie et experientie, et max ime in scientiis, quarum una est medicina. See Little and Withington, Opera hacte nus Inedita Rogeri Baconi, p. 154. See, for example, Lawn, Quaestio Disputata, p p. 668; Siraisi, Medieval and Early Renaissance Medicine, pp. 17, 18. 81 82 83

84 The Latin tradition of the Rational and Learned Doctor. Frederick was reasserting Norman control ove r Sicily, and it is at such times that the rules are changed or written down.84 In the new Latin Kingdom of Jerusalem, case-law was established by 1245 and spec i ed that should a patient die after undergoing a recognised mode of treatment the doctor should be whipped round the streets, holding a urine ask symbolically in his hand, and then hanged.85 Here was an excellent reason to be good at prognost ication. Whatever their source, the new logic and philosophy were used more syst ematically in the north, which remained a resource for the south in these matter s down through the rst half of the fourteenth century. Before the medical faculti es were incorporated in the north the word faculty was in use in a more general se nse in the south, meaning an area of study in which it was possible to become a master. In the south, we know from John of Salisbury that, like Salerno, Montpel lier was a good place to go to learn medicine, but, unlike Salerno, it became a full university, defended by the monarchs through whose hands it passed. Its med ical training was probably vocational until the arrival of the new logic and phi losophy.86 In short, philosophy and other technical material in Arabic (and incr easingly in Greek) had uses as varied as the men who sought it out. Men of the c hurch wanted to know how other cultures worked. Kings husbanded their resources of men educated in the arts course by protecting the universities. The pope effe ctively patronised the friars by sending them all over Europe, inserting them in to faculties of theology and telling the local bishops to support them as mendic ants. The doctors thought philosophy would improve their medicine and make them better doctors. They also found that it was attractive to pupils and enhanced th eir reputation as teachers. t h e pantegni a n d s c h o l a s t i c m e d i c i n e Scholastic as an adjective applied to medieval medicine is often used in a pe jorative way,87 indicating excessive reliance on logic and authority in place of the use of the senses. This is partly an inheritance from the Hellenists of the Renaissance, who wanted to get back to the medicine 84 85 86 87 On Sicily in general see Donald Matthew, The Norman Kingdom of Sicily, Cambridge (Cambridge University Press), 1992, esp. chap. 5. See the articles by Darrel W. Amundsen in Warren T. Reich, ed., Encyclopedia of Bioethics, 4 vols., New York (Free Press), 1978; vol. 3. On Montpellier medicine see Louis Dulieu, La Mdecin e a Montpellier, 2 vols., Avignon (Les Presses e Universelles), 1975. Cf. the rh etorical question posed by Jacquart in Medical scholasticism. See also Siraisi, Med ical scholasticism and the historian, pp. 14056.

Medieval schools 85 of the Greeks and who disliked the period in-between. They called this period th e middle ages, that is, intervening, and derided its technical and dialectical com mentaries and analysis. This was, in short, what we are calling in this book the Latin tradition of medicine; it did not die out, as the Hellenists hoped, but c ontinued in the schools into the seventeenth century. Most of it took its form f rom the very fact that it was taught in the schools, and we shall use scholastic i n this more neutral sense. We have seen in this chapter some of the circumstance s of the medieval schools and we shall see in the next the full expression of th e move towards incorporation of medical teaching. We can conclude here with a br ief look at how the constraints of classroom teaching gave shape to scholastic m edicine. We can best do so by glancing at the rst major Arabic medical text to be translated into Latin, and thus one of the major sources of the Latin tradition of medicine. This was the Pantegni of Haly Abbas (as the Latins called him), rst loosely translated by Constantine the African.88 A second translation was made by Stephen of Antioch in the early twelfth century, both before the formalisatio n of the Western schools.89 The rst half of the text is a discussion of medical t heory, and is often referred to by doctors of the high Middle Ages as Halys Theory, and undoubtedly this is what was novel about the work. Haly begins by declaring that Hippocrates, the great or most glorious,90 was the Father of Medicine, the rst to write down the art; and his works, particularly the Aphorisms, contained all that was needed for the recovery and maintenance of health. Yet so cryptic was H ippocrates language, continued Haly, that the reader needed much exposition and m any examples to understand it. Galen, who was second only to Hippocrates, was pr olix and diffuse; and as Greek authors such as Oribasius and Paulus gave way to the Arabic writers such as Aaron and John (son of Serapion), most authors began to write works that were defective in one important respect, namely that they ga ve insuf cient attention to the naturals. These for Haly are the fundamentals of nat ural philosophy, the elements and their qualities and their mixtures that produc e secondary 88 89 90 While Constantines translation of the Theorica more or less corresponds to Halys tex t, the Practica is Constantines compilation from a range of other sources. See Bu rnett and Jacquart, Constantine the African, p. vii. Stephen called his translat ion The Royal Book, Liber Regalis, but it is more convenient to retain the widespr ead name Pantegni. See Lindberg, Transmission, p. 58. A printed version of Stephen of Antiochs translation was edited in the Renaissance by Michael de Capella: Hal y Abbas, Liber Totius Medicine Necessaria Continens, Lyons (J. Myt), 1523. Const antine and Stephen used different terms. See Danielle Jacquart, Le sens donn par C onstantine e LAfricain a son oeuvre: les chapitres introductifs en Arabe et en La tin, in Burnett and Jacquart, Constantine the African, pp. 7189, at pp. 84, 86.

86 The Latin tradition bodies, some common to living things. Like the Aristotelianism that was to give the Rational and Learned Doctor a basis for his account of medicine in the funda mentals of the world picture, the Pantegni provided an attractive rationalism to medicine. Medieval doctors would have seen the work as an expansion of the doct rines of the Isagoge of Joannitius: both begin with the division of medicine int o theory and practice; both list the naturals, choosing to add to the usual numb er of seven the ages, colours and gures of the patients and the difference betwee n men and women. Halys plan, therefore, was to begin with the axioms of natural p hilosophy and to proceed with rigid rules of exposition in order to include all that is necessary. His method is division of doctrine, one of the modes of procedu re that medieval doctors loved to discuss, and he breaks it down into ve sub-cate gories. In a similar way he treats the opinions of Hippocrates and Galen as rules , norms and propositions which can be treated syllogistically.91 The whole theory of medicine, then, is to be derived from rst principles in a very rationalist wa y, thus overcoming the faults of earlier expositions. It is a technique aimed at , if not derived from, a rationalist teacher handling words (not observation) in the classroom for students who needed a method to help them memorise all they h ad to learn in a short time. Haly expects that his readers will know their logic and the arts of what the Latins called the quadrivium: this could well be seen as offering support for treating medicine as a higher discipline, and even for H aly it must have been an ideal, for the examples he gives for the use of these a rts in medicine are not very convincing: geometry for the shape of wounds, music to read the pulse and astronomy for the astrological signs for preparing remedi es.92 What he has to say on medical deontology also relates to the classroom. Fr om Hippocratic sources he draws the principle that the pupil must magnify the na me of his teacher and spread his glory abroad. It is the fatherson relationship o f the Oath, in which newcomers, if suitable, are treated as sons and taught with out payment, and where successful pupils share rewards with their teacher. In th e Latin tradition of medicine we often meet cases where the pupil has a duty of faith to his master, which seems rooted in these classroom ethics; it was generall y extended to the teacher of all teachers, back down a line to Hippocrates and G alen. Good is the word of Hippocrates!, exclaimed Haly.93 In the practice of medic ine the doctor must be ethical, modest, abstemious, always reading and learning 91 Haly, Continens, f. 6va. 92 Ibid., f. 7rb8rb. 93 Ibid., f. 7rb.

Medieval schools 87 from others and from cases including those in hospitals. The result will be love , honour and an honest fame with men and God. In this chapter we have seen how a medical elite arose during the formation of the Latin tradition of medicine. Ot her forms of practitioner are considered in this book only for the ways in which they were excluded by the elite (although historians are increasingly studying them). The central issue is that the Learned and Rational Doctor took control of , or emerged from, a series of increasingly formal schools. It has been argued t hat early Western medicine was partly a continuation of Methodism,94 but the exi gencies of the classroom led more teachers to Rationalism. The learned teacher g ained his authority partly from texts translated from the Arabic and Greek, and when medical teachers began to agree on which were the important texts and autho rs, they had the authority to determine the nature of medicine. The doctors were not without their critics and much of their rationality and learning can be see n as professional patter the Good Story used in defence. The recovery of Galenic medicine and Aristotelian natural philosophy provided a huge boost for this. Th e elite doctor in the classroom saw himself in a tradition reaching back to Hipp ocrates and Galen and inculcated in his pupils a loyalty to the medical traditio n and its fathers. 94 See Nutton, God, Galen and depaganization, p. 19.

chapter 4 Scholastic medicine i n t ro d u c t i o n The natural context of the Rational and Learned Doctor wa s scholastic medicine. The term scholastic is taken here in a simple sense to mean that which relates to the schools. The schools were the incorporated studia gen eralia, and within them, the incorporated medical faculty. Scholastic medicine ou rished most vigorously from the beginnings of the faculties in the late thirteen th century to the middle of the fourteenth century, when the Black Death arrived . In terms of personalities, it spanned the period from the oreat of Taddeo Alder otti to the death of Gentile da Foligno. This was the high point in the history of rational and learned doctors: their reputation was growing, their numbers wer e small and they were patronised by popes and monarchs.1 Instead of breaking dow n the period into smaller fragments, this chapter presents the story of the scho lastic doctor from entry into the studium to his practice of a potentially lucra tive trade.2 b e co m i n g a r at i o n a l a n d l e a r n e d d o c to r Wher e to go It was known in the twelfth century that Salerno and Montpellier were go od places to go to learn how to be a doctor. Bologna, too; and in the north, the size of the city of Paris gave many opportunities for medical practice, and 1 2 See Joseph Ziegler, Medicine and Religion c.1300. The Case of Arnau de Vilanova, Oxford (Clarendon Press), 1998, p. 19. It has been estimated that there were be tween one and six university-trained physicians for every 10,000 people in south ern Europe. See Luis Garca-Ballester, Michael McVaugh and Augustn Rubio-Vela, Medi cal Licensing and Learning in Fourteenth-Century Valencia (Transactions of the A merican Philosophical Society, 79, part 6), Philadelphia, 1989. Medicine was not always lucrative for teachers and practitioners. The doctors who secured a reta ined position in a great household generally did better. See Nancy Siraisi, Medi eval and Early Renaissance Medicine. An Introduction to Knowledge and Practice, Chicago (University of Chicago Press), 1990, p. 21. 88

Scholastic medicine 89 so was attractive to medical teachers.3 Indeed, until the middle of the fourteen th century, Bologna, Paris and Montpellier had a virtual monopoly of the teachin g of medicine.4 Prospective medical students knew these things, just as arts stu dents knew of the reputations of heroic teachers of logic.5 By the thirteenth ce ntury Salerno was fading as the new studia generalia developed, and by the early fourteenth century the language and doctrines of its masters could look old-fas hioned to a teacher in a studium such as Perugia.6 The differences between these places would have determined the choice of a student who wanted to study medici ne, and they seem to have arisen from the mode of teaching and the nature of the organisation of the studium. Although it was generally true that the masters ag reed on the nature of medicine and settled upon the Articella as a textbook comm on to collaborating masters and their pupils, there were considerable difference s between the studia. The consortium at Paris was an association of masters, as were those of Oxford and Cambridge, where it was also possible to study medicine .7 We have little evidence about early teachers in the two English universities, perhaps simply because medicine was a minor subject here; but it was much bigge r in Paris, and there too there were no notable commentators until the latter pa rt of the fourteenth century. Possibly the collaboration between the masters ext ended to teaching a common commentary, as happened in the treatment of natural p hilosophy at Oxford and probably Cambridge.8 3 4 5 6 7 8 See Cornelius OBoyle, The Art of Medicine. Medical Teaching at the University of Paris, 12501400, Leiden (Brill), 1998, pp. 1016. See Danielle Jacquart, Medical sch olasticism, in M. D. Grmek, ed., Western Medical Thought from Antiquity to the Mi ddle Ages, trans. A. Sugaar, Cambridge, Mass. and London (Harvard University Pre ss), pp. 197240, at p. 210. See R. W. Southern, The schools of Paris and the schoo l of Chartres, in R. L. Benson and G. Constable, Renaissance and Renewal in the T welfth Century, Oxford (Clarendon), 1982, p. 115: there was a bush telegraph for t he location of good teachers, and students refer to their teachers, not to their schools. Gentile da Foligno speaks of antiquus ille Maurus in his commentary on the third book of the Canon, f. 147r. This is in two volumes: (i) Tertius Can. Avic. cum amplissima Gentilis fulg. expositione. Demum commentaria nuper addita videlicet Jacobi de Partibus super fen VI et XIII. Item Jo. Matthei de Gradi sup er fen XXII quia Gentilis in eis defecit. This volume ends at fen 9 tract 1. (ii ) Secunda pars Gentilis super Avic. cum supplementis Jacobi de Partibus parisien sis ac Joannis Matthei de Gradi mediolanensis ubi Gentilis vel breviter vel taci te pertransivit, Venice (O. Scotus), 1522. See Faye Getz, Medicine in the Englis h Middle Ages, Princeton (Princeton University Press), 1998. Work on the Oxford g loss has hardly begun. See Charles Burnett, The introduction of Aristotles natural philosophy in Great Britain: a preliminary survey of the manuscript evidence, in Aristotle in Britain in the Middle Ages, ed. John Marenbon [Rencontres de philos ophie mdivale, 5], Turnhout, e e Belgium (Brepols), c. 1996, pp. 2150; Roger French , Teaching Aristotle in the medieval English universities: De Plantis and the phy sical glossa ordinaria, Physis, 34 (1997) n.s. fasc. 12, 225206. It is not yet know n whether the Articella contained a similar gloss.

90 The Latin tradition Many of the Parisian masters were also clerics, and nancial support from the chur ch was not uncommon, for both masters and students. Technically, a teacher on a stipend could not accept fees from his students (but he often contrived to accep t gifts) and perhaps advertising oneself as a heroic teacher by writing major co mmentaries was not appropriate. The churchs attitude to doctors was traditionally ambivalent and perhaps affected the status of the medical men in Paris, Oxford and Cambridge, the only universities in the thirteenth century where the pope al lowed theology to be taught. It is important to note too that the friars had sec ured a commanding position in the faculty of theology and the masters of arts we re obliged to teach a natural philosophy that served as a preliminary to the the ology of the friars.9 This philosophy was also in an institutional and intellect ual sense preliminary to medicine which, like theology, was a higher faculty. In contrast, the Italian studia were originally more vocational and the students w ho went there to learn a productive art formed themselves into their own incorpo ration and again at rst chose what they wanted to learn and who was to teach them . The organisation was secular rather than ecclesiastical as in the north, altho ugh the church retained the right to give the licence.10 In the south, too, medi cine was not a higher faculty but was taught alongside the arts, and graduation was in both disciplines. Some of these differences lie behind the fact that most of the commentators and medical authors of the period were Italian. Taddeo Alde rotti, Dino and Tommaso del Garbo, Mondino, Pietro dAbano, Torrigiano, Gentile da Foligno and others compiled monuments to the scholastic method which were also claims to a fame that could attract students. They wrote for their students (who m they often address directly) and for the promotion of their studia. They were in competition, for the collaborative enterprise between the masters of one stud ium did not extend to masters from another, and there was no feeling of a need f or an ethics of collaboration across the profession. The loyalty that the master strove for in his pupils did not extend further than them. These are the new he roic teachers of scholastic medicine. And although in theory the churchs licence to teach enabled the new master to teach anywhere the ius ubique docendi in prac tice each 9 10 See Roger French and Andrew Cunningham, Before Science. The Invention of the Fri ars Natural Philosophy, Aldershot (Scolar Press), 1996. In the Crown of Aragon on ly about 1 per cent of medical men were also clerics. See Michael McVaugh, Medic ine before the Plague. Practitioners and their Patients in the Crown of Aragon, 12861345, Cambridge (Cambridge University Press), 1993, pp. 72, 75. There was a g eneral withdrawal of clergy from medicine during the thirteenth century as the pr ofession consolidated itself in the universities and faculties. But in fourteenth -century Oxford a fth of the known medical scholars also studied theology. Ziegle r, Medicine and Religion, p. 8.

Scholastic medicine 91 studium was jealous of its own privileges and recognised those of others relucta ntly. It was therefore necessary to travel a considerable distance to get a medi cal education, often at great expense. Control and rewards What made this worthw hile for the prospective doctor was the nancial reward of practice. Throughout th e thirteenth century medical education was increasingly recognised and its pract ice controlled. We might properly call these changes professional, and their ult imate effect was the creation of the medical faculty within the university as a corporation with some features of autonomy. Early steps in the direction of regu lating the business of medicine were by royal decree. We have already seen that Frederick II, on the advice of his doctors, imposed a period of study of logic b efore the student began his medicine. Even before him, in 1140, Roger II of Sici ly was able to take the advice of Salernitan doctors (Salerno being within the K ingdom) and, rst, lay down what a proper medical education was and, second, perpe tuate a system of examination of candidates by municipal of cials and established doctors. This was long before the discovery and use of the new logic and the nat ural philosophy of Aristotle, but in the thirteenth century these two features c ame to be bound up in the conception of what a proper medical education was. It is notable that control of medical practice from the top of the political ladder was exerted in newly acquired territories, such as the Kingdoms of Jerusalem an d Sicily. These were initial moves and control then passed down through society ultimately to the doctors themselves. This was part of the formation of a profess ion and it depended in the rst instance on the doctors agreeing what medicine was, that is, who its heroes were and what a medical teaching curriculum looked like . Elsewhere, in the absence of an agreed medical curriculum in the Salernitan ma nner, similar events came later. The Kingdom of Valencia was another new territo ry, seized by the Christian Spanish from Islam in 1238. It was partially integra ted under a single monarch along with Catalonia and Aragon as the Crown of Arago n. In 1289 Alfons III enacted that medical men could practise only after examina tion by the proper of cers of the town and established physicians signi cantly, the enactment was modelled on another for lawyers. No university training is speci ed, and it is clear enough that this kind of royal initiative allowed on the one ha nd a system of guild-licensing, and on the other an environment in which respect for university training could lead to the introduction of new criteria into loc al licensing.

92 The Latin tradition After the Valencian decree of 1289, those who locally controlled practice in the cities and towns throughout the Crown of Aragon began to insist on the possessi on of a medical degree.11 Indeed, such royal initiatives often preceded the form ation of medical faculties within the studia and were part of the story about th e establishment of scholastic medicine as a discipline located in a corporation. Royal initiatives of this kind often had to be renegotiated, perhaps with a cha nge of monarch or as the desirability of university education became more obviou s. The Aragonese King Jaume I tried in 1272 to prevent anyone practising medicin e in Montpellier who had not received a degree from a university. Four years lat er Montpellier passed into the hands of the kings of Mallorca and before the end of the century it was a possession of the kings of France. Each change was an o pportunity for royal insistence on the possession of the medical degree for prac tice. The argument involved the bene t not only to public health but to the fame o f the studium.12 The university doctors agreed, because it gave them a monopoly of practice.13 The medical faculty What made moving to a university, selecting a master and paying fees worthwhile was the medical faculty. This was essentially a corporation of teaching masters who negotiated with civil and other authoriti es the right to a monopoly of the teaching and practice of a certain kind of med icine in exchange for a guarantee of quality. Medical faculties began to appear in the later thirteenth century; before that, the term facultas meant simply an area of study proper for a studium.14 The difference was that the faculty now ha d its own rules, of cers and oaths in addition to those of the studium as a whole. It was a professional body that took tribute from and protected those joining i t. For example, the members of the Parisian faculty in the middle of the thirtee nth century had to swear by the statutes of the university, its ceremonies and i ts power of cessation of teaching. But from 1270 to 1274 11 12 13 14 This did not apply to licences for surgery and to those issued to Arabs and Jews . Garca-Ballester et al., Medical Licensing, p. 12. Garca-Ballester et al., Medica l Licensing, p. 3. The value of a monopoly in securing quality of the product wa s clear to others, besides the doctors, for example to the papal legate acting i n Montpellier in 1220. See Darrel W. Amundsen, Medical deontology and pestilentia l disease in the late Middle Ages, Journal of the History of Medicine, 32 (1977) 40321, at p. 407. Medical teachers there had to have a licence from the bishop, a fter examination. See Pearl Kibre, The faculty of medicine at Paris, charlatanism , and unlicensed medical practices in the later middle ages, Bulletin of the Hist ory of Medicine, 27 (1953) 120, at p. 5. See Alfonso Maier , University Training in Medieval Europe, trans. D. N. Pryds, Leiden (Brill), 1994, u p. 76.

Scholastic medicine 93 the faculty issued its own statutes relating to its proper business of teaching medicine: the texts to be read, the manner of examination and inception.15 As in the case of most corporations, its privileges had to be acquired by constant ef fort; by 1330 the chancellor, the traditional master of the schools, was obliged to give the licence to anyone recommended by the faculty; and by 1336 the facul ty was claiming the right to control the apothecaries.16 Medicine in the norther n European universities tended to follow the pattern of Paris, where it was a hi gher discipline that followed the study of the arts. Cambridge had a medical fac ulty with its own statutes by the 1270s,17 and in Oxford the rst medical graduate appeared in 1312. Oxford medicine was miniscule in comparison to the big centre s abroad, and although the reading required for inception was similar to that st ipulated in Paris in 1270, sometimes the statutes cover arts and medicine togeth er, and for many medicine was simply a stage in an ultimately theological educat ion.18 In German-speaking countries, the medical faculties appear in the period after the Black Death.19 In the south, where medicine was not a separate faculty , formalisation of medical teaching occurred a little earlier, the rst recorded m edical degree in Bologna, for example, being awarded in 1268.20 Many faculties s eem to have been consolidated by incorporation in similar ways. In Montpellier, the long-standing tradition of medical teaching was formalised in new statutes o f 1309 which Arnau of Vilanova helped to draw up.21 An important aspect of incor poration was the promise taken by members of the group to act in concert. They u sed this in a political way, for example, in solving disputes by the threat of t he cessation of teaching. A studium was a major economic resource for a town and the threat of the masters and students going elsewhere was a serious one. It is well known that in the early thirteenth century there was a migration of schola rs from Paris to 15 16 17 18 19 20 21 See OBoyle, The Art of Medicine, pp. 19, 20ff. See Kibre, The faculty of medicine at Paris, p. 14. Damian Riehl Leader, A History of the University of Cambridge. V olume 1 The University to 1546 , Cambridge (Cambridge University Press), 1988, p . 203. See also M. B. Hackett, The Original Statutes of Cambridge University, Ca mbridge (Cambridge University Press), 1970. See Faye Getz, The faculty of medicin e before 1500, in J. I. Catto and Ralph Evans, eds., The History of the Universit y of Oxford. Volume II Late Medieval Oxford, Oxford (Clarendon Press), 1992, pp. 373405. See Vivian Nutton, Medicine at the German Universities, 13481500, in Roger French, Jon Arrizabalaga, Andrew Cunningham and Luis Garca-Ballester, eds., Medic ine from the Black Death to the French Disease, Aldershot (Ashgate), 1998, pp. 8 5109. See Siraisi, Medieval and Early Renaissance Medicine, p. 60. On Montpellier in general see Luke Demaitre, Theory and practice in medical education at the un iversity of Montpellier in the thirteenth and fourteenth centuries, Journal of th e History of Medicine and Allied Sciences, 30 (1975) 10323.

94 The Latin tradition Oxford and then from Oxford to Cambridge, which helped to consolidate the school s. The migrating masters took their students with them and needed little else sa ve books for their essential business, as their legitimacy as teachers was secur ed by the church, which had granted them licence to teach. Something similar hap pened in the Italian studia in the period we are now dealing with. Medicine had a somewhat slender beginning in the Italian cities; for example, the studium fou nded in 1224 in Naples by Frederick II encountered many dif culties. Even in Padua , where medical teaching began in 1222, the process of establishing a university medical faculty was not complete until 1350.22 Bologna was the mother of Italia n studia in terms of medicine, and when there was a papal interdict there, teach ers such as Dino del Garbo moved to Siena in about 13068. Here again in Siena the re had been teachers of medicine in the thirteenth century and attempts were mad e to attract Bolognese scholars; but these were not very successful until 1321 w hen a new wave of Bolognese scholars arrived. Siena now made serious efforts to create a proper, incorporated studium, borrowing money to pay salaries, but no p apal bull was forthcoming and Siena had to wait until 1357 for an imperial decre e enabling it to give degrees.23 There was likewise a migration from Bologna to Perugia in 1321, where the studium began to give the degree of doctor in arts an d medicine.24 Graduation was the key. Even where, as in Siena, the studium was t o be magisterial, the pattern of graduation was Bolognese,25 and in Padua part o f the arrangement negotiated in bringing in ex-Bolognese students was that the B olognese statutes would be followed.26 We have seen that graduation was the char acteristic act of the academic corporation and became most signi cant in medicine only after the consolidation of the medical faculty.27 In Italy this coincided w ith the development of the professional 22 23 24 25 26 27 Jacquart, Medical scholasticism. H. Rashdall, The Universities of Europe in the Mi ddle Ages, ed. F. M. Powicke and A. B. Emden, 3 vols., Oxford (Oxford University Press), 1936, vol. 2, p. 31. See also Peter Denley, Recent studies on Italian un iversities of the middle ages and renaissance, History of Universities, 1 (1981) 193205, at p. 198. The migration was the result of a dispute between town and gow n after the execution of a student. Rashdall, Universities, vol. 1, pp. 172, 589 . Denley, Recent studies on Italian universities. Rashdall, Universities, vol. 2, p. 16. See also Carlo Malagola, Statuti delle Universit e dei Collegi dello a S tudio Bolognese, Bologna, 1888, p. 129 and Maier , University Training in Medie val Europe, p. 39. u On the in uence of Montpellier as a model, and the nature of the examination, see Luis Garca Ballester and Augustin Rubio-Vela, Lin uence de Montpe llier dans le contr le social de la profession o e e mdicale dans le Royaume de Va lence au XIVe si cle, Histoire de lEcole Mdicale de Montpellier, e e ee Actes du 11 0e Congr s National des Socits Savantes, Montpellier (CTHS), 1985, pp. 1930.

Scholastic medicine 95 colleges; and that of Bologna, for example, was not really effective until the 1 260s.28 Logical reason and philosophical learning During this period changes wer e happening in logic and natural philosophy, the scholastic subjects so importan t to the Rational and Learned Doctor. Logic was, of course, fundamental to the a rts course and the subjects that depended on it, like medicine. But in the late thirteenth century and the early fourteenth logic was being greatly developed in the northern universities. The dialectic with which Pietro dAbano resolved probl ems between the philosophers and the physicians had been acquired in Paris, and, later, an Italian humanist such as Petrarch could express his hatred of monstro us logical constructions built by masters at Oxford.29 Italian medical men took to them more readily, and heroically vied with each other in resolving problems set up by the ever-growing theory of medicine. A Parisian training in arts and m edicine was seen as desirable by many in Italy the lord of Padua, for example, s ent twelve youths there at the suggestion of his physician (Gentile da Foligno). Part of what motivated the physicians to study logic was the belief that it app lied directly to the physical world, that is, that proper, demonstrative knowled ge of nature could be gained by arguing about and examining natural bodies. In f act, it was at this point that the learning and the reason of the doctor interac ted most directly. While most of medieval logic was a complex investigation of t he uses of words, in some areas it approached natural philosophy. One such area was the intension and remission of forms and the associated quanti cation of eleme ntary qualities, which was of great interest to the medical man. Much of this wa s an English business and it reached the doctors fairly quickly. Gentile da Foli gnos discussion of quanti cation may have been in uenced by Walter Burley, whose name he mentions.30 He may even have heard Burleys quodlibet at Bologna in 1341.31 28 29 30 31 Jacquart, Medical Scholasticism. Francesco Petrarcha, Invective contra Medicum, ed . Pier Giorgio Ricci, Rome (Storia e Letteratura), 1950. Petrarch thought of Eng lish logic as a monster wielding double-edged enthymemes. See also Brian Lawn, T he Rise and Decline of the Scholastic Quaestio Disputata , Leiden (Brill), 1993, p . 107. Another Italian humanist, Niccolo Niccoli, dreaded the very names of Engl ish logicians such as Ockham and Swineshead because of the effect they had on mo dern logic. See Roger French, Canonical Medicine. Gentile da Foligno and Scholas ticism, Leiden (Brill), 2001, p. 40. See Edith Dudley Sylla, The Oxford calculato rs, in Norman Kretzmann, Anthony Kenny and Jan Pinborg, eds., The Cambridge Histo ry of Later Medieval Philosophy, Cambridge (Cambridge University Press), 1990, p p. 54063, at p. 555.

96 The Latin tradition Gentiles pupil Tommaso del Garbo was more de nitely in uenced (as we shall see) by Wi lliam Ockham (d. 1347/9) so there seems little doubt that the medical men were k een to make use of medieval developments of logic. Burley was also concerned wit h the instant of time in which a thing came into and passed out of existence (Ar istotles generation and corruption) and he necessarily turned to physics. Ockham was also interested in what kind of entities exist in the outside world and he t oo approached natural philosophy. Aristotles Topics also deals with the real worl d (place, duration, number and so on) and it is in this rather physical context that Ockham discusses the theory of logical consequence. In non-logical language , this was a study of the relationship between statements and the inferences tha t could be drawn from them. It included insolubles such as the liar paradox: a man says he is a liar. Do you believe him? Is he a liar? A third area of logic that came to share a solution with consequences was induction, the attempt to draw u niversal statements out of repeated particulars. Induction was always imperfect, because observed particulars were always nite and could not add up to a complete ly general statement. The common solution to these problems lay in establishing a chronological distinction. The medievals made an induction as complete as poss ible by adding to it something like etcetera, meaning and so in all the other cas es: this was the same thing as saying that the general statement was true in resp ect of the time in which the particulars were observed.32 There was a special ph rase for this, which seems to have been used as much in medical texts as it was in logical works. This was ut nunc, as of now, and logicians such as Ockham used i t in contrast to absolute consequences.33 As of now could ease the dif culties of in solubles, and in the sense of the present conditions of the world34 it was useful in induction.35 Imperfect inferences (as in induction) depended more on the mean ing of terms than on the formal relation between them and so could be better ada pted to the physical world. The concept of ut nunc was well known to the medical man and it was a case in point of how a logical concept could be applied to the physical body. The Galenic Tegni described three states of health of the body: healthy, ill and neutral. But the scholastics wanted to know if a body 32 33 34 35 See French, Gentile, p. 127. See Eleonore Stump, Topics: their development and ab sorption into consequences, in Kretzmann et al., The Cambridge History of Later M edieval Philosophy, pp. 27399, at p. 295. William of Sherwood used the phrase in the previous century (p. 291). E. P. Bos, A contribution to the history of theori es of induction in the middle ages, in Klaus Jacobi, ed., Argumentationstheorie. Scholastische Forschungen zu den logischen und semantischen Regeln korrekten Fol gerns, Leiden and New York (Brill), 1993, pp. 55376, at p. 563. See Paul Vincent Spade, Lies, Language and Logic in the late Middle Ages, London (Variorum Reprin ts), 1988, item V, p. 119. Ockham also used the term: item I, pp. 910.

Scholastic medicine 97 that had been ill but had been made healthy in the past was truly healthy. They distinguished an absolutely or simply healthy body from one that was healthy at this moment in time: the one was healthy simpliciter, the other ut nunc. Health, of course, was a balanced complexion, which depended on the logically axiomatic elementary qualities that the doctor was obliged to accept without question fro m natural philosophy: it was all a physical as well as a logical business. The t erms ut nunc and simpliciter would have been known to educated doctors from the Latin translation of the commentary on the Tegni by Haly Abbas, a routine compon ent of the Ars Commentata. Whatever the Arabic words, Haly and his translator we re using familiar technical terms, and Haly distinguishes a medical ut nunc, the extended present moment, from the philosophical, the instant of time between pa st and future. He says these terms are commonly used in the arts and sciences. T he natural philosophy with which the new heroes of the fourteenth century extended their reputations came mostly from the north. It has been said that natural phi losophy was a latecomer to Italian medicine, perhaps introduced by Taddeo Aldero tti or the friars.36 In Oxford there is good evidence that men connected to the studium knew Aristotles natural philosophy before the end of the twelfth century, and teaching it went on when it was banned in Paris in 1210 and 1215. The bans were effective until the 1240s, when it was reintroduced from Oxford.37 After th e physical works became statutory for the arts course in Paris in the 1250s the consortium of masters reluctantly, under pressure from the pope, admitted Thomas Aquinas to their membership. We have seen that Aquinas was a very important gure in making Aristotelian natural philosophy consistent with Christianity and it s eems that he, like Pietro dAbano later, came north for his Aristotle. The later L atin medical tradition The arrangements for teaching in the faculty did not enti rely blot out the earlier system in which the pupil sat at the feet of an older style of heroic teacher. On entering the faculty the pupil attached himself prim arily to a certain master, who had a major part in teaching him and who promoted him at graduation, that is, the master took him for examination by the 36 37 See Nancy Siraisi, Taddeo Alderotti and his Pupils. Two Generations of Italian M edical Learning, Princeton (Princeton University Press), 1981. Tradition has it that Roger Bacon took Oxford natural philosophy to Paris, but the commentaries o f Adam of Buck eld are much more likely to have been the vehicle. See E. J. French , Adam of Buck eld and the Early Universities, PhD thesis, University of London, 199 8.

98 The Latin tradition masters peers. It was, of course, central to the success of the incorporated facu lty that the collaborating masters agreed on the nature of medicine, its authori ties, and the texts on which they examined the candidate. In short, they knew wh at the medical tradition was, and they placed themselves in it. The masters also drew their pupils into the Latin medical tradition. The teaching master strove to develop a classroom culture in which his pupils had not only to understand, but to believe what he told them. His approach was to begin with the Ciceronian, rh etorical, device of making his audience well disposed and attentive.38 There is a discernible moral loading in what some masters said to their students about me dicine. Partly it was the duty of the medical man not to question the natural-ph ilosophical axioms on which the theory of medicine rested. As we saw in the prev ious chapter, the rules of subalternation made it in a sense improper for a medi cal man to try to question these axioms. Partly, too, the correct translation of theory into practice was a medical path that the good doctor could not decently l eave in treating his patients.39 The moral tone of the exhortations of some mast ers was consonant with the almost religious respect accorded to the ancient auth orities. The ultimate aim of medical education was, by the devices of commentary and disputed question, to make the ancients so clearly understood it was as if they were in the same room, speaking.40 This involved dif culties. In the northern universities, the student coming into medicine had spent a statutory amount of time in the arts, particularly philosophy. In the south, the philosophy and medi cal courses were taken in parallel, but the student had to be familar with philo sophy before being able to understand the bulk of medical theory. But we have se en that the physician took over where the philosopher nished, and philosophical a uthorities were different. Quite apart from subalternation, philosophy said some things about the human or animal body that differed from what the medical autho rities had declared. The medical teacher had to explain 38 39 40 The practice was not uncommon in the preliminary material of commentaries on nat ural philosophy. See London, British Library, Harleian 3487, f. 173r: In prohemi o huius libri tria facit primo ut reddat auditorem benevolum . . . secundum ut r eddat docilem . . . tertio ut reddat eum attentum. The theory of teaching was an ongoing topic of discussion among scholastic doctors and their sources. See Fre nch, Gentile, p. 24; also Danielle Jacquart, LEnseignement de la mdecine: quelques termes e fundamentaux, in her La Science mdicale Occidentale entre deux Renaissanc es, Aldershot (Variorum), e 1997, item XII. See Roger French, Gentile da Foligno and the via medicorum, in J. D. North and J. J. Roche, eds., The Light of Nature, Dordrecht (Kluwer Academic Publishers), 1985, pp. 2134. See Roger French, Where t he philosopher nishes, the physician begins: medicine and the arts course in thir teenth-century Oxford, in Cornelius OBoyle, Roger French and Fernando Salmon, eds. , El Aprendizaje de la Medicina en el Mundo Medieval: las Fronteras de la Ensena nza Universitaria, Granada, 2000 (Dynamis, 20, 2000).

Scholastic medicine 99 this to his arts-educated pupils, and why it was that they now had to give their assent to medical doctrines and authorities. The career of the medical teacher highlights the case, for it was common for a university master to spend some yea rs teaching philosophy before coming to teach medicine, and comprehensively chan ge his medical hat. Behind these circumstances was the medical faculty as an inc orporation, with its internal rules or ethics. In fact the situation was radically different from that of the educators of the late twelfth century and before, wh o had discussed the divisions or branches of philosophy regarded as the whole body of knowledge or knowledge of God-and-His-works.41 It was the hope of such men t hat the damage done to human knowledge by the Fall could be repaired for Christi an purposes. But Aristotle changed all this. The arrival of the new logic and th e physical works seemed to provide a programme for the creation of certain knowl edge about the natural world which, unless Aristotle was read in the right way, seemed to be without a creator. The new universities were peopled by specialists who promoted their own disciplines rather than working for the unity and repair of all knowledge. This had an institutional basis in the university, and when, for example, the Parisian philosophers began to grow con dent of the range and pow er of philosophical enquiry, they brought upon themselves the theologians condemn ations of 1277.42 The consolidation of the medical faculties at the end of the c entury and in the early fourteenth extended this process, effectively establishi ng boundaries round the discipline of medicine. The academic sciences were no long er a family of philosophy centred on the creation and the created, but a concate nated chain of separate disciplines subalternated back to the study of being in ge neral, Aristotles Metaphysics. m e d i c a l t e x ts Medical learning It was obs erved in the previous chapter that the rationality of the Rational and Learned D octor was acquired from the new logic of Aristotle, which 41 42 On the divisions of philosophy see Gundissalinus, De divisione philosophiae, ed. Ludwig Baur [Beitr ge zur Geschichte der Philosophie des Mittelalters, 4, gen. e d. C. Baeumker], M nster, 1906; Bro. a u Charles Henry Buttimer, ed., Hugonis de Sancto Victore Didascalicon. De Studio Legendi, Washington, DC (The Catholic Uni versity of America Press), 1939. See Deni e, Chartularium, vol. 1, p. 543. See als o Edward Grant, The effect of the condemnation of 1277, in Kretzmann, Kenny and Pi nborg, Cambridge History of Later Medieval Philosophy, pp. 5379; see also his Issu es in natural philosophy at Paris in the late thirteenth century, Medievalia et H umanistica, n.s. 13 (1985) 7594.

100 The Latin tradition became available shortly before the Aristotelian physical works were translated in the late twelfth and early thirteenth centuries. The other half of this story is the doctors learning, the technical content of his discipline. We have seen t hat in the new universities the Ars medicine version of the Articella was replac ed by the Ars commentata. This remained the basic textbook of medicine down to t he early sixteenth century. Sometimes the brief tracts at its beginning the intr oduction by Joannitius and the little treatises on prognostication from the puls e and urine by Philaretus and Theophilus were dropped because they seemed too pr eliminary for an increasingly sophisticated audience. They were often replaced b y longer works on the same topics by Isaac Israeli. In fact, the Greek and Byzan tine inner core of medical education was vastly supplemented by an in ux of Arabic material. Isaacs treatises on diets, in general and particular, became statutory . The Canon of Avicenna, translated in the eleventh century by Gerard of Cremona , came slowly into use, although it was not equally popular everywhere, for exam ple in Montpellier. Although a huge compilation, its highly systematised content s made it a useful teaching text.43 Avicenna sets out in the same formula the an atomy, complexion, diseases and treatment of all parts of the body, from head to toe. He lists medicines appropriate for various conditions in a systematic way; he also lists diseases separately. He gives rules for making compound medicines and systematically lists the antidotes that can be so constructed. The Canon wa s effectively the medical mans bible, giving chapter and verse for each disease, bodily part or treatment. Identifying a disease for the medical man was capitulat ion, that is, nding the chapter in which Avicenna had described it. There were Ara bic and Hebrew versions of the text and assiduous scholars could make textual co mparisons. But there were problems. Acquiring a copy of the whole text would hav e been very expensive, and when the Canon featured in statutes it was a question of which books should be read. It is even arguable that acquiring good copies o f such large and central texts may have been one of the advantages of medical ma sters agreeing to collaborate in the new studia. Moreover, to be useful in teach ing, the text needed a commentary, which was hardly achieved before the Black De ath. Another major text was Averroes Colliget, translated in 1286 and so, in prin ciple, available to the faculties consolidated by the early fourteenth century. 43 See also Nancy Siraisi, Changing concepts of the organization of medical knowledg e in the Italian universities: fourteenth to sixteenth centuries, in La Diffusion e delle Scienze Islamiche nel Medio Evo Europeo, Rome (Laccademia), 1987, pp. 2933 21.

Scholastic medicine The New Galen 101 To this assemblage of medical authorities was added another kind of medical lite rature that has been called the New Galen of the late thirteenth century.44 Its im portance for the learning of the doctor was almost as great as the new logic had b een for his rationality. It arrived in the 1270s and 1280s, at a time, that is, when the universities began to allow the consolidation of medical faculties. Whe n in 1309 Arnau of Vilanova gave advice to Pope Clement V for a new curriculum a t Montpellier, it centred on the New Galen texts on complexion, crisis and simpl es.45 The New Galen was a professional business, and it has been argued that it widened the doctors intellectual world in a dramatic way.46 The theoretical parts of the New Galen were concerned with the theory of complexion, the fundamental construct of medieval medicine. Complexion was made up of the four elementary qu alities that were so basic to the peripatatic world picture. Medicines and foods had complexion. Health was a balanced complexion, illness an unbalanced complex ion and therapy was a restoration of complexion. Scholastic medicine reached its height of elaboration when the theorists applied the mathematics of quanti cation to the qualities that made up complexion.47 Scholastics such as Dino del Garbo and Gentile da Foligno wanted to know in mathematical terms how intension and 44 45 46 47 See Luis Garca-Ballester, The New Galen: a challenge to Latin Galenism in thirteen th-century Montpellier, in Klaus-Dietrich Fischer, Diethard Nickel and Paul Potte r, eds., Text and Tradition. Studies in Ancient Medicine and its Transmission Pr esented to Jutta Kollesch, Leiden (Brill), 1998, pp. 5583. De Complexionibus, De Malicia Complexionis Diverse, De Simplici Medicina, De Morbo et Accidenti, De Cr isi et Criticis Diebus, De Ingenio Sanitatis. It is notable that De Iuvamentis M embrorum and its structural functional anatomy is not included: the rationality is still complexional. See Michael McVaugh, The nature and limits of medical cert itude at early fourteenth-century Montpellier, Osiris, 2nd series, 6 (1990) [Rena issance Medical Learning. Evolution of a Tradition, ed. Michael R. McVaugh and N ancy G. Siraisi], pp. 6284. See also Luis Garca-Ballester, Medical ethics in transi tion in the Latin medicine of the thirteenth and fourteenth centuries: new persp ectives on the physicianpatient relationship and the doctors fee, in A. Wear, J. Ge yer-Kordesch and R. French eds., Doctors and Ethics: The Earlier Historical Sett ing of Professional Ethics, Amsterdam (Rodopi), 1993, pp. 3871, at p. 39. He de nes the New Galen as De Naturalibus Facultatibus, De Interioribus (De Locis Affecti s), De Morbo et Accidenti, De Complexionibus, De Malicia Complexionis Diverse, D e Crisi, De Creticis, De Ingenio Sanitatis, de Medicinis Simplicibus, and variou s works on the pulse. McVaugh, Medical certitude, p. 66. See also Luis Garca-Balles ters introduction to Luis Garca Ballester, Roger French, Jon Arrizabalaga and Andre w Cunningham, eds., Practical Medicine from Salerno to the Black Death, Cambridg e (Cambridge University Press), 1994, p. 10. See Danielle Jacquart, De crasis a c omplexio: note sur le vocabulaire du temprament en Latin e mdivale, in her La Scienc e mdicale Occidentale entre deux Renaissances, Aldershot (Variorum), e e e 1997, item VI. The scholastic doctor also quanti ed the qualities of medicine in determi ning the appropriate dose. The work of Michael McVaugh is central to this topic. See his edition of Arnau de Vilanova Opera Medica Omnia. II Aphorismi de Gradib us, Granada-Barcelona (University of Barcelona Press), 1975 and the fuller editi on in the same series, 1992.

102 The Latin tradition remission of qualities interacted and what the perfect complexion was. The langu age they used was that of the Merton calculators and their discussions were high ly elaborate. The body itself worked by the actions of the qualities of the comp lexions of its parts. We can distinguish this complexional rationality from a four teenth-century anatomical rationality which was associated with a wider dissemin ation of Galens De Usu Partium, which was based on the practice of dissection, wi th which, too, Galen had made his vivisectional demonstrations in Rome.48 We tak e a closer look at this below. To some extent the New Galen divided medical opin ion on whether the old Greek or the much more recent Arabic authors should be gi ven priority. But everyone agreed that these authors were authority: these were the names that medical professionals used to justify their beliefs and actions a nd which non-professionals could not challenge. They were part of the language o f authority that the doctor used with his patient, his pupils and the law-givers . d i a l e c t i c i n ac t i o n Disputations Like other university-educated m en, the doctor was rational in a dialectical way, in using Aristotles logic and i ts medieval developments.49 He was trained in this according to statutory rules that governed how often pupils and masters should dispute. In most universities masters were obliged to respond to questions, including quodlibets.50 Bolognese doctors who were entitled to teach had to dispute once a week and make arrangeme nts for the publication of their solution to the questions. Physicians and philo sophers of standing were also obliged to dispute on or near feast days; we know that Dino del Garbo did so in Bologna and that he once disputed with Gentile da Foligno in the street.51 We have seen how, even in the twelfth century, logic wa s popular in the heroic schools, and now that the Posterior Analytics of Aristot le seemed to supply a programme for investigating the natural world, its range a nd power were greatly increased. Disputations were exercises in sustaining one t hesis over another by questioning its premisses or logic, and an important techn ique was the distinction where different 48 49 50 51 For a wider discussion, see Roger French, Anatomical rationality, in French et al. , Medicine from the Black Death to the French Disease, pp. 288323. In the later t hirteenth century Paris was an important in uence on European logic. Pietro dAbano, for example, had studied there. By the early fourteenth century Oxford logic im pressed some Italians and depressed others. See Maier , University Training in Medieval Europe, p. 131. u See French, Canonical Medicine, pp. 456.

Scholastic medicine 103 meanings could be drawn out of a single term. The result could be an exciting or noisy meeting (we have noted Bacons complaint that doctors were too anxious to d ispute). They were also public affairs and provided an external face of universi ty rationality, whether medical or otherwise. Dubia The written form of disputat ion was the dubium, the disputed question. This had a rigid and complex form and some disputed questions were hugely elaborate. These two features have repelled both sixteenth-century Hellenists and humanists and some later historians, but it will serve our purposes to take a quick look at the form. A disputed question was one that arose from the study of a text and normally took the form of a que stion that expected a positive answer, beginning An . . . or Utrum . . . (Whether . . .). Then came a section in which all the negative arguments were brought for ward. Ideally, the form of the argument was syllogistic, with both major and min or propositions being drawn from the text, from the words of another authority o r from sensory experience. These arguments were then attacked and destroyed in t he same way, leaving the postive answer unscathed. Along the way other small obj ections or instances were brought up and disposed of, as if to show that all possi ble objections could be satis ed. Commentators such as Dino del Garbo and Gentile da Foligno in the rst half of the fourteenth century commonly put the objections in the mouth of the reader, a sort of student- gure: But you will at once say . . ., Sed statim tu dices . . . Glosses, commentaries and the new heroes The disputed question was such an important feature of high scholastic medicine that we need to know something more of its background. Because disputed questions were matte rs of theory, they involved a great deal of natural philosophy, and whereas full y-blown medical disputations seem to have happened only in the incorporated facu lties, in the earlier arts course they evolved as a new type of teaching. The rst versions of the physical works of Aristotle were taught by means of commentary or gloss which ran parallel to the text and explained what was going on in it, a nd solved dif cult points of language and textual variation. These were in a stron g sense personal interpretations, and in Oxford, for example, we know that the g loss written on some of the physical works by their translator, Alfred of Shares hill, was in use in the early thirteenth century. Only a generation

104 The Latin tradition later, Oxford commentators such as Adam of Buck eld were laying much greater stres s on the logical structure of the text than Alfred had done. Although Adams comme ntary was also a personal interpretation, its form was dictated by the logical s tructure of Aristotles text, and it could be and was used by other teachers acros s Europe. Indeed, it was an aspect of the collaborative teaching of the corporat ion of the masters of arts at Oxford that they adopted, for half a century or so , a common gloss to explain the physical works. Something similar seems to have been the case with medicine. The two similar commentaries on De Sectis by John o f Alexandria and Agnellus of Ravenna may be variants of a common commentary. The same may be true of commentaries on the Articella.52 As this textbook developed , so the commentaries of Galen on the Hippocratic texts it contained were widely adopted. But, probably towards the end of the thirteenth century, there was a c hange in teaching methods in philosophy from commentary to disputed question.53 Because of the close association of philosophy with medicine, it seems likely th at when the medical faculties were consolidated, they adopted the disputed quest ion as a major technique of teaching. Disputed questions did not cover the medic al texts comprehensively, but enquired very deeply into certain points. Each mas ter could handle different points or the same points differently. It is apparent that they were in competition in doing so: medical teachers in Bologna, Perugia and Padua, for example, strove to out-perform each other in commenting on the C anon of Avicenna. They were, in fact, the new heroic teachers of the fourteenth century. They were partly competing for students, and when Dino del Garbo for a while taught from Turisanus Plusquam Commentum as if it were his own, the size of his class rose considerably.54 The loyalty expected by a teacher of his pupils did not extend from one studium to another. Even the teachers nicknames are evide nce of this: Turisanus was the Plusquam Commentator because he commented more tha n anyone else.55 Gentile was the Speculator 52 53 54 55 Paul O. Kristeller, Bartholomaeus, Musandinus and Maurus of Salerno and other ear ly commentators of the Articella, with a tentative list of texts and manuscripts, Italia medioevale e umanistica, 19 (1976) 5787. See D. A. Callus, Introduction of Aristotelian learning to Oxford, Proceedings of the British Academy, (1943) 22981 . See OBoyle, The Art of Medicine, pp. 2012 for nature of early medical commentari es. See Per-Gunnar Ottosson, Scholastic Medicine and Philosophy. A Study of Comm entaries on Galens Tegni (c. 13001450), Uppsala (Bibliopolis), 1982, p. 23. Turisa nus came from Florence, studied arts in Paris sometime between 1305 and 1319 and began to teach and practise medicine there. He returned to Bologna, where he ha d rst studied medicine under Taddeo. The Plusquam commentum was nished in Bologna. See also OBoyle, The Art of Medicine, p. 34.

Scholastic medicine 105 because he saw deeper into problems of theory.56 Pietro dAbano (1257c. 1315) was t he Conciliator because he solved questions disputed between philosophers and phy sicians.57 In contrast, in the north, there were fewer heroic commentaries: hard ly any on the Articella in Paris in the thirteenth and fourteenth centuries,58 w here the masters were more concerned with securing positions in important househ olds,59 and the silence of English commentators is commensurable with the small size of their faculties.60 ph y s i c i a n s a n d ph i lo s o ph e r s Differe nces and resolutions Students attending or reading disputed questions were perfo rming classroom exercises that re ected the nature of the incorporated faculties. As an example, let us take the disputations of Pietro dAbano, which were widely r ead by fourteenth-century academic teachers of medicine. His book is a collectio n of differences which were likely to occur between philosophers and physicians. I t was therefore popular among those whose statutory obligations compelled them t o constantly nd new topics for disputations. For the same reason, right up to the Renaissance, scholars searched through medical works such as commentaries to pi ck out and list separately dubia and questiones. Pietros Conciliator also provide d model answers in a dialectical manner that he may have acquired in Paris. In i t Pietro is writing as a medical man who has gone beyond the point where the phi losopher nished and his overall (but not explicit) purpose is to justify the form that medicine had taken in the studia. The differences are not therefore randomly chosen, but deal rst with the questions that were most fundamental to scholastic medicine of the faculties. The rst of them is Does the physician need the theoret ical sciences? This is followed by Does the physician need logic? and the third is I s medicine a science? Now, it is clear that the answer to all three is Yes, because a medicine that was a mere 56 57 58 60 See, for example, the colophon of the second volume of Gentiles commentary on the third book of the Canon; the term was contemporary with him. Pietro translated several works from Greek to Latin and taught in Paris from before 1295 to about 1306. He was also known as The Great Lombard. The rst draft of Conciliator was co mplete by 1303 and was based on his previous ten years of teaching. The nal versi on dates from 1310 when he was teaching medicine and astrology in Padua. See OBoy le, The Art of Medicine, p. 34 and Siraisi, Medieval and Early Renaissance Medic ine, pp. 60, 81. 59 Jacquart, Medical scholasticism. OBoyle, The Art of Medicine, p . 199. Indeed, medical doctors educated in England cannot be found before the fo urteenth century. Getz, Medicine in the English Middle Ages, p. 17.

106 The Latin tradition productive art (not a scientia) without logic, the arts or philosophy, would be taught by experience and example and hardly at all by words. But the university teacher was full of words. He wanted to show that medicine had the intellectual standing of a scientia and was indeed a development of the Aristotelianism of th e arts course. Above all (as we shall see) he wanted to avoid creating the idea that medicine was empirical. Art or science At the same time the scholastic doct or wanted to claim that his medicine was effective in physical, practical terms, for otherwise the vast intellectual structures of commentaries and disputed que stions would appear as booklearning only. He accordingly argued that it was the very knowledge and reason of the Rational and Learned Doctor that made his medic ine effective. Pietros were model answers because of the exhaustiveness of the me thod: arguments against, arguments for, de nitions and distinctions, citations of authority, demonstration of the truth and removal of objections, always in that order. It was strictly logical and, more loosely, also dialectical, because the opposing arguments were ultimately shown to result in absurdity. This was the ul timate scholastic test when knowledge was to be constructed or validated. The me thod had a useful exibility. One of the strongest arguments against the physician needing the theoretical sciences was that Hippocrates had not known them. Indee d, they had not then been invented. It was commonly thought that Hippocrates had such powers of mind that he did not need the aid of the theoretical sciences; P ietro says it was as if God had created Hippocrates as infallible in order to pr ovide man with a perfect medical tradition.61 This tradition, although pure and divine (says Pietro), needs to be interpreted, and this is where the sciences ar e useful for mortals lesser than Hippocrates. In this way Pietro saw himself in a medical tradition that had ancient and almost divine origins and could be inte rpreted and re ned by ancients and moderns. Like a number of medical men re ecting o n the nature of their subject, Pietro gave it a history to explain and justify i ts present. It was Aristotle (says Pietro) who said that the most necessary of t he arts and sciences, including medicine, were invented rst. The rst medical god w as Aesculapius, whose sons fought in the Trojan War and who were followed by a s tring of heroes down to Democritus, traditionally seen 61 Pietro dAbano, Conciliator Controversiarum, quae inter Philosophos et Medicos ver santur, Venice (Heirs of L. A. Giunta), 1565, f. 3r.

Scholastic medicine 107 as a pupil of Hippocrates. Pietros little history does not extend beyond Galen, w hose description of the three sects Pietro adopted for his own time. re co n s t ru c t i n g a n c i e n t m e d i c i n e Doctors and the history of medicine We can learn a little more about the Latin tradition of medicine by noting one o r two other things about how Pietro and others saw the history of medicine. It w as (in ending with Galen) a Greek business that had now to be presented in a Lat in form. Scholarly doctors (such as Pietro) knew and translated from Greek62 but their audience pupils, patients, important learned men communicated at the form al level in Latin. Latin medical texts were a professional matter. They had medi cal gods and heroes (Aesculapius, Podalirus, Machaon) who could be cited without dif culty in a medieval Christian context. At really important places in big comm entaries, Gentile and Dino address the Christian God directly in the form of a p rayer, but when they needed authority for their piety it came from the pagan phi losophers of old, or the much more recent Muslim writers. They do not cite bibli cal authority or the Sentences, which were the professional arena of the school theologians. It is notable that an author such as Pietro, who saw the history of medicine ending with Galen, made considerable use of Arabic authorities. Indeed , the doctors had done much to remedy the situation that provoked Bacons criticis m. Commenting on Avicennas Canon was a lifes work for Gentile. After its translati on in the 1280s Averroes Colliget became increasingly used as an authority. Haly Abbas and Haly Ridwan remained popular. In Latin translation these authors provi ded much material for European medicine, but they were not part of medical histo ry, the self-conscious Latin tradition. That tradition indeed had as its major c oncern the reconstruction of ancient medicine. Not only was the aim of education to be able to understand the ancients as though they were present and speaking in the same room, but the circumstances and the practice of the ancients were to be reconstructed. Galen was the best candidate for this. He wrote widely, and o ften about himself. The New Galen of the early fourteenth century was thus in th e rst instance a literary construction brought about by a determined effort to re nder the old Galen into Latin in the interest of better medicine. Galens 62 Pietro says he translated the Aristotelian Problems. See Conciliator, f. 3r.

108 The Latin tradition ideals and even circumstances now became medieval ideals and circumstances. An i mportant text was Galens small De Sectis ad Introducendos which, as we have seen, was the rst work in the Alexandrian curriculum and which attracted commentary ea rly in the Middle Ages. Those commentaries, designed by professional teachers fo r a formal classroom, identi ed with the Rationalist Sect of Galens Rome. The same was true of the later Middle Ages, when the faculties had become incorporated wi thin the universities: teachers who had reasons to make their medicine as philos ophical and logical as possible naturally selected the Rationalists as their own predecessors. We can usefully return to Pietro dAbano to look at one form of the argument. His point of departure is De Sectis and he begins by dismissing the M ethodists as unskilled because they thought only in universals and despised part iculars. In contrast, the Empirics considered only particulars and despised univ ersals. Only one of the three sects used both in a balanced way, and this was th e Rationalist Sect, the logici, sive rationales (Pietro does not use the less att ering term dogmatici).63 It is apparent that Pietro is using terms of contempora ry logic which almost certainly did not represent the three sects of Galens Rome; moreover he has, in reconstructing Galens circumstances, brought those into his own time too. This brings us to an important point. Scholastic teachers identi ed with the Rationalists, for reasons we have met in outline. They identi ed with Gal en and adopted his enemies as their own. While Galen had some sympathy for empir ical procedures within medicine, the scholastics had none. There were practition ers in their own day who lacked theory because they had not been educated in a u niversity or medical faculty. This did not stop them practising, for there were local means of licensing them. They were, in fact, rivals to the university doct ors in the medical marketplace, and the doctors complained greatly that the lack of theory meant bad medicine: their own claim to the monopoly of internal medic ine was, after all, based on the supposition that a theory-directed medicine was more effective. The major selling-point of scholastic medicine was that it gave the causes of things. From 1271 the Paris faculty argued that the lower ranks o f the profession acted randomly in their prescriptions because they did not know causes; in the next two centuries knowledge of causes came increasingly with Ar abic medicine.64 The New Rationalists thus invented the New Empirics. And 63 64 Conciliator, f. 3r. Jacquart argues that there was no suitable word for cause in m edicine before this. See Danielle Jacquart, The introduction of Arabic medicine i nto the West. The question of etiology, in her La Science mdicale Occidentale, ite m III. e

Scholastic medicine 109 circumstances were now different from Galens Rome, for where the power of the fac ulty operated it could prosecute at law the unlicensed practitioner, the mere em piric. Rationalising Hippocrates In distancing themselves from the new empirics, the new rationalists created a problem for themselves. We have seen that they w anted to show that their medicine was effective, but they could not afford to em phasise observation and experience, which looked rather empirical, at the expens e of theory. Worse, the great Hippocrates, widely revered as the Father of Medic ine, was it was generally admitted without the arts and sciences. He was surely not, then, empirical? The Learned and Rational Doctors hastened to his rescue. P ietro dAbano argued that Hippocrates could be regarded as the rst rationalist beca use he wrote his medicine down. As we have seen, a more usual explanation was th at the hugeness of Hippocrates mind enabled him to use naturally what only later came to be codi ed with the aid of dialectic. Pietro argues in a similar way in ex plaining how Hippocrates used, without logic, the three doctrines that Galen lat er set out at the beginning of the Tegni. This could almost be the programme of medieval medicine: to explain the medical wisdom of Hippocrates, especially in t he Aphorisms, with the dialectical apparatus set out by Galen in the Tegni.65 An other way of making Hippocrates a rationalist was to argue that although life wa s short and the art was long, his great mind had been able to frame valid genera lisations or, in medieval terms, universals. The Aphorisms seemed to be not only oracular pieces of wisdom but universals which could be used as axioms. They co uld be used as unassailable starting points in a rationalist argument, like the philosophical principles that came into medicine by subalternation. Opposites cur e opposites became known as the law of Hippocrates and was the fundamental and unqu estionable axiom at the root of the whole theory of complexion.66 As we have see n, medieval logic as used in medicine derived the premisses of its syllogisms fr om earlier demonstrated knowledge, from sense observations and from the sayings of great men: Hippocrates had a rationalist role here too. In this way aphorisms tted neatly into the logical structure of medical writing. But the medical mans l ogic was not a paper or verbal exercise: words signi ed things, and it was things that showed logic. The very cohesiveness 65 66 These seem to be the most heavily glossed works in the Articella. Pietro says it does not need proof, being logically and medically axiomatic. Like the whole is greater than the parts, it is a common conception of the soul. Conciliator, f. 6r .

110 The Latin tradition and connectedness of the physical world demonstrated logical relationships betwe en its parts. It was, of course, an Aristotelian world, but the order and design that the medieval doctors saw in it may re ect also the rationality of the Creato r. Aphorisms could be treated as expressing the natures of things, and medical m en found their axiomatic authority an attractive form of expression. Some author s sought related forms. Gentile da Foligno looked for canons that were rules of co rrect procedure in medicine. He was commenting on the Canon of Avicenna, of cour se, but as he used the term it had extensions to canon law and canonical religio us life.67 Bernard of Gordon also used canons of procedure68 and other authors, such as the Bolognese doctors, derived rules, regule, of procedure. There had be en a suggestive parallel in theology. As revealed knowledge the Bible was the au thority, greater even than Hippocrates, whom, as Pietro dAbano said, God had crea ted as a foundation of the medical tradition. But the Bible was of little use in serious discussions with in dels or heretics, who did not believe that it was the word of God. The new theology of the thirteenth-century schools was accordingly sometimes expressed dialectically, when its authority was derived from reason. There were rules of the Christian faith which eschewed quotation of the sacred pag e and moved from one proposition to another.69 This may have owed something to t he mode of procedure in geometry, but the result looked rather like an aphorism. An idea useful in conjunction with this was common conceptions of the soul, state ments based on reason which, once grasped, could not be denied by any rational m an. For Pietro dAbano, the law of Hippocrates as a common conception of the soul wa s axiomatic and needed no proof. Aphorisms and new authority Arnau of Vilanova a lso chose to express some of his medical wisdom in aphorisms or rules. The rst of them are mostly general and relate to the nature of medicine and the doctor. Th ey are, that is, deontological and designed to guide the doctor in good practice . But it is possible that Arnau 67 68 69 French, Canonical Medicine, pp. 1114 and ch. 5. Luke Demaitre, Dr Bernard de Gord on: Professor and Practitioner, Toronto (Ponti cal Institute of Mediaeval Studies) , 1980, p. 130. See, for example, the De Arte seu Articulis Catholice Fidei of A lain of Lille, in J. P. Migne, Patrologiae Cursus Completus (Latin series), Pari s, 1866, vol. 210, p. 594. It has been more recently attributed to Nicholas of Am iens: see C. H. Lohr, The pseudo-Aristotelian Liber de Causis, in Jill Kraye, W. F . Ryan and C. B. Schmitt, eds., Pseudo-Aristotle in the Middle Ages: The Theolog y and Other Texts, London (Warburg Institute), 1986, pp. 5362.

Scholastic medicine 111 had in his mind other readers in addition to his colleagues. Some of the aphoris ms are rather obvious (such as the course of action is determined by the desired effects) and some seem designed to de ect criticism of the doctors. Arnau rst remind s his readers that all good ows down to him from God and that he serves God by pr actising properly (we can recall that in earlier criticism doctors had been accu sed of elevating nature above God). He then declares that the doctor who practis es for money will fail (the greed of doctors had been a byword). Further aphoris ms deal with the roles of reason and experience in practice and insist on the ne cessity of knowing the variation between individuals and the control of regimen, that is, the Rational and Learned Doctors preferred form of practice. It would h ave done their image no harm at all if these aphorisms had also been read by the ir patients. Arnau also called his aphorisms canons, with the range of connotation s implied by Gentile. They were also parables, parabole, a term which tapped into a Christian range of meaning.70 The essence of the parable was allegory, in whic h a simple story of a particular happening revealed a more general truth. As in Aesops fables, a particular dog in a manger or a fox eyeing the grapes illustrate s a deeper and wider principle, the moral. In the Middle Ages there were (at lea st) two ways of reading the scriptures: the literal (as William of Conches read the story of the creation of Eve) and the moral, or spiritual, the inner and dee per meaning.71 That is, the Fall had rendered man incapable of understanding the direct voice of God, which he could now best hear by way of allegory and the us e of the arts and sciences. Arnaus medical parables expressly seek to reveal a sp iritual meaning,72 and the terms of his medical learning were used as religious metaphors. Arnau was perhaps unusual in the intensity of his piety,73 and wrote directly religious works of a heterodox nature which led to his arrest.74 70 71 72 73 74 See also Jole Agrimi, Aforismi, parabole, esempi. Forme di scrittura della medici na operativa: il modello di Arnaldo da Villanova, in Le Forme della Communicazion e Scienti ca, ed. Massimo Galuzzi, Gianni Micheli and Maria Teresa Monti, eds., Mi lan (Franco Angeli), 1998, pp. 36192. See in general Gillian Evans, The Language and Logic of the Bible: the Earlier Middle Ages, Cambridge (Cambridge University Press), 1984; Beryl Smalley, The Study of the Bible in the Middle Ages, 3rd edn , Oxford (Clarendon Press), 1984. See Arnaldi de Villanova Opera Medica Omnia. V I.2. Commentum in quasdam Parabolas et alias Aphorismorum Series: Aphorismi Part iculares, Aphorismi de Memoria, Aphorismi Extravagantes, ed. Juan A. Paniagua an d Pedro Gil-Sotres, Barcelona (University of Barcelona), 1993. See Michael McVau gh, Moments of in ection: the careers of Arnau de Vilanova, in Peter Biller and Jose ph Ziegler, eds., Religion and Medicine in the Middle Ages, The University of Yo rk (York Medieval Press), 2001, pp. 4767. See Ziegler, Medicine and Religion p. 5 3. The medical language of men such as Arnau and his fellow Catalan Ramon Lull ( d. c. 1316) incorporated parables or metaphors which reached outside medicine. L ull was interested in degrees of qualities in medicine, and argued that the mora l virtues were at a mid-point of a latitude while the vices were its extremes.

112 The Latin tradition In some sense, Conciliator, Plusquam, Speculator, Dino del Garbo and the Bologne se doctors were setting themselves up as new authorities.75 Gentile sometimes ad mits that an abstruse development of a theory could have no application whatever and indeed could not exist outside the imagination. Such things were written pa rtly for the status they conferred on the authors. That had been true also of th e authorities which the new heroic writers wanted to emulate: where there were o bjective reports of actual medical practice, for example in case-histories, theo ry was almost totally forgotten, and it has been recognised that Byzantine and A rab theorists were writing for status.76 The same is true of surgery, where the operations described were ctitious.77 By the later thirteenth century, Italian su rgeons such as Guglielmo da Saliceto were trying to bring learned medicine and s urgery together; Guglielmo argued that it was possible to learn surgery from boo ks, like learned and rational medicine. Medieval surgeons recognised that writin g a surgical text as an author conferred greater respect than commenting on old texts.78 Gentile, calling himself an oculista, was quite con dent on the basis of his reading that he knew the best operation for couching a cataract. He had neve r done it and did not know whether it could be done; but it was still the best. The scholastics took their sources literally, without realising the personal mot ives of their authorities, and some procedures they adopted in trying to re-esta blish ancient medicine, such as surgical operations or dissecting the human body , were reconstructions from words only. Thus the university doctors had a Good S tory to tell their patients, pupils and employers that included the clinical eff ectiveness that came from true knowledge of the world, the body and its diseases . They could refer to the great authorities, which added power to their medicine in an age that revered the ancients. They claimed to be part of a grand and suc cessful tradition of medicine. Their grasp of logic gave them the power that log ic 75 76 77 78 See Fernando Salmon, Technologies of authority in the medical classroom in the th irteenth and fourteenth centuries, in OBoyle et al., El Aprendizaje de la Medicina en el Mundo Medieval, pp. 13557. See Cristina Alvarez Milln, Graeco-Roman case his tories and their in uence on medieval Islamic a clinical accounts, Social History o f Medicine, 12 (1999) 1943; and her Practice versus theory: tenthcentury case hist ories from the Islamic Middle East, in Peregrine Horden and Emilie Savage-Smith, eds., The Year 1000: Medical Practice at the end of the rst Millennium [Social Hi story of Medicine, 13, 2000], pp. 26578. See Siraisi, Medieval and Early Renaissa nce Medicine, esp. ch. 6. See also Emilie Savage-Smith, The practice of surgery i n Islamic lands: myth and reality, in Horden and Savage-Smith, The Year 1000, pp. 30721. See M. McVaugh, Therapeutic strategies: surgery, in Grmek, ed., Western Med ical Thought from Antiquity to the Middle Ages, pp. 273318.

Scholastic medicine 113 had been supplying to the men of the schools since the twelfth century, the powe r to dazzle those without it and to win arguments against those less skilled in the art. They poured scorn on the new empirics, a category they had helped to in vent. They contrived a professional ethics that did their image no harm by being d irected towards the bene t of the patient. Their ideal form of practice was to be retained in a big household and to govern the regimen of people who were not ill . Their story emphasised how individuals varied with age, sex, location and inna te disposition and that skill in medicine was the correct evaluation of these th ings. In contrast, the empiric had a medicine for each disease: it was a speci c and probably secret (a nostrum is our medicine). They were therefore well placed in s udden epidemics, when time was short and people were anxious. dissection In one studium, that of Bologna, the medical student in the rst half of the fourteenth c entury would have met something unusual: human dissection. Historians have spent much time on the origins of anatomy; mostly because it looks like an essential stage in the growth of our anatomy-based medicine. On both counts we cannot give the topic much space here, but there are issues that relate to the history of t he Rational and Learned Doctor. First, postmortem examination of corpses had bee n known from the thirteenth century, often in conjunction with the law and desig ned to reveal the cause of death. Mondino, the dissector at Bologna, made no cla im that he was doing anything new, unless it was to write a book about dissectio n, which he justi es in a standard literary way. His dissections were for teaching purposes, no doubt so that physicians could learn what was normal (and so be in a position to recognise the pathological) and that surgeons could be safer and more effective. But he was well known to his colleagues, even in different studi a, as the famous anatomist, famosus anatomista. The term implies that the anatomis t was a specialist, pursuing his own discipline with some of the autonomy and au thority of medicine as a whole. The term is parallel to legista, the school lawy er, which also implies professional boundaries. Within medicine, anatomy has a s pecial relationship with philosophy. Almost every anatomist down to early modern times gave a philosophical or theological reason for doing anatomy before he ga ve a medical or surgical reason. There was philosophical interest in how the bod y had been put together and how it worked, and justi cation for dissection could b e found in Aristotle and Galen. Anatomy was also central to the enduring questio n

114 The Latin tradition of whether reason or sensory observation was more important in medicine, and we shall see that the sensory component enabled anatomy to survive the crisis of ph ilosophy. But here we need to examine the reasoning involved in anatomy, for it was fundamental to the thinking of the Learned and Rational Doctor. Anatomical r ationality derived from Galen. He provided a hierarchy of action, use and utility of t he similar and organic parts, and the whole was presented in the teleological framew ork of the creative demiurge, who was partly Platos deity and partly rational natu re who had constructed the body. Galens experiments on blood vessels and nerves sh owed that the machinery of the body could be understood and partly controlled. A natomy was functional, for, as Aristotle said, knowledge of a part is knowledge of what it is for. Galens functional anatomy was best expressed in the text known in the Latin tradition as De Usu Partium, but it is not clear whether Mondino k new the full work or a translation of the truncated Arabic paraphrase that had b een circulating for some time. Mondino had no suspicion that Galen had not disse cted human bodies, and so in adopting a Galenic practice Mondino was claiming anci ent authority. The rote of observables he has in dissection is drawn from John o f Alexandrias commentary of Galens De Sectis and Mondino clearly saw himself as pa rt of a learned anatomical tradition. Medical men who gave their allegiance more to Avicenna than to Galen had another kind of anatomical rationality. The domin ating thread of medical theory in the high Middle Ages was complexion, the combi nation of elementary qualities of the parts. Therapy sought to restore an unbala nced complexion, often by evacuation. It could be argued, for example, that it w as when the complexion of the muscles was changed by an incoming complexion of t he nerves that function resulted. As we saw, Avicenna routinely gives the anatomy of the parts of the body before discussing them medically. As a systematiser rat her than an experimenter, Avicennas anatomy consisted partly of the locations of different complexions, a doctrine that would be greatly developed by his comment ators. g r a d uat i o n Having selected his school and his master, having kept his terms of residence and having heard lectures and disputed according to the s tatutes, the student was ready to seek the professional quali cation which would a llow him to practise internal medicine. This was a complex business and varied f rom studium to studium, but there was generally a ritual display at some point i n the proceedings.

Scholastic medicine 115 The procedure began when the master thought that his student was ready for exami nation by other masters.79 This was the rst examination and it was conducted in p rivate, probably because there was a real possibility of failure.80 It is notabl e that the essence of the examination was not to test the students grasp of medic ine; rather, the candidate was expected to perform the characteristic exercises of the teaching master. He was expected to nd the points in a portion of a text (wh ich was generally the Galenic Tegni, followed by the Aphorisms), that is, the ar ticulations in the logic of the author.81 This was equivalent to the expositio, the rst part of a formal commentary. For example, Taddeo begins his commentary on the Aphorisms with an exposition which, he says, is like light, without which o ne cannot see either colours or the scientia of the author.82 A commentator woul d normally follow the exposition with an interpretation, and in the same way the medical candidate was expected to verify the text he had just divided.83 Because he was working with the Aphorisms and Tegni, medical veri cation often took the form of giving the physical reasons derived from the latter that explained the appea rances contained in the former (which again underscores the importance of these two texts in medieval medical education).84 Verifying the text was to explain it , the masters privilege in a magisterial lecture, and when the candidate, nally, d efended his veri cation against objections,85 he had in a sense given a specimen m agisterial performance (a masterpiece, as they said in the productive guilds). It will be noticed that the heroic masters we have been discussing Dino, Taddeo, Ge ntile were Italian. Arnau and Bernard of Gordon 79 80 81 82 83 84 85 It may have been in the form of a disputation on a topic set previously. See Jac ques Verger, Teachers, in de Ridder-Symoens, ed., A History of the University in E urope. Volume 1, pp. 14468. See also OBoyle, The Art of Medicine, p. 148. There we re rules for the masters voting on the candidate in the private examination, know n in the Paduan college as the examinatio tentiva. See Donato Gallo, Statuti ined iti de Collegio Padovano dei dottori darte e medicina: una redazione quattrocente sca, Quaderni per la storia dell universit a di Padova, 2223 (198990) 5994. Bologne se masters covered nine points in their lectures; see the statutes of the universi ty of arts and medicine, 1405: Malagola, Statuti, p. 254. Maier , University Tr aining, p. 50, says that the nine u points covered a cycle of lectures. Punctum seems to have been taken over from law usage: Jacquart, Medical scholasticism, p. 210. Taddeo then divides the text and gives his interpretation: commentum dividam et sententiam ponam. See Thaddei Florenti Expositiones in arduum aphorismorum Ip ocratis volumen. In divinum pronosticorum Ipocratis librum. In preclarum regimin is acutorum Ipocratis opus. In subtilissimum Ioannitii Isagogarum libellum, Veni ce (A. Giunta), 1527. The term appears only in medical statutes. Maier , Univer sity Training, p. 58. u For these texts in the statutes, see Malagola, Statuti, p. 437. Et primo legere debeat pro prima lectione testum totum puncti dati libri Tegni Galieni, deinde bene dividendo, veri cando et exponendo testum secundum ins tantiis. Malagola, Statuti, pp. 4389.

116 The Latin tradition probably represented something similar in Montpellier. In contrast, in northern Europe there were no notable authors before the Black Death. At all events, this highlights a difference we must take note of. In the north, the successful stud ent ultimately joined the consortium of masters: this was inception. This was qu ite a different procedure from receiving the licence to teach, which was given a fter an examination conducted by the bishops chancellor, in his role as controlle r of the schools. In the south, the medical student received his education at th e hands of the teaching masters of his studium but was examined and given his pr ofessional quali cation by the professional college, which was not co-extensive wi th the teaching faculty. It contained doctors who did not teach and did not cont ain all those that did teach; its autonomy was emphasised by the fact that some students went for their degree to another college, where perhaps it was cheaper. B ut in both north and south the candidate, having been successful in his private examination and having proved that he had kept his terms and had attended all th e required disputations and readings, petitioned for the licence from the chance llor.86 In Paris the bachelor again provided evidence of his terms of residence, conducted a solemn disputation and chose a master to present him to the chancel lor, who duly replied with a formal sealed letter. The award of the licence invo lved a grand affair with the whole faculty processing before an audience of the chancellor, representatives of the other faculties and ecclesiastical, civil and visiting dignitaries.87 Many left their professional quali cation at this stage a nd went off to practise, for taking the doctorate was expensive. Some entered in to contracts as town physicians, and after a period returned to their university for the doctorate. Joining the ranks of the university-trained Rational and Lea rned Doctors inception was a very public occasion, in contrast to the private ex amination. It was a ceremony in which the learned doctors made it clear what it was to join their ranks. It often took place in a church, which, along with the churchs licence, gave authority to the proceedings.88 The new doctor was presente d with gifts as signs of his new status: in Italy, a biretta and ring, taken fro m the altar. The biretta was the doctors hat in a physical and metaphorical sense ( we have seen that philosophers and medical men could wear different hats at differ ent times in their career); 86 87 88 There are varying accounts of the different stages in the process of inception a nd taking the licence. See Jacques Verger, Teachers, in de Ridder-Symoens, ed., A History of the University in Europe. Volume 1, pp. 14468; Carl C Schlam, Graduatio n speeches of Gentile da Foligno, Mediaeval Studies, 40 (1978) 96119; Maier , Uni versity Training, pp. 58ff. u OBoyle, The Art of Medicine, p. 256. In Bologna from 1219 the licence (to teach) was given by the archdeacon of Bologna. Siraisi, Me dieval and Early Renaissance Medicine, p. 19.

Scholastic medicine 117 it symbolised the proximity of a man with a scientia to God. The ring symbolised the marriage of the man to the science. The learning of the Learned and Rationa l new Doctor was represented by the gift of a book; and a kiss marked the gift o f eloquence: his rationality. There was a speech from the promoting master, perh aps linking eloquence with the formal disputation conducted by the candidate, or indulging in word-play with his name. Dress was important: in Paris on public o ccasions the medical men wore a distinctive cope over their academic robes. Here the new doctor was given a doctoral bonnet and, in return, gave hats and gloves . There followed a procession, a public statement of the characteristics of the group on display; and a feast, a traditional way of declaring community of inter ests and purposes. The essential thing about medical graduation was that it impr essed the candidate and the onlookers that a major event had taken place. The me dieval student learned his Latin at school perhaps indeed a grammar school89 and at fourteen or fteen went to his studium to learn the arts. It took about ve year s to reach the grade of master and another ve to become a doctor of medicine. The se periods were constantly revised,90 which indicates the importance put on them by the teaching masters. Whatever the precise length of study, it was an enormo us commitment of resources; and it reminds us of how much knowledge the Rational and Learned Doctor had absorbed. It is signi cant that part of the ceremony of gra duation was the proof of residence and of reading for the required time: the cand idate normally presented letters or a schedule, cedula, a term used for formal and written documents, like a request from a local doctor for a consilium from a mo re famous one.91 This was not mere administration. For example, most of the cand idates for medical graduation in Paris were known to have been through the Paris ian arts course, but they still had to prove their terms. It was more dif cult to prove this if the candidate had learned his arts in another university, and some times the authorities at Paris insisted on the full university seal of Oxford on the schedule of an Oxonian candidate. Proving terms of residence was a measurab le part of the public display, the effect of which was to announce the quality o f the new doctor: his quali cation to practise. 89 90 91 See Garca-Ballesters introduction to From Salerno to the Black Death. OBoyle, The A rt of Medicine, p. 20. See, for example, Lynn Thorndike, Consilia and more medica l works in manuscript by Gentile da Foligno, Medical History, 3 (1959) 819; Jole A grimi and Chiara Crisciani, Les Consilia mdicaux e [Typologie des sources du Moye n Age occidental, 69], Turnhout, Belgium (Brepols), 1994; French, Gentile, p. 27 7.

118 The Latin tradition t h e m e d i c a l m a rk e t p l ac e Other learned doctor s These were the outward signs of the incorporated faculty and they contributed la rgely to the public perception of the Learned and Rational Doctor. The new docto r paid for the feast and paid sums to his master and the university. He was buyi ng professional support largely in the form of the freedom to practise internal medicine. He was joining a club whose numbers were limited by the length and exp ense of the training and he probably expected his share of the market to be prop ortionately large.92 Perhaps, too, the church approved of a form of incorporatio n that limited the number of practitioners, for we have seen that for a long tim e there had been nervousness about medicine damaging the recruitment to theology . The size of the club was also governed more directly, for example by assumptio n of control of the southern universities by the church (as we saw in the previo us chapter) and in practice restricting the ius ubique docendi to Bologna and Pa ris.93 Teaching masters in general controlled the size of their own group, as in the magisterial universities in the north; and in Bologna the college of doctor s was subject to a similar numerus clausus which limited its numbers, which were xed and low.94 Another strategy open to the elite doctors was to extend the leng th and therefore the cost and exclusivity of the university medical course, part icularly when faced with growing competition from outsiders.95 The doctoral cere monies were rites of passage that marked the end of medical education. The class room culture that brought the student into the masters vision of the medical trad ition often left him with a loyalty to his alma mater that did not extend to oth er schools. Italian masters who had taught students in one studium were highly c ritical of those who went off to be examined by a college in another town and ev en more critical of the college that poached them. Studia were often major sourc es of revenue for their town, which was jealous of their privileges. Heroic teac hers often 92 93 94 95 Paris produced an average of perhaps ve medical doctors a year. OBoyle, The Art of Medicine, p. 65. See R egg, Themes, in de Ridder-Symoens, ed., A History of the Un iversity in Europe. Volume 1, p. 17. u Verger, Teachers, in de Ridder-Symoens, ed. , A History of the University in Europe. Volume 1, p. 149. The medical guilds, w hich largely grew up alongside the faculties and professional colleges, containe d many non-university doctors. On the length of the course see Nancy Siraisi, The faculty of medicine, in de Ridder-Symoens, ed., A History of the University in E urope. Volume 1, pp. 36087; certainly by 1405 the Bolognese statutes suggest that the medical course was now longer (p. 379); for the situation in Paris, see OBoy le, The Art of Medicine, p. 21.

Scholastic medicine 119 wrote for the students and the glory of their studium. One of the functions of h eroic commentaries after all was to do more, or better, or see further, or resol ve the opinions of other teachers. We have seen that Gentile da Foligno once had a difference of opinion with Dino del Garbo in the street, and held in general that the doctors in Bologna gave too much credit to Galen. Gentile taught in Per ugia and found that it was not always easy to tell quite what the Bolognese doct ors were teaching.96 In other words there was in the late thirteenth and early f ourteenth centuries no deontological or ethical imperative to present a uni ed fac e of university medicine. Like John of Salisbury many years before, Pietro dAbano recognised that disagreements between doctors had disastrous effects on public con dence. Particularly in relation to acute diseases and prognosis, says Pietro, the vulgar are so distrustful of doctors that they refuse to consult them even o n matters of diet and regimen; even surgery was preferable, because it was open to the senses.97 Part of Pietros complaint is that the vulgar did not understand medical theory. The result, of course, was that they could not be impressed with it, and the doctor was deprived of a major image-making device. It was a case o f the doctors over-playing their hand, for in general they strove to speak a tec hnical language to the patient that was just above his head. An enduring example is blockage of the liver where blockage is oppilatio, a Latin term calculated to im press but not enlighten the patient.98 Other kinds of practitioner The processes and rituals that led to medical inception and a licence provided a hallmark of quality for the new teacher or practitioner. It was essentially an act of a corp oration with legal standing. Bishops, popes, kings99 and emperors could also giv e full licences, but it was normally on the advice of a panel of fully quali ed do ctors. (In a later period the London College of Physicians came into existence i n this way.) But the university-trained doctor was not the only kind of practiti oner. Guilds older than the medical 96 97 98 99 On the problems of medical communication the numbers of books and their inaccess ibility, and the consequent writing of summaries etc. see Luke Demaitre, Scholast icism in compendia of practical medicine, 12501450, Manuscripta, 20 (1976) 8195. Pi etro dAbano, Conciliator, f. 7r. The Cautele Medicorum attributed to Arnau of Vil anova, printed in Arnaldi de Villanova medici acutissimi Opera nuperrime revisa, Leyden (Scipio de Gabiano), 1532. Siraisi, Medieval and Early Renaissance Medic ine, p. 18 says Peter the Ceremonious of Aragon issued licences informally to Je ws in the 1340s but complaints from the profession made his successor in 1356 re instate university study and examination as a condition of offering the licence.

120 The Latin tradition faculties and including doctors could issue licences (but their consolidation se ems close in time to that of the faculties).100 Specialists could gain licences on the testimony of successful practice. Most such local licences were partial, limited for example to surgery or even a single kind of operation and often held by followers of another trade. The university doctors claimed that only their l icence was complete, since it alone extended to the giving of internal medicines ; and since they claimed that their own knowledge subsumed that of the various k inds of practice, they claimed control, too, over these other medical trades.101 There were, then, many niches in the medical marketplace. In practice the learn ed and rational physician tended to avoid surgery, and his control over the othe r branches of medicine was often nominal and limited to large towns. The surgeon or specialist in external medicine was called out when something went wrong and earned his reputation by his success and by word of mouth recommendation. In co ntrast the university-trained physician had some sort of reputation by virtue of his licence and training. He was not infrequently retained in a large household or had a contract with a town.102 And as we have seen, his business was to regu late the regimen of those under his control (and visit the poor free of charge, if a city physician). He was successful, then, if nothing happened; but if it di d, he had a multitude of reasons why, and why or not his treatments worked. Conv ersely, a magnate or a monarch who was supporting a physician had a learned man on his hands who could be put to other uses while the household remained in heal th. Arnau of Vilanova, physician for the second time to Jaume II of Aragon after 1300, was dispatched on a diplomatic mission to France.103 The French king, Cha rles V, had at least fteen Paris-trained physicians, and between 1250 and 1400 th ere were at least seventy- ve Paris doctors in big households, mostly secular. For eign potentates sent their protgs to e e Paris to gain a medical education before employing them as doctors. The physician on a contract did not legally promise t o cure the diseases af icting his patients, but to be diligent in his advice and h is visiting, to let blood prophylactically at the appropriate time of year and t o be on 100 101 102 103 There were thirteenth-century Italian guilds containing doctors. Florences guild of medici, apothecaries and grocers was established in 1293 and was by 1315 a fe deration of the three autonomous trades. Siraisi, Medieval and Early Renaissance Medicine, p. 18. There was, for example, a case of 1322 when the Paris faculty successfully prevented a woman from practising. Siraisi, Medieval and Early Rena issance Medicine, p. 19. This was the case in thirteenth-century Italy and it wa s a conspicuous feature in later German towns. In the middle of the fourteenth c entury Venice employed about four medici and ten surgeons a year, at a time when monastic houses began to retain medical men. Siraisi, Medieval and Early Renais sance Medicine, pp. 18, 38. Ziegler, Medicine and Religion, p. 23.

Scholastic medicine 121 hand when epidemics arrived. The success of the physician depended on his doing these things well, and we are reminded that we cannot make judgements about the clinical success of a physician. The expectations of the laymen who secured phys icians on a contract are manifest in the terms of what the physician undertook t o do in return for his retainer, and it is part of the argument of this book tha t the physician himself helped to create those expectations. The rational and le arned physician, after all, was the expert who de ned what medicine was (and conse quently what its boundaries were). It was agreed, for example, that diseases cou ld be the vengeance of God. They could equally well be the result of a persisten t lax and self-indulgent lifestyle: in neither case was there an expectation tha t the physician alone could effect a cure. The practice of giving long-term advi ce to people who could pay for it was associated with a new genre of medical lit erature, the regimens of health. Especially in the second half of the thirteenth century and the rst half of the fourteenth, this form of medical advice had seve ral advantages for the learned doctor. He could practise his medicine in the tra ditional way, centred on the individual and modi ed according to the individuals co nstitution and circumstances. The doctor knew how the body was constituted and h ow it varied according to age and sex (the naturals); he knew how each particula r patient reacted to things that caused illness (the preternaturals); and he cou ld give medical advice concerning diet, exercise, sleeping, sexual activity and bathing (the non-naturals). The doctor had every opportunity to explain the reas oning behind this and so construct his Good Story and the patrons expectations. T he advice was generally addressed to powerful people, like that of Guido da Vige vano to the French king, Philip VI of Valois. Such patients were advised to eat an d take exercise in a manner that became their class: to avoid the food of the po or and to go horseriding. This was real exercise, while the activity of the lowe r classes was mere labour. To address such people added to the status of the phy sician, just as did his writing consilia, and physicians such as Bernard of Gord on and Arnau of Vilanova developed the genre fully.104 A consilium was a piece o f medical advice on a particular case, written by a well-known doctor for a dist ant patient and doctor, on the receipt of the latters request and descriptive sche dule. What made consilia interesting was that they dealt with real cases and were not merely theoretical discussions. In offering a diagnosis and suggesting a th erapy, they could be used to indicate that medicine 104 See Pedro Gil Sotres, The regimens of health, in Grmek, ed., Western Medical Thoug ht from Antiquity to the Middle Ages, pp. 291318.

122 The Latin tradition was not merely book-learning. They also often named the patients involved and we re more convincing if the patient were famous: he or she was, in a sense, a witn ess to the practical skill of the doctor (who took care, of course, to report mo stly his successes).105 Consilia were collected together and published, by the d octors involved or others, and formed an effective mode of advertising. It has b een pointed out that consilia in the later fteenth century existed in a different medicinal environment from those in the thirteenth and fourteenth centuries: th ere were new diseases, full development of the medical guilds outside the facult ies, humanism and court culture. Consilia became formalised on the Avicenna mode l and rearranged according to anatomy and disease.106 f o re n s i c m e d i c i n e The success of a medical student who had completed his course and become a Rational and Learned Doctor could be called on to provide skilled testimony in a reas on the edge of medicine. As a healer, he could offer evidence in cases of m iraculous cures, often used as evidence in the process of canonisation.107 For p urposes of segregation he could be called on by civic authorities to detect lepr osy in suspect patients.108 If he were appointed as physician to a city, his dut ies would include those of the physician on a private contract, but also the obl igation to report suspicious deaths and cases of wounding to the city authoritie s.109 For example, the Venetians in 1281 passed a law that obliged medical pract itioners to report immediately all serious cases of wounding that looked like th e result of violence; the medical man was not simply an expert witness, but was an of cial of the court, essentially an investigating judge.110 Taddeo Alderottis f ame was such that these obligations were lifted, but others such as Bartolomeo d a Varignana, 105 106 107 108 109 110 Jacquart, Medical scholasticism, p. 231, and Agrimi and Crisciani, Les consilia mdi caux. e See Nancy Siraisi, Avicenna and the teaching of practical medicine, pp. 637 8 in her Medicine and the Italian Universities, 12501600, Leiden (Brill), 2001. Z iegler, Medicine and Religion, p. 4. The point was to prove that natural cures c ould not have worked. See also Zeiglers Practitioners and saints: medical men in c anonization processes in the thirteenth and fteenth centuries, Social History of M edicine, 12 (1999) 191225. Papal coroners inquests sought cause of death from medi cal men; by the end of the century this was introduced also to civil law mainly in Italy but also in Aragon and the south of France. Most of the rules for canon isation had been formalised by 1200. See Luke Demaitre, The relevance of futility : Jordanus de Turre ( . 131335) on the treatment of leprosy, Bulletin of the History of Medicine, 70 (1996) 2561. In the case of Bolognas city physician, see Siraisi, Taddeo Alderotti and his Pupils, p. 298. See Catherine Crawford, Medicine and th e law, in W. F. Bynum and Roy Porter, eds., Companion Encyclopedia of the History of Medicine, 2 vols., London (Routledge), 1993; vol.2, pp. 161940, at p. 1622.

Scholastic medicine 123 who had successfully secured an aristocratic clientele, performed autopsies and delivered medico-legal judgements to the civic authorities.111 To know whether a death was natural in this context pathological or violent, the doctor conductin g the postmortem had to be aware of the normal appearance of the body, and we ma y suppose that human dissection in teaching played a part in this. The Rational and Learned Doctor was also an expert witness in another legal area, that relati ng to childbirth. In cases of paternity, adultery and so on, the lawyers wanted to know at what age a girl could become pregnant and when a boy might be a fathe r. They needed advice on the length of pregnancy and the resemblances that might be expected between a father and his child. The doctors built up the matter of procreation into a topic, perhaps for professional use in the law courts. The de velopment of the foetus was, after all, a matter at some distance from the ordin ary practice of medicine. The doctor could not see the foetus, he could not know whether it was ill and could not treat it. It was entirely a matter of theory ( but yet with practical application in treating the mother and in giving answers to the lawyers). The medical men of the fourteenth and early fteenth centuries ha d three main sources for this topic: Avicennas chapter on the anatomy of the uter us in the Canon, Hippocrates De Natura Fetus, and the new translation of Galens De Spermate by Nicolo da Reggio.112 On the question of the onset of puberty, Tomma so del Garbo, son of Dino and pupil of Gentile, said that in a political context a girl could be given in marriage at twelve, when she could conceive, but a man should not marry until he could generate sperm. In legal terms this meant that it was proper for a girl of fourteen to marry, while the man should be twenty-fo ur. It is not clear what system of law Tommaso is referring to, but it is perhap s ancient, for he adds the not uncommon complaint that in the modern, lax and gr eedy age, we all mature more quickly.113 On the question of the length of pregna ncy, the doctors had to explain a piece of wisdom inherited from the ancients, t hat while the normal period was nine months, yet a seven-month and a ten-month c hild stood a better chance of surviving than one of eight months. The question 111 112 113 Siraisi, Taddeo Alderotti and his Pupils, pp. 36, 47. A frequently cited contemp orary authority was Giles of Rome, Egidius Romanus. See f. 40vb of Expositio Jac obi supra Capitulum de Generatione Embrionis cum Questionibus eiusdem. Dinus sup ra eodem. Dinus supra librum Ypocratis de Natura Fetus, Venice (Bonetus Locatell us for the heirs of Octavian Scot), 1518. This is a collection put together larg ely to supply materials for disputation in the early sixteenth century: Tommaso del Garbos name does not appear on the titlepage and the editor explains that som e attribute his commentary to Dino and others to Gentile da Foligno. The comment ary of Tommaso, son of the once very famous Dino, begins at f. 33r.

124 The Latin tradition was bound up with the duration of the various stages of pregnancy, which had som etimes been put on a geometrical or mathematical basis. Dino, Tommaso and Jacopo d a Forl were inclined to think that such explanations relied too much on numerol ogy, and they agreed that the real reason was that each stage of development was controlled by one of the seven planets. The sequence began with Saturn, a plane t with malign effects, and a cycle of eight months returned the unborn child to these effects at a vulnerable stage. Nine months brought the child again to Jupi ter, a benign planet. Jacopo and Tommaso liken the period of pregnancy to a cris is in a fever, so that the eight-month birth is like a crisis on the wrong day.1 14 In both cases the rational doctors built in a degree of latitude in their cal culations that covered most eventualities (particularly in explaining why, if th e rst two Hippocratic crises were on the seventh and fourteenth day, the third wa s on the twentieth rather than the twenty- rst). A medical month could be calculated from the daily or yearly motions of the sun, or the phases of the moon: the cou nting could be inclusive or could ignore the dark period immediately before a new moon. In any case, the doctors agreed that the term of human pregnancy was more variable than that of animals,115 and it is clear that the doctors rationality co uld explain most appearances. Also of potential legal interest was the degree of resemblance between the child and its natural parents. Here the Rational and Le arned Doctors wrestled with huge problems of theory. On the one hand, Aristotle had said that the formation of the embryo was solely due to the action of the ma le semen on the passive matter of the female, and it became a complex problem to explain the fact that some children resembled their mothers more than their fat hers. On the other hand, Galen had said that both male and female produce sperm and that the embryo develops from a mixture of both. Hippocrates was generally r ead as saying that the semen is derived from all parts of the body, the characte ristics of which it conveyed to the embryo. In that case, wondered our doctors, was it possible that acquired characteristics were inherited? Were diseases inhe rited?116 Dino argued that the force of the imagination of the mother might make an illegitimate child resemble her husband more than the natural father,117 an argument that might appeal to a lawyer. These texts are scholastic in a professi onal sense, for they represent the authority of the doctor as the master of an a utonomous discipline, the face he presented to other professionals. Much of the internal development of 114 116 115 For example, Jacopo, f. 7ra. Jacopo, f. 6va, Tommaso, f. 41vb. 117 D ino del Garbo, f. 77rb. For example, Tommaso, ff. 19va, 20rab.

Scholastic medicine 125 his discipline can at least be related to this presentation. One of the earliest of these treatises on the embryo is that by Dino, who comments on the Hippocrat ic De Natura Fetus. As we have seen, Hippocrates was famously of such profound m ind that he did not need the other arts and sciences in his medicine. The work h as a correspondingly simple structure. But Dino knew that Hippocrates could be m ade even more convincing by showing how he could be explained in Aristotelian an d scholastic terms. He brings a big apparatus to bear, showing the relationship between a science and its subject and how the sciences are grouped. He introduce s fragments of Aristotles physical works to substantiate what he says; what is un usual, however, is that he treats these brief extracts as texts to be commented on, and writes a brief secondary exposition before returning to Hippocrates. Fin ally, these texts are scholastic in a number of other ways. Sometimes they begin with professional piety, invoking the name of God, but only after citing authorit y from non-Christian medical writers and their God. They ask questions that can never be more than theoretical and arguable. One such concerned the growth of th e embryo. It was clearly being nourished, but this process, restauratio, was hel d to be that by which the independent body restored the losses occasioned by act ivity, resolutio. But the foetus was not active in this way: could there be rest auratio without prior resolutio?118 One problem that passed from the theoretical realm to the practical in the Renaissance was that of how the foetus, enclosed in the uterus, urinates. Mondino offered an answer, ostensibly on anatomical gro unds, but his colleagues disagreed, also citing anatomy. The matter was put to s everely practical and experimental tests only as late as Berengario da Carpi, be fore 1521, who had acquired a nearly full-term foetus. Lastly, an apparently sen sory observation that could have been of legal interest was that the fetus in ut ero (and presumably a still-born child) had red lungs, coloured by the blood in the vessels. In contrast, the lungs in a child that had breathed air after birth were white, after expansion; such things may have been important in cases of su spected infanticide. Although there were many niches in the medical marketplace, they were not protected. The medical hierarchy was not as rigid as the universi ty doctors would have wished. Latin literacy was not limited to doctors and medi cal texts were available to many educated people who could read and use them. Ma ny were translated into the European vernaculars. In England, university trainin g in medicine was not automatically seen as desirable and in general in the nort h there were many secular clergy who practised 118 Jacopo, f. 13ra.

126 The Latin tradition medicine.119 From the thirteenth to the fteenth centuries less than half of the t otal number of practitioners had learned their medicine in a university. These p ractitioners included women and Jews who, while they may have attended lectures in some universities, could not graduate.120 Their own system of education had b een on the closed model, a few students round a single teacher, like early medieva l European schools. They did not develop an open, collaborative type of school o r the scholasticism which went with it. But they admired scholastic medicine and its success, and while some felt depressed at their own intellectual weakness, others a disproportionate number of the Jewish population became well read in sc hool texts and well rewarded in terms of practice.121 There was always pressure on the European Learned and Rational Doctor to defend and develop his kind of me dicine. 119 120 121 See Siraisi, Medieval and Early Renaissance Medicine, esp. ch. 1; Getz, Medicine in the English Middle Ages. See also Stephen R. Ell, The two medicines: some ecc lesiastical concepts of disease and the physician in the high middle ages, Janus, 68 (1981) 1525. Historians disagree about this. On the importance of Jewish phys icians see Linda M. Paterson, The World of the Troubadours. Medieval Occitan Soc iety, c. 1100c. 1300, Cambridge (Cambridge University Press), 1993. See also Garca -Ballester et al., Medical licensing, esp. p. 88. See in general J. Shatzmiller, J ews, Medicine and Medieval Society, Berkeley (University of California Press), 1 994; Luis Garca-Ballester, Lola Ferre and Eduard Feliu, Jewish appreciation of fou rteenth century scholastic medicine, Osiris, 2nd series, 6 (1990) 85117; John M. Ef ron, Medicine and the German Jews, New Haven (Yale University Press), 2001.

chapter 5 The weakening of the Latin tradition i n t ro d u c t i o n Medical scholasticism may not have died in the Black Deat h, but it was not quite the same afterwards. The ambitions of the early scholast ics had not been realised, and it was recognised that the goal of achieving a pr elapsarian state of knowledge was unobtainable.1 The guild-like structures of va rious branches of knowledge discouraged interdisciplinary approaches. The techni calities of Avicenna and the New Galen did not encourge clerics to continue to e ngage in medicine.2 Following the institutional separation of medical theory and practice in Paris and Bologna before the Black Death, practical medicine became more important and better rewarded, while theory was reduced simply to an intro duction.3 The ethos that led Gentile da Foligno to lofty heights of entirely imp ractical speculation was rejected by his pupil Tommaso de Garbo, who found his t eacher too prolix. Tommaso wielded the famous razor of the Oxonian Ockham and th ought it undesirable to multiply entities; in particular he had a nominalists dis like of elaborate and numerous distinctions.4 For example, where Gentile, callin g himself an oculista, had a hugely elaborate theory of vision, Tommaso denied t hat a real species a quasi-material simulacrum moved between object and eye. Bel ieving that shape, number and motion signi ed only things in the soul and could no t be sensed per se, Tommaso seems happy to disagree even with Aristotle. Tommaso made a great deal of money from 1 2 3 4 See R. W. Southern, Scholastic Humanism and the Uni cation of Europe. Volume 1 Fou ndations, Oxford (Blackwell), 1995, pp. 10, 52, who argues that the failure to r ecapture prelapsarian knowledge was felt most in natural philosophy. See Joseph Ziegler, Medicine and Religion c. 1300. The Case of Arnau de Vilanova, Oxford (C larendon Press), 1998, p. 5. See Danielle Jacquart, Medical scholasticism, in M. D . Grmek, ed., Western Medical Thought from Antiquity to the Middle Ages, trans. A Sugaar, Cambridge, Mass. and London (Harvard University Press), 1998, pp. 19724 0, at p. 233. See Katharine Park, Doctors and Medicine in Early Renaissance Flor ence, Princeton (Princeton University Press), 1985, p. 207. 127

128 The Latin tradition his medicine and rose to a position of prominence in Florence: he was successful in the terms we are using, and part of his image seems to have been cultivated by keeping up with new developments in logic (which later became known as the vi a moderna). Histories of medicine normally pass from the Middle Ages to the new departures of the Renaissance, such as human dissection and medical botany. But when looking at medicine as a prescienti c activity a story that does not have sci enti c medicine as its conclusion continuities are as important as novelty. The ai m was still to understand the ancients (and the Arabs) as if they were speaking in the same room. Medical theory was still a development of natural philosophy f rom the point where the philosopher nished. But there were now signs of the weake ning of this link, which we shall follow. There was a continuity too in the fact that the new heroic teachers were small in number, and that the bulk of medical teaching, to say nothing of practice, continued in a less heroic way. The major centres were few: Paris, Bologna, Montpellier and Padua at the beginning of our period, while many new studia, for example in the Germanic countries, followed the model of Paris but remained comparatively small. There were some new heroic commentators such as Jacques Despars (?13801458) in France and the Italian Mattha eus de Gradibus (d. 1480) but their style of commentary did not differ in kind f rom the high scholastic.5 Both authors commented, for example, on Book III of th e Canon of Avicenna, and their expository analyses, nota, distinctiones and dubi a were similar to those of the late thirteenth and early fourteenth centuries, a nd came to be printed with them.6 Disputations remained central to medical educa tion. There were continuities too in the production of material for use in the s chools. The commentaries of Taddeo, Dino, Gentile and others were printed in a f ormat which indicates that they were intended for school use: black-letter type, g enerally in double columns, structured by lemmata from the text and 5 6 On Jacques Despars (Jacobus de Partibus) see Danielle Jacquart, Le regard dun mdeci n sur son e temps: Jacques Despars (1380?1458), Biblioth que de lEcole des Chartes , 138, Paris-Geneva (Librairie e Droz), 1980, pp. 3586; and item XIV in her La Sc ience Mdicale Occidentale entre deux Renaissances e (XIIe s. XVe s.), Aldershot ( Variorum), 1997. For Matthaeus see M. Portal, Histoire de lAnatomie et de la Chir urgie, 6 vols., Paris, 17703 (vol. 1). Matthaeus is sometimes called Ferrarius de Gradi. See Tertius Can. Avic. cum amplissima Gentilis Fulgi. expositione. Demum commentaria nuper addita videlicet Jacobi de Partibus super fen vi et xiii. Ite m Jo. Matthei de Gradi super fen cxxii quia Gentilis in eis defecit. The comment aries are in two volumes, the second being Secunda pars Gentilis super tertio Av ic. cum supplementis Jacobi de Partibus parisiensis ac Joannis Matthei de Gradi mediolanensis ubi Gentilis vel breviter vel tacite pertransivit, Venice, 1522. T he commentary on the canon of Avicenna by the Parisian master Jacques Despars (J acobus de Partibus parisiensis) had already been printed in Venice in about 1499 .

The weakening of the Latin tradition 129 the steps of logical analysis.7 Indeed, the cost of printing enormous works of m en such as Nicholas the Aggregator and Gentile must have represented a huge invest ment8 that the publisher expected to recoup through steady sales in the marketpl ace. Clearly, those who, in the rst half of the sixteenth century, bought printed versions of works now two hundred or so years old did not see themselves as bre aking with the past. What we have called in this book the Latin tradition of med icine continued in the classroom and embraced new generations of students. While we see very easily novelties in the appearance of printed books and the feature s of a rebirth of culture such as Hellenism and Humanism, the great bulk of medica l men learned their trade in the same way and from the same sources. The concept of a period of the middle ages, to be followed by a new cultural start, was a lat er construction, built by a minority of scholars with a special agenda. We shall meet them later. Yet there was a major discontinuity not long before the beginn ing of the period with which this chapter is concerned. The plague, later called the Black Death, had a huge demographic impact on Europe, with signi cant effects in many other aspects of life.9 Some medical scholars, born in the next century , saw the plague as the dividing line between what was old and new.10 So devasta ting was the plague that historians have looked for and found signs of collapse of public con dence in the ability of physicians to do anything at all about it.11 Others have found no such public disillusionment. 7 8 9 10 11 The Humanists and Hellenists in contrast often affected an italic type or one re sembling the uncials of early Latin manuscripts, in a single column broken up in to paragraphs. Printed scholastic texts came to be presented in the same way: se e, for example, Plusquam Commentum in Parvam Galeni Artem, Venice (Heirs of L. A . Giunta), 1557. See Giovanni Mardersteig, The Remarkable Story of a Book made i n Padua in 1477. Gentile da Folignos commentary on Avicenna printed by Petrus Mau fer, London (Nattali & Maurice), 1967: printing the commentary without the text nearly ruined the publisher, who recouped his losses by printing large volumes o f law texts used in the schools. For aggregators in general see Roger French, Ca nonical Medicine: Gentile da Foligno and Scholasticism, Leiden (Brill), 2001, pp . 1913. For a selection of plague tracts, see Karl Sudhoff, Pestschriften aus den ersten 150 Jahren nach der Epidemie des schwarzen Todes 1348, Archiv f r Geschichte der Medizin, 4 (1911), 5 (1912), 6 (1913), u 7 (1914), 8 (1915), 9 (1916), 11 (1 917), 17 (1925). See Niccolo Leoniceno, Opuscula, Basel (A. Cratander & J. Bebel lius), 1532, ff. 47v, 51v: Jacobus de Partibus is described as the recent commenta tor on Avicenna, Gentile da Foligno is the old in having lived before the plague ( ff. 29v, 43r). It is argued by Nancy Siraisi, Medieval and Early Renaissance Med icine. An Introduction to Knowledge and Practice, Chicago and London (University of Chicago Press), p. 42, that the Black Death did not produce a lasting loss o f con dence in the medical profession. See also her Medical reputations in humanist collective biographies, in her Medicine and the Italian Universities, 12501600, L eiden (Brill), 2001, pp. 15783, at p. 160. On the other hand, it has been argued that the failure of scholastic medicine was clear and this provoked some kind of crisis in medical doctrine and the profession. See Jole Agrimi and Chiara Crisc iani, Charity and aid in medieval Christian civilization, in Grmek, Western Medica l Thought, pp. 17096, at p. 196.

130 The Latin tradition If that was so, then clearly the expectations of the public were that the doctor s, if powerless, were understandably so.12 When the Paris faculty replied to the king that the cause of the plague had been astrological, the implication was th at the principle of determinism in the actions of the planets had to be applied, a necessity so professionally framed with mathematical apparatus that it de ected criticism from the doctors. It also allowed for the recognition that disease wa s often Gods punishment, which the doctors could not avert, as we saw in the last chapter.13 Before the plague, for example, it was widely acknowledged, even by the doctors themselves, that leprosy was incurable.14 Whatever the clinical fail ure or success of the Learned and Rational Doctor (which, as we have seen, canno t be part of this story), civil administrations ultimately came to see plague as an entity that travelled from town to town, often along trade routes, and they took practical measures to try to prevent this. From our point of view the failu re of the learned physicians was to identify the plague, that is, to discover it s proper ancient name. Only by doing this could they rapidly and completely draw it into the learned apparatus. They could not do so completely, and, insofar as medicine is a response to disease, this opened further opportunities for the ci vic health of cials and the empirics. As corporations, the faculties of arts and m edicine (even in the face of these changes) were conservative. They had worked o ut a successful relationship with each other and with other aspects of life. The doctors depended intellectually on philosophy for the content of their theory a nd institutionally on the faculty of arts. Their understanding with society, and particularly with its law-givers, was that their philosophical medicine was the best and deserved a monopoly. Where the faculties of medicine were new or small 15 they had to struggle to implement this agreement and were under constant pres sure to demonstrate the superiority of a philosophical 12 13 14 15 Thus the criticism of the Florentine chronicler Matteo Villani (before 1368) was largely that the doctors had no explanation of the plague in natural-philosophi cal or medical terms. As Siraisi observes, learned explanation and systematic reg imen, rather than cure . . . were and would long remain optimum therapeutic expe ctations. See her Medicine and the Italian Universities, pp. 160, 183. The Paris faculty was also responding professionally to its patron and defender, in whose court we may suppose astrology had a bigger place than it had in the schools. Se e Siraisi, Medieval and Early Renaissance Medicine, p. 42. Lepers, tainted by th e stigma of their disease, were in a sense a race apart and, with the Jews, were sometimes accused of plotting against Christendom. See Luke Demaitre, The releva nce of futility: Jordanus de Turre ( . 131335) on the treatment of leprosy, Bulletin of the History of Medicine, 70 (1996) 2561. Cf. the discussion of the faculties in chapter 4.

The weakening of the Latin tradition 131 and dialectical (i.e. Aristotelian) medicine in a natural world that was by agre ement much as Aristotle had described it. After Aquinas, the church accepted tha t the world had been put together and worked in an Aristotelian way, and church and medicine found mutual support in each other, especially in the north, where many medical men were also bene ced clergy. The university served its patrons, its students, its town and itself. As corporations of experts who had de ned medicine and philosophy in curricular and statutory terms, there was a lot to be said fo r keeping matters as they were; change would have been destructive in a complex set of relations. It is argued here that the doctors helped to construct the exp ectations of the people who experienced medical help and who were steered to app rove most of the long-term advice, routine bleeding and uroscopy, charitable tre atment of the poor and attendance at epidemics of their doctors. Yet when Europe had recovered from the consequences of the Black Death matters were changing. A number of movements combined to weaken the authority that the Rational and Lear ned Doctor derived from his reason and learning. The Hellenists of the late fteen th century tried to bypass the Latin tradition and hear the old authorities in t heir own tongue, Greek. Astrology provided a mathematical rationality that was a t best indifferent to the physical reasoning of Aristotle. In Italy, ducal and o ther courts were cultural centres that did not directly depend on the universiti es. Italian Civic Humanism, like Hellenism, was not a creature of the incorporated faculties. There were physicians, too, outside the universities, who came to ha ve an important in uence on medicine (we shall look at Paracelsus and Cardano,16 w ho were for periods rejected by the university physicians). Further into the six teenth century the Reformation changed the way some people thought about Christi anity and weakened the mutual support of the traditional areas of thought. The L atin tradition of medical scholasticism so far covered in this book corresponds broadly with what historians sometimes call the universal age of medieval Europe. The term expresses the difference between old and new Europe. The old corresponds ro ughly with the old Roman Empire, while the new, to the north and east, included areas not Christianised until the rst millennium; the universal age covers the pe riod of their common history, from about 1200 to about 1380, from Innocent III t o the Great Schism.17 The latter meant loss 16 17 See chapter 6. See Peter Moraw, Careers of graduates, in Walter R egg, general ed., A History of the University u in Europe. Volume I Universities in the Middle Ag es, ed. Hilde de Ridder-Symoens, Cambridge (Cambridge University Press), 1992, p p. 24479, at p. 252.

132 The Latin tradition of authority, and afterwards regional pressures in Europe began to threaten the unity of Christendom. a s t ro lo g y Mathematical and predictive astrology was found by Europeans in Arabic sources at about the same time as Aristotles physica l works in the late twelfth century. There had been an older astrology concerned with matters like the astral circumstances of a birth, but the new was a highly mathematical treatment of the geometry of the planets and their effects on the sublunar world. There was a necessity in this causal relationship which made it possible to predict what would happen as the malign and benign in uences of differ ent planets waxed and waned. Much of this related to medicine. Control of parts of the body was distributed around the zodiac, allowing the construction of a ce lestial anatomy.18 Astrology dictated when and where to let blood or take drugs. T he course and outcome the prognosis of acute diseases were predicted from the mo tion of the moon, while those of chronic diseases were predicted from the sun. L ike the doctor, the astrologer had an impressive stock of theory, based (like th e doctors) on macromicrocosm relationships, which impressed the client; the astrol ogical good story. Astrology had been linked closely in the Arabic sources19 to me dicine and even to Aristotelian natural philosophy, but when it was used in twel fthcentury Europe the Aristotelianism of it meant little. Roger of Hereford, the late twelfth-century source of much English astrology, knew nothing of Aristotl es natural philosophy. The natural link with medicine remained, however, and medi cal men before and outside the new studia used it extensively. An example is Wil liam of England, who practised medicine in early thirteenth-century Marseilles a nd who constructed a form of prognostication combining uroscopy and astrology. T he physicians display of examining the patients urine, brought to him in a jordan carried in a wicker basket, was a show that demonstrated his skill at diagnosis and prognosis while still distant from the unseen patient. Williams display was t o show his skill at something even more dif cult: to make astrological judgements about the urine without seeing it.20 18 19 20 See Roger French, Foretelling the future. Arabic astrology and English medicine i n the late twelfth century, Isis, 87 (1996) 453480. Most important of these for We stern readers is the Introductorium in Astronomiam Albumasaris Abalachi octo con tinens libros partiales, Venice (no publisher given), 1506. The text is the De U rina non Visa. It dates from 1219 and has not been published; it came to be taug ht by statute in Bologna. There are many mss., for example Cambridge, Trinity Co llege, 0.8.31.

The weakening of the Latin tradition 133 But when the medical men organised themselves in the new studia it was on the ba sis of their theory being derived from Aristotles natural philosophy. This was ra tionality quite different from the astrological. Aristotle held that numbers (th e basis of the astrologers impressive calculations) could not reveal the essences of things. The personalities of the planets, which determined their benign or m align in uences on things below the moon, were antithetical to Aristotles world. In deed, the capricious actions of Jupiter or Mars were precisely what the old Gree k philosophers had wanted to exclude from the world, and we have seen that when Aristotle wanted to introduce purpose into the natural world, it was an aspect o f nature in his rather special sense. Moreover, for Aristotle the heavenly bodie s re ected perfection of a kind and were carried in their circular orbits by spher es. Scholastic medicine was not, therefore, very astrological. Certainly, Willia m of Englands tract was taken into the curriculum in some of the Italian studia, but up to and including the consolidation of the faculties in the early fourteen th century, medical statutes remained committed to the Articella, the New Galen, and the big Arabic treatises. We have less information about what went on in th e doctors practice, of course, and certainly there was interest in astrology in p rincely courts, where prediction of earthly events was as important as medical p rognosis. Medical advice could also be astrological, and from Pietro dAbano to th e Black Death and the French Disease at the end of the fteenth century astrology could be used to explain medical events and to show that doctors could do little against celestial necessity. Pietro was well aware that the doctors reputation c ould be enhanced by using astrological prognostication when the patients symptoms were ambiguous.21 Doctors at the time disputed about whether astrology was part of medicine or an adjunct to it,22 in terms reminiscent of the philosopher/phys ician disputes. Indeed, it seems that these later disputes also represent a disc iplinary boundary. If he crossed the boundary, the astrologising doctor had to p ut on another hat, accept other authorities and adopt a form of rationalising quit e distinct from the Aristotelian. To the considerable extent to which medicine w as astrological by the end of 21 22 Differentia 168: Pietro dAbano, Conciliator Controversiarum, quae inter Philosoph os et Medicos versantur, Venice (Heirs of L. A. Giunta), 1565. This was the subj ect of a dispute in 1496 on the French Disease between Simon Pistoris, a scholas tic doctor of Leipzig, and Martin Pollich of Mellerstadt, a Humanist. Pistoris a rgued that astrology was not a proper part of medicine, but a useful art of the doctor; Pollich changed his mind when his Italian hero, Pico, argued against ast rology. See Jon Arrizabalaga, John Henderson and Roger French, The Great Pox. Th e French Disease in Renaissance Europe, New Haven and London (Yale University Pr ess), 1997, p. 92.

134 The Latin tradition the fteenth century, it was partly divorced from its reliance on Aristotelian nat ural philosophy. But the doctor used astrology in the same way, for if his patie nts believed in astrological determinism, it was good for the doctor to be seen as skilled in its technicalities. Astrology was fashionable throughout society i n the fteenth century and the doctor responded by adopting it as part of his clin ical patter; even the medical opponents of astrology (such as Jacques Despars in Paris) recognised that the physician might have to pretend to rely on it.23 The decline in fashion of astrology began perhaps with the attack on it by Giovanni Pico della Mirandola, who contrived to make it appear scholastic in an old-fash ioned way and a practice of a minority the Jews. He argued that the astrologers had wormed their way into positions close to powerful gures by using plausible bu t fallacious stories of the effectiveness of their trade; in fact, exactly the s ame as the doctors were doing.24 Substitute medicine for astrology and we have an al legory for the story of this book. h e l l e n i s m a n d t h e a n c i e n ts Another movement growing up outside the schools was an interest in things Greek. Civic teachers of Greek had been sponsored for the purposes of trade between th e Italian city-states and Greek-speaking areas to the east.25 By the fteenth cent ury Greece was a dwindling area around Constantinople, the old capital of the East ern Roman Empire that had long since become entirely Greek in language and chara cter. Under pressure from the Turks, Byzantine envoys negotiated at the Council of Florence in 1439 for the military help of the Italian cities. It was not fort hcoming, and the nal disappearance of the Eastern Empire in 1453 was associated w ith a ood of Greek emigrs to Italy. The aims of these men included the setting up of a e new Greek state and they made targets of the politically powerful, arguin g in princely courts rather than universities.26 23 24 25 26 Jacquart, Medical scholasticism, p. 234. Astrology was in the statutes of Bologna by 1405. See Nancy Siraisi, The faculty of medicine, Universities in the Middle Ag es, ed. de Ridder-Symoens, pp. 36087, at p. 379. Giovanni Pico della Mirandola, D isputationes adversus Astrologiam Divinatricem, ed. Eugenio Garin, 2 vols., Flor ence (Vallechi), 194652; vol. 1, pp. 603. See Deno John Geanakoplos, Greek Scholar s in Venice: Studies in the Dissemination of Greek Learning from Byzantium to We stern Europe, Cambridge, Mass. (Harvard University Press), 1962, and Interaction of the Sibling Byzantine and Western Cultures in the Middle Ages and Italian Rena issance, 13001600, New Haven (Yale University Press), 1976. The disputes about th e French Disease in courts in Ferrara and Rome were, for example, in contrast to the scholastic university disputations in Leipzig. See Arrizabalaga et al., The G reat Pox.

The weakening of the Latin tradition 135 The Greeks were convinced of their own cultural superiority. They had resented t he Westerners as barbarians since a crusade had been diverted to Byzantium in th e early thirteenth century, when a short-lived Latin kingdom had been set up the re.27 A number of Westerners agreed with the cultural claims of the Greeks and w ere accordingly called Hellenists. As for the medical men, many recognised that th e authorities of their subject had been Greek and that perhaps the medicine of t he Arabs was derivative. It followed for the Hellenists that if one wanted to he ar the ancients as though they were speaking in the same room, one had to listen i n Greek. Greek medicine was purer because it was older; it was a modern duty to learn the language of the ancient doctors. This meant that Latin became the lang uage merely of commentators. It was, moreover, ugly, and even Western Hellenists talked of the stutterings of barbarians in contrast to the eloquence of Greek. Commentaries, disputed questions and all the apparatus that the men of the schoo ls had used to understand the ancients could be bypassed by listening to the uni nterrupted voices of the ancients in their own language. Part of the apparent ug liness of the technical language of medicine was that it was full of neologisms, partly derived from the Arabic. The school physicians stoutly defended their Ar abic sources as their professional authorities,28 while the Hellenists indignant ly accused the Arabs of stealing and distorting Greek medicine; and, as we have seen before, brief accounts of the history of medicine generally stop with Galen . The medicine of the schools was also highly dialectical, which did not add to its beauty in the ears and eyes of the Hellenists. The older Western Humanists, whose business was with literature and poetry, had also been horri ed and intimida ted by the schoolmens use of complex modes of rational argument, many of them Eng lish in origin. Hellenists, moreover, were not so tightly bound to Aristotle as the scholastics and talked a great deal more about Plato.29 Hellenism was not, t hen, the same thing as Humanism. Hellenist was a contemporary term, used for examp le by the anatomists Berengario da 27 28 29 The culturally important event was the attempt in 1205 by Innocent III and the n ew emperor, Balduinus, to encourage a migration of masters from Paris to Constan tinople to reform the studium, the seat of Greek learning. See Heinrich Deni e and E mile Chatelain, eds., Chartularium Universitatis Parisiensis, 4 vols., Paris, 18 8997, vol. 1, p. 62. But it is notable that no new translations from the Arabic w ere made after the thirteenth century. Jacquart, Medical scholasticism, p. 215. Fo r an introduction to these developments see the articles in Quentin Skinner and Eckhard Kessler, eds., The Cambridge History of Renaissance Philosophy, Cambridg e (Cambridge University Press), 1988.

136 The Latin tradition Carpi and Gabriele de Zerbi.30 In this example, the context was characteristic: Greek, Arabic and Latin sources had given a number of terms for the structures o f the abdominal wall, some of which in their native tongues had been synonyms, w hich encouraged the anatomists to look for more structures than there were. The Hellenists used the Greek term, ignored the others and had a correspondingly sim pler anatomy. Scholastic medical men had used some of the devices of humanism, p articularly a historical evaluation of texts, to try to reduce problems of this kind, and by the sixteenth century medicine was humanised as much as a technical s ubject could be. Some Hellenists had a humanist education before going to a univ ersity for one of the specialised sciences.31 One of the skilled Hellenists known to Berengario was Niccolo Leoniceno (14281524), who was able to attack Avicenna a nd Pliny with such a training; Berengario himself had had a humanist training wi th Aldo Manuzio before learning medicine. It should be noted that the Hellenists , although having drawn the attention of historians as heralds of change, were f ew in number and that the bulk of even elite medical men continued as they had d one for very many years.32 Platonism and early neo-Platonism were ways of lookin g at the world that differed greatly from the Aristotelianism of the schools. Mu ch celebrated in accounts of the Renaissance, these movements touch our story in sofar as they were re ected in medicine and its traditional reliance on natural ph ilosophy. Like the newly rediscovered atomism of the ancients, it offered an alt ernative view of the world that threatened to cause problems for the medical man . In principle, the doctors views were already partly informed by Galens Platonism , and they could nd Platonic support for their disputations with the philosophers when they argued that the brain and not the heart was the origin of the nerves, and that the body had been put together in a rational way by a bene cent deity.33 Likewise the medical men 30 31 32 33 The term they used was periti eleni. See Jacopo Berengario da Carpi, Carpi Comme ntaria cum amplissimis additionibus super Anatomia Mundini una cum textu eiusdem in pristinum et verum nitorem redacto, Bologna (Hieronymus de Benedictis), 1521 , f. 49r; Gabriele de Zerbi, Liber Anathomie Corporis Humani et singulorum Membr orum illius, Venice (Octavianus Scotus), 1502, f. 7v. For a discussion of the an atomy concerned, see Roger French. Berengario da Carpi and the use of commentary in anatomical teaching, in Andrew Wear, Roger French and Iain Lonie, The Medical Renaissance of the Sixtenth Century, Cambridge (Cambridge University Press), 198 5, pp. 4274. See Paul Oskar Kristeller, Humanism, in The Cambridge History of Renai ssance Philosophy, pp. 11337. See also Vivian Nutton, Hellenism postponed: some as pects of Renaissance medicine, Sudhoffs Archiv, 81 (1997) 15870, who remarks on th e small numbers of Hellenists and the shortage of Greek texts, partly in a Germa n context. Galens Platonism became more apparent in his De Placitis Hippocratis e t Platonis, which was known in a few manuscripts from the fourteenth (or even th irteenth) century. See Vivian Nutton, De Placitis Hippocratis et Platonis in the Renaissance, in Le Opere Psicologiche di Galeno, Atti del Terzo

The weakening of the Latin tradition 137 could nd in Galen a particular mode of forming inductions from sensory observatio n. This became known as the rule of Socrates and was a way of bringing a number of observations together to make a single statement, which was then divided at the natural articulations that had become apparent. The Hellenist Niccolo Leoniceno complained that Pliny had not used this method and was accordingly in error;34 and in his own explanation of the famously obscure three doctrines set out by Gale n at the beginning of the Tegni, Leoniceno said that the doctrines to be used in investigating (rather than teaching) included the three Platonic methods of resol ution, division and de nition (these had nothing to do, of course, with scholastic methods with the same titles).35 But most Platonism was at an entirely differen t level. Its advocates were generally not men of the schools not incorporated an d lacked the institutional and intellectual barriers between the disciplines. To them, school philosophy, perhaps particularly the Averroistic Aristotelianism o f Padua, was too rigid and too pagan. School medical thinking also tended toward s Averroism, no doubt because of the availability of the Colliget. The Platonist s did not accept the strict separation of philosophy and theology, as maintained by the school Aristotelians, and held that a Platonic account of the world coul d and should be pious in a Christian way. Plato, after all, had described a worl d created in a rational and bene cent way by a deity, and a soul that returned to the heavens at the death of the body, on all of which Aristotle was conspicuousl y silent. The search for the most ancient authors those who authored the purest form of knowledge focused upon the gure of Hermes Trismegistus, thought by some t o be the source of Platos wisdom.36 To the Platonist the natural world was so obv iously part of God that there was a living sympathy between its parts.37 Marsili o Ficino (143399) held that earthly talismans sympathised Colloquio Galenico Internazionale, Pavia, 1012 settembre 1986, ed. Paola Manuli a nd Mario Vegetti, Naples (Bibliopolis), c. 1988, pp. 281309. Niccolo Leoniceno, O puscula, Basel (A. Cratander & J. Bebellius), 1532, ff. 2r, 3rv, 5r, 16v. Galen h ad identi ed the rst stage in the rule of Socrates as a bringing together of similari ties, which enabled him to nd it too in the Hippocratic surgical works. It is not clear how widely this was known to medical men in the Renaissance. See Nicholas Jardine, Epistomology of the sciences, The Cambridge History of Renaissance Philo sophy, pp. 685711, at p. 705. Leonicenos orientation was Paduan Aristotelianism: s ee Roger French and Jon Arrizabalaga, Coping with the French Disease: university practitioners strategies and tactics in the transition from the fteenth to the six teenth century, in Roger French, Jon Arrizabalaga, Andrew Cunningham and Luis Gar ca-Ballester, Medicine from the Black Death to the French Disease, Aldershot (Ash gate), 1998, pp. 24887, at p. 265. Ficino was commissioned by Cosimo de Medici to translate the corpus hermeticum, which he completed in 1463. On Ficino see Charl es H. Lohr, Metaphysics, The Cambridge History of Renaissance Philosophy, pp. 53763 8, at p. 571; and Brian P. Copenhaver, Astrology and magic, ibid., pp. 264300, at p . 283. 34 35 36 37

138 The Latin tradition with their celestial counterparts. Important for the story of this book is that Ficino (not a scholastic, but a courtier and a leading member of the Florentine Academy) developed a notion of occult qualities. Certainly there were primary, e lementary qualities of the traditional kind, and secondary qualities that follow ed from them, like hardness or sweetness, but he also gave attention to tertiary qualities, qualitates occultae. The doctrine was ultimately medical, deriving f rom the medieval development of the whole substance action of drugs:38 Ficino quot es Taddeo Alderotti, Arnau of Vilanova and Jacopo da Forl , and the doctrine bec ame important in the slow erosion of Aristotelian natural philosophy.39 While ne o-Platonism encouraged thought on natural magic and astrology, it was not entire ly sympathetic to the mathematical predictive astrology practised by doctors. Wh en Giovanni Pico della Mirandola (146394) attacked judicial astrology it was beca use its determinism offended his conception of the nobility and freedom of man.4 0 Pico, although not a man of the schools, had his medical followers and there w ere disputes in Italy and Germany at least on whether astrology was part of medi cine.41 In dismissing astrology Pico made it look old fashioned, impious and sup erstitious. Ideally, then, it was practised by other people, and as we have seen , he points to the Jews. Not only did they fail to predict the French Disease, h e said, they failed to foresee their own persecution and expulsion. t h e res la tina Distinct from the Hellenists of the fteenth century were the Western Humanis ts. These were the men who studied and taught the more human topics such as ancien t literature and poetry; the humanista was, like the legista or anathomista, a s pecialist and he did not venture into technical subjects like medicine. Originat ing perhaps in northern France, humanism spread to Italy: the humanist existed alo ng with his colleagues in other disciplines early in the history of the universi ties and it is inaccurate to think of humanism as a Renaissance phenomenon that changed the nature 38 39 40 41 See Linda Deer Richardson, The generation of disease: occult causes and disease o f the total substance, in Wear et al., Medical Renaissance, pp. 17594. We shall ex amine the medical Platonism of later years in the next chapter. There were major developments, too, arising from a new style of thinking that appeared in the la te fteenth and early sixteenth centuries and which at once offered an alternative to traditional natural philosophy and hence to the theory of medicine, Lucretia n atomism and Pyrrhonian scepticism. Disputationes adversus Astrologiam Divinatr icem, Bologna (Benedictus Hectoris), 1496. See Arrizabalaga et al., The Great Po x, pp. 90ff and chs. 3 and 4. It is signi cant that the disputes were about an epi demic that placed strains on medicine.

The weakening of the Latin tradition 139 of university teaching and was opposed to scholasticism. Indeed, the early Human ists have been called scholastic.42 Certainly in Italy there was some con ation of humanism with the later Hellenism, and Italian civic humanism ourished outside t he universities. However, in Germany for example, humanism remained mostly a sch ool business, despite following an Italian lead.43 Although the Humanists did no t tackle the technical subjects such as medicine and philosophy, a number of the ir techniques were applicable to them. As mentioned above, they developed a hist orical sensitivity to their texts, thinking of them in relation to the circumsta nces that produced them. The same could be applied to medical texts by the men w ho read and taught them, and by the early sixteenth century medicine had probabl y absorbed as much humanism as it could take. Medical men such as Berengario da Carpi in Bologna and experts in the equally technical eld of law, such as Collenu ccio, who defended Pliny from Leonicenos attack, were content to call themselves s cholastic in the sense of being masters of a complex discipline.44 Only later did the Hellenists and Humanists outside the universities use scholastic in a pejorat ive sense to mean (in the case of medicine) over-subtle and over-extensive use o f logic and the practice of analysing texts by breaking them down into points. Leo niceno mocked Gentile da Foligno, whom he called the old expositor of Avicenna45 ( that is, before the plague), and the practice of citing lemmata of the text to i dentify where the commentary should go, so that his discussion was littered with there . . . and there . . ., ibi . . . ibi. Leoniceno, of course, wanted the clear and unbroken voice of the Greek author to be heard without hindrance. Scholastic m edical men such as Berengario and Gabriele de Zerbi in Padua knew of the Helleni sts and their desire to abolish all but Greek technical terms. They were the per iti eleni, and their love of Greek was graecitas.46 But the men of the schools r esented the high cultural tone adopted by the 42 43 44 45 46 See Southern, Scholastic Humanism, vol. 1, esp. ch. 1. See Lewis William Spitz, The Religious Renaissance of the German Humanists, Cambridge, Mass. (Harvard Uni versity Press), 1963; M. Watanabe, Gregor Heimburg and early humanism in Germany, in E. P. Mahoney, ed., Philosophy and Humanism: Renaissance Essays in Honor of P aul Oskar Kristeller, Leiden (Brill), 1976; P. Joachimsen, Humanism and the growt h of the human mind, in Gerald Strauss, ed., Pre-Reformation Germany, New York (M acmillan), 1972. See Pandolfo Collenuccio, Pliniana Defensio Pandul Collennuciii Pisaurensis Iuriconsulti adversus Nicolai Leoniceni Accusationem, Ferrara (Andre as Belfortis), 1493. Leonicenos Opuscula contain fragments, of which no. 22 conta ins a reference to Gentile the expositor of Avicenna. At f. 29v Gentile is the ol d expositor of Avicenna (older at f. 43r) where the chronological division is the p lague. In contrast, Jacobus de Partibus, writing in the century after the plague , was for Leoniceno one of the recent commentators (Opuscula, f. 47v). Leoniceno defends himself against the charge of affectation of Graecitas in his Opuscula.

140 The Latin tradition Hellenists when addressing each other in the elaborate prefaces of their books. They resented their own language of exposition and commentary being described as stuttering and the implication that they were rustics or barbarians. Perhaps in r eaction to graecitas they drew attention to their own Latin culture, the Latin bu siness, Res Latina. One of their heroes was Pliny, who had been scornful of Greek vanity, vanitas Graecae,47 especially in relation to medical theory. Drawing on another Latin hero, Celsus, as a model of clear and elegant Latinity, they cele brated Western scholarship in medicine, what we are calling in this book the Lati n tradition.48 It was into this tradition that the teacher of the schools worked to draw his pupils. His aim was to instil in them a faith in what they were bein g taught, in him and in the teachers of teachers, back to the founding fathers o f medicine. This tradition included formal exposition, commentary and disputed q uestions. The considerable bulk of medieval material being printed in the early sixteenth century shows that the schools retained their appetite for the Latin w ay of doing things: it was the conservatism of the incorporated faculty. Authori ty for the Hellenists was Greek only and their histories of medicine jump from G alen to themselves. In contrast the older scholastics such as Gentile began to t urn their contemporaries and immediate predecessors into authorities,49 who beca me authorities, too, to the readers of the sixteenth-century editions. New autho rs of the late fteenth and early sixteenth centuries also found that they could g ive authority to themselves by publishing their own works, but what they produce d remained small in comparison to the printing of scholastic material.50 It was this faith in the Latin tradition that the scholastics saw the Hellenists as try ing to destroy. Leonicenos attack on Pliny was, after all, on a major Latin autho r, a classical authority from whom much medicine had been derived over the centu ries.51 Collenuccio, the lawyer who came to Plinys defence, did not argue that Pl iny had never made mistakes, but that minor crimes could be excused if the gure i nvolved were an 47 48 49 50 51 See O. Pedersen, Some astronomical topics in Pliny, in Roger French and Frank Gree naway, eds., Science in the early Roman Empire: Pliny the Elder, his Sources and In uence, London (Croom Helm), 1986, pp. 16296, at p. 188. Celsus writings were red iscovered in 1426 in Siena. See Nutton, Hellenism postponed, p. 164. See Fernando Salmon, Technologies of authority in the medical classroom in the thirteenth and fourteenth centuries, in Cornelius OBoyle, Roger French and Fernando Salmon, eds., El Aprendizaje de la Medicina en el Mundo Medieval: las Fronteras de la Ense anz a Universitaria, Granada, 2000 n [Dynamis, 20 (2000)] pp. 13557. See French and A rrizabalaga, Coping with the French Disease, p. 269. See also Arrizabalaga, The dea th of a medieval text: the Articella and the early press in French et al., Medici ne from the Black Death to the French Disease, pp. 184211, at p. 187. For example , a collection called the Medicina Plinii was published in Rome in 1509.

The weakening of the Latin tradition 141 ornament to his society Latin society: Leoniceno was rather unusual in combining a technical subject, medicine, with Hellenism, and he urged other Hellenists to do likewise. Collenuccio saw this as a Hellenist programme to invade scholastic topics, and argued in turn that scholastics like himself should extend their ow n boundaries and embrace Greek. But he knew that the separation of academic disc iplines was still secure and that as a lawyer he risked censure in using his scyt he in a foreign eld, that is, one of eloquence and letters, which were Hellenist codewords for Greek. All this left its mark on European culture and the way we look at its past. The Hellenists succeeded in the courts of the great and among the upp er classes of society rather than in the schools. But ultimately, as we shall se e, the schools traditional learning was replaced and genteel education remained c lassical for a long time. Few of us have been untouched by the Hellenists victori es outside the schools: just when scholasticism acquired a pejorative meaning, so the period of the Middle Ages became identi able as a period between them (the cla ssical past, mostly Greek) and us (who are trying to promote its rebirth in a Ren aissance). The middle ages was thus de ned as a period between two cultural stools, a s it were. The word barbaric, as a classical sneer for this intermediate period, c ame into use even in medicine in the early sixteenth century.52 The English term Middle Ages seems to be an invention of the Enlightenment,53 a local culmination of the movement to restore classical values begun by the Hellenists. Faith in th e medical tradition was broken in a much more radical way by Vesalius. He consti tutes a topic on which much has been written, but it is not the purpose of this book to retell the stories of medical heroes. Rather, let us return to the topic with which we started. Vesalius was conspicuously successful, becoming physicia n to the Holy Roman Emperor.54 His career in a sense shadows that of Galen, the man whose theory of anatomy he 52 53 54 It was used of Gentile himself. See Nancy G. Siraisi, Avicenna in Renaissance It aly. The Canon and Medical Teaching in Italian Universities after 1500, Princeto n (Princeton University Press), 1987, p. 73. But the Hellenist Leoniceno recogni sed Gentiles worth on the topic of compound medicines: Opuscula, Basel (A. Cratan der & J. Bebellius), 1532, f. 29v. Gentile, he says, is the medicus with the gre atest authority of our age. The term Middle Ages seems not to occur in English bef ore the eighteenth century (OED) and it seems to be the product of an Augustan a ssumption of identity with the classical past, leaving a period in between to be named merely by its position. Medieval is rst noted in the early nineteenth centur y in English, and worthwhile study of the period seems to have followed an encyc lical of Pope Leo XIII in 1879. See Southern, Scholastic Humanism and the Uni cati on of Europe, vol. 1, p. 2. The Fabrica has been called a status-statement and a patronage artefact. See Mario Biagioli, Scienti c revolution, social bricolage, and etiquette, in Roy Porter and Miluk Teich, The as Scienti c Revolution in National Con text, Cambridge (Cambridge University Press), 1992, pp. 1154, at p. 17.

142 The Latin tradition so strongly attacked, but which directed the shape of his own work; it was partl y on the merits of Galens anatomy that he had become physician to Emperor Marcus Aurelius and his son Commodus. Perhaps the only equivalent to being an imperial retainer in Vesalius day was being a papal one, and to earn such a position (as A rnau of Vilanova did) was the highest ambition for the Learned and Rational Doct or: he was a success. Yet, of course, we have little information on how effectiv e Vesalius was as a clinician. His success was that he changed the nature of ana tomy and made himself highly conspicuous. In the late 1530s he guessed that Gale n had never dissected a human body. This meant that the whole of Galens anatomy w as potentially wrong and the business of the anatomist was now to start at the b eginning and con rm or deny Galens descriptions. The impact of Vesalius De Humani Co rporis Fabrica was immeasurably increased by the impressive woodcuts, drawn and engraved by craftsmen of the highest order (who seem to have given him some trou ble).55 In the text, Vesalius attacked Galen with vigour and some venom. In orde r to correct Galen on as many points as possible, Vesalius was obliged to follow Galens anatomy closely. This, together with the striking illustrations, meant th at Vesalius anatomy was largely morphological; Vesalius either agreed or was not concerned with Galens account of function, which had been perhaps the prime objec t of anatomy in the philosophical tradition from Aristotle onwards. The book div ided the medical community. Those who opposed Vesalius felt that he had exhibite d bad faith in attacking Galen in so bitter a way. It was breaking the faith in almost a religious sense: Vesalius was the apostate who refused to respect the t eacher of all teachers. As in the case of Leonicenos attack on Pliny, the point f or many commentators was not that Galen could make mistakes (for he was human) b ut that he should be attacked in so wanton a way. Anatomists had already shown t hemselves capable of criticising Galen on the detail of his anatomy, while very properly continuing to regard him as the founder of the discipline. What rankled most among the defenders of Galen was Vesalius claim that Galen had cheated , pr etending to have dissected human bodies but in fact making do with animals. On t he other hand, there were those who thought that Vesalius had made a bold new st art and a con dent assertion that medicine could progress without constant recours e to the ancients. 55 For the authority of anatomical illustrations see Martin Kemp, The mark of truth: looking and learning in some anatomical illustrations from the Renaissance and e ighteenth century, in W. F. Bynum and Roy Porter, Medicine and the Five Senses, C ambridge (Cambridge University Press), 1993, pp. 85121.

The weakening of the Latin tradition 143 Vesalius himself claimed that by dissecting human bodies he was restoring the an atomy of Herophilus and Erasistratus (about which he could have known little). T his looks like the Humanists and Hellenists search for the true old form of discip lines, the prisca scientia of the ancients, but it is not easy to include Vesali us in one or other of these categories. Certainly he eschewed medieval commentar y and disputed questions, which had been standard components of anatomy texts ev en for the generation before him.56 In attempting to dethrone Galen he did not t urn away from Greek medicine and anatomy, but it was the Hellenists among his en emies who accused him of de ling the pure founts of Greek knowledge. He did not ha ve sympathy with Arabic medicine but used Hebrew, in an age when religious sensi tivities and a search for ever older sources of knowledge gave importance to the language. He was a man of the schools as a student and teacher, but he avoided the double-column, black-letter textual format, the hallmark of medical and lega l texts designed for the school market. He used scholastic in a pejorative way. Hi s topic was a technical one, and manual, yet he gave his Latin the elevated tone and structure that most Hellenists sustained only in their self-regarding prefa ces and dedications.57 In fact the Fabrica seems well designed for Vesalius purpo ses, one of which was undoubtedly self-promotion. He addresses the emperor as a client and sounds like somebody looking for a patron and a retained position for himself. His message is about medicine, not just anatomy. His argument is that medicine should be (and in ancient times had been) a single discipline and that its practitioner should grow and collect herbs, make up medicines and perform su rgery, rather than leaving these tasks to specialists. He claims to have done th is, involving himself personally and manually in dissection in order to learn th e anatomy that was an integral part of a complete medicine. Vesalius generates t he image of the good anatomist handling the scalpel, demonstrating the parts to an audience and knowing (critically) the standard texts. This would have been fa r removed from the usual situation in which, according to Vesalius, an illiterat e artisan would cut the body, an ostensor would point to the organs and a learne d teacher would sit in a chair reading a text of Galen. As Vesalius says, this s tyle of dissection had 56 57 For example, Berengario da Carpi, Commentaria. A modern translation is therefore useful. See Andreas Vesalius, On the Fabric of the Human Body. A Translation of De Humani Corporis Fabrica Libri Septem, Books 1 and 2, trans. William Frank Ri chardson and John Burd Carman, San Francisco (Norman Publishing), 1998. The stand ard biography of Vesalius is C. D. OMalley, Andreas Vesalius of Brussels 15141546 , Berkeley (University of California Press), 1965.

144 The Latin tradition prevented any discrepancy between the appearance of the body and the words of th e text becoming apparent. But then, such a thing was not the purpose of medieval dissections; and it is Vesalius picture that has coloured many historical accoun ts.58 Dedications to potential patrons quickly became a feature of printed books . Medieval manuscripts customarily begin with the text itself, so that its rst wo rds serve to identify it, although there is occasionally some prefatory material , such as Alfred of Shareshills address to Roger of Hereford in his commentary on the pseudo-Aristotelian De Plantis (late twelfth century).59 Early printed book s often have a title-page addressing the potential reader directly and listing wha t the volume contains: Lector, habes in hoc volumine . . . But soon, between the reader and the text, appears the gure of the editor, who justi es the selections o f a text and its preparation from the manuscripts and who in effect promotes the text.60 As we saw, when authors began to publish works in their own lifetime th en printed books could be effectively used for self-promotion.61 Dedication to a potential patron could be reinforced by congratulatory verses about the author by a third party.62 medical ethics We have seen that the Hippocratic ethical wor ks were, in part, defences of the medicine of one group of doctors in rivalry wi th another. In the medieval 58 59 60 61 62 For a novel view of the purposes of human dissection, see Andrew Cunningham, The Anatomical Renaissance. The Resurrection of the Anatomical Projects of the Anci ents, Aldershot (Ashgate), 1997. For in-school critics of ancient medicine it is w orth noting Giovanni Argenterio (151372), who taught in Pisa from 1543 to 1555 th e dates of the two editions of Vesalius Fabrica attacked Galen, developed the whol e substance doctrine of disease and was called a Pyrrhonian sceptic for his view that medicine was not a true scientia. See Nancy Siraisi, Giovanni Argenterio: me dical innovation, princely patronage, and academic controversy, in her Medicine a nd the Italian Universities, pp. 341, 346. See Nicolaus Damascenus, De Plantis. Five Translations, ed. H. J. Drossaart Lulofs and E. L. J. Poortman, Amsterdam ( North-Holland), 1989. An example is the discussion of the merits of Arnau de Vil lanova and Gentile da Foligno in the biographical essay on Arnau written by Symp horien Champier and the editor of Arnaus Opera omnia. See Arnau de Villanova, Ope ra Omnia, Basel (Conrad Waldkirch), 1585. For a discussion of the role of the ed itor, see Arrizabalaga, The death of a medieval text, p. 190. See Arrizabalaga, The death of a medieval text, p. 187. A number of well-known gures in the history of medicine were successful (in the sense used in this book) in seeking and securin g patronage. Leoniceno taught medicine and was physician to the dukes of Ferrara for over half a century. His pupil Giovanni Manardi was physician to the king o f Hungary. Giovanni Matthioli was a doctor at the Hapsburg court and was able to employ a team of artists for an edition of Dioscorides. Its translation into Cz ech and German was sponsored by Emperor Ferdinand partly for reasons of prestige . Court physicians such as Johannes Crato von Crafftheim (at the imperial court in Vienna) acted as centres of correspondence and wielded considerable power. Se e Nutton, Medicine at the Courts of Europe, introduction, pp. 7, 9.

The weakening of the Latin tradition 145 classroom, the internal ethic of the pupil putting his trust in the teacher and the medical tradition was similar. The pupil received his knowledge from the tea cher, was promoted by him in exercises that made him too a potential teacher, an d perhaps went on to teach. The Hippocratic and the scholastic defended the repu tation of their kind. But in the Middle Ages this training did not extend beyond the school in which the pupil had been taught.63 Gentile da Foligno and Berenga rio da Carpi wrote partly for the honour of their studia, in Perugia and Bologna , and it was normal in disputed questions to undermine the opinions of masters i n other institutions. This caused little dif culty where the faculty or profession al college was powerful and protected the interests of its members. But the pote ntial for discord was there. In particular, the separation of the teaching studi um from the examining college in Italy caused problems. There was hard feeling w hen students left their studium to take their degrees (perhaps because it was ch eaper) at another college. The college included practitioners who did not teach and who had interests different from the doctors who did teach. By the Renaissan ce some doctors recognised that disagreements between these kinds of Rational an d Learned Doctors could lead to a loss of reputation for all university-trained physicians.64 Some such professional clash seems to have been behind the De Caut elis Medicorum of Gabriele de Zerbi in Padua.65 This is a book of medical ethics , addressed to rational and learned physicians as a whole. Probably it was promp ted by Zerbis experience of being contradicted publicly by other physicians whose authority he could not deny. They were collegiants, doctors from a college separa te from the studium in Padua: perhaps they were members of the powerful college in Venice, the city that controlled Padua as part 63 64 65 McVaugh points out that in the Crown of Aragon in the fourteenth century physici ans hardly thought of themselves as a group, and competed at a personal level. I n Barcelona they refused the opportunity to form a professional college. See Mic hael McVaugh, Medicine before the Plague, Cambridge (Cambridge University Press) , 1993, p. 235. In London, the College of Physicians was modelled on the Italian professional colleges. Parliament agreed on the attributes of the ideal physici an, particularly his ethics or deontology and his learning, subjects that consta ntly recur in this book: the physician should be p[ro]founde, sad and discrete, g oudlie lerned and deplie studied in physyk. Quoted by Harold Cook, Institutional s tructures and personal belief in the London College of Physicians, in Ole Grell a nd Andrew Cunningham, eds., Religio Medici. Medicine and Religion in Seventeenth -Century England, Aldershot (Scolar Press), 1996, pp. 91114, at p. 92. Gabriele d e Zerbi, Opus perutile de Cautelis Medicorum, in Pillularium Omnibus Medicis Nec essarium clarissimi doctoris magistri Panthaleonis, Lyons (Antonius Blanchard), 1528. See also Roger French, The medical ethics of Gabriele de Zerbi, in Andrew We ar, Johanna Geyer-Kordesch and Roger French, Doctors and Ethics: the Earlier His torical Setting of Medical Ethics, Amsterdam (Rodopi), 1993, pp. 7297. For a slig htly different interpretation, see David E. J. Linden, Gabriele Zerbis De Cautelis Medicorum and the tradition of medical prudence, Bulletin of the History of Medi cine, 73 (1999) 1937.

146 The Latin tradition of the Veneto.66 Zerbi saw that the vulgar and the plebians, ever ready to poke fun at the learned pomposity of doctors, could cause immense damage to the reput ation of all properly trained physicians by showing that, since they disagreed i n their learning, it could not be trusted. Central, then, to Zerbis ethics was th e need never to air disagreements with other doctors in public. This was medical ethics in the sense we have met before, rules designed at least as much for the bene t of the doctors as of the patient. The doctor should live in a big house, p artly so that everyone knew where it was and partly because it suited his status . The doctor should not play games, go shopping, cultivate land or join in polit ics, each of which would detract from his image as a man totally immersed in med icine. He should, of course, devote himself to reading, partly because learned m edicine was the best and it would be unethical with regard to the patient to pra ctise anything else,67 and partly because learning impressed the patient. The do ctors were often direct about their self-interest, and it was a commonplace that the fee they extracted from a patient in pain was greater than that received wh en he was returning to health.68 The doctors also knew that expensive remedies a cted more surely than cheap ones: princes expected to pay a great deal, leaving common cures to the common people. This belief was no doubt encouraged by the do ctors, especially if they worked closely with the apothecaries, but it was not w holly cynical. The doctor believed that his treatment would be more effective if he had the trust of the patient: in the doctors terms this was a question of ass erting their authority over the patient and securing his obedience. In all these ways the doctor was moulding the expectations of the patient into forms the doc tor could reasonably hope to meet: it was by this (and not by any modern criteri on) that his success was measured. The ethics of a medical man such as Clementi Clementini (a nearcontemporary of Zerbi) were partly the result of a recognition that Hippocratic ethics could apply to all those who had become learned in the 66 67 68 Sometimes the colleges, such as that in Milan, restricted entry exclusively to t hose of local origin. See Ann G. Carmichael, Epidemics and state medicine in fteen th-century Milan, in French et al., Medicine from the Black Death to the French D isease, p. 222. See Luis Garca-Ballester, Medical ethics in transition in the Lati n medicine of the thirteenth and fourteenth centuries: new perspectives on the p hysicianpatient relationship and the doctors fee, in Wear et al., Medical Ethics, p p. 3871. This was also a criticism of the doctors which was made at least since t he time of John of Salisbury. Dum dolet accipe he said of the doctors attitude to his fee. See C. I. I. Webb, ed., Ioannis Saresberiensis Episcopi Carnotensis Po licrati sive de nugis curialium et vestigiis philosophorum, 2 vols., Oxford (Cla rendon Press), 1929; vol. 1, p. 168. On the taking of fees see also Carole Rawcl iffe, The pro ts of practice: the wealth and social status of medical men in later medieval England, Bulletin of the Society for the Social History of Medicine, 37 (1985) 2730.

The weakening of the Latin tradition 147 medical tradition. The ethical works began to appear in the old medical textbook , the Articella, and Renaissance editions of the Hippocratic works sometimes beg in with them, as though they were the deontological imperatives for the whole of medicine.69 This is perhaps why Clementini dwells on prognosis, the attractions and dangers of which had been well known since Western doctors began to read th e glorious Hippocrates.70 Do not make more prognostications than necessary, says C lementini, because the outcome of diseases, like that of wars, is uncertain. If the case looks hopeless, do not tell the patient (it would be a self-ful lling pro phecy) but take the assistants to one side. In any case make your prognosticatio ns gloomier than the case warrants, to avoid blame if the patient dies and to re ap the rewards of money and glory if he recovers.71 Prognostication, concludes C lementini, is made on the basis of learning and experience, but learning especia lly philosophy has also the quite different function of enabling the physician t o stand out from and even control the ignorant crowd. The rewards of medical exp erience are also twofold. It should be gained, says Clementini, from charitable practice among the poor: this will make you pleasing in the eyes of God (who wil l reward you in his own way), and constant charitable practice will make you a b etter doctor, which will increase your reputation, which will multiply your fees .72 m e d i c i n e a n d re l i g i o n The Reformation changed many attitudes to authority, including the European learned tradition. This was notably the cas e in natural philosophy, and consequently had an effect upon the theory of medic ine. Aristotle was, once again, central. We have seen that in the thirteenth cen tury Aristotles physical works could in different circumstances be used to both p romote and suppress heresy different perceptions of authority. After Aquinas mast erly synthesis of natural philosophy and Christianity, the churchs guidance was i ntellectual as well as spiritual. But the reformers disliked the fact that this guidance was provided only by priests and they began to question its content. Ar istotle, after all, had considered that the world was eternal and did not have a Creator; philosophy began to look rather pagan. At the reforming university of Wittenberg Jakob Milich tried to construct part of an arts course using Plinys Na tural History in place 69 71 72 70 See chapter 3, above. See chapter 1, above. For the physicians reason for not telling the truth in his prognosis, see Winfried Schleiner, Medical Eth ics in the Renaissance, Washington, DC (Georgetown University Press), 1995, esp. p. 30. Clementi Clementini, Clementia medicinae . . . noviter in lucem aedita, Rome (J. Mazzochius), 1512.

148 The Latin tradition of Aristotles Meteorology.73 While Luther rejected Aristotle, reformers like Mela nchthon used him constructively in discussing topics such as the human soul. Ind eed, the use of Aristotle in the newer German universities began with the medica l faculties, where Vesalius Fabrica was part of a new look at human anatomy.74 Mo re generally, Protestants often held that Aristotles philosophy was useful, but, like the rest of Catholic knowledge, needed reforming.75 An important consequenc e of the Reformation with respect to medical discussions was the new attention p aid to the soul and the body. The soul was, of course, the immortal soul of Chri stian teaching, and the body, its terrestrial home, was often seen as the image, or temple, of God. To return to Philip Melanchthon (14971560) in Wittenberg, we see that he turned to the anatomy of Vesalius and had anatomical gures printed fo r his students.76 This meant that anatomy was now taught in the arts course and not in conjunction with the higher faculty of medicine. Potentially at least, it reached far more students; and in removing the connection with medicine it rein forced the autonomy that anatomists had looked for. As an arts course subject in a reformed curriculum, anatomy reached as far as St Andrews, Glasgow and, by th e early seventeenth century, Aberdeen, where they used the up-to-date textbook o f Bauhin.77 These circumstances played their part in ensuring that anatomy survi ved the crisis in the theory of medicine, as we shall see. In extreme cases the Protestant attitude led to complete rejection of the learned tradition. It is we ll known that Paracelsus thought that he could learn more medicine by travelling and observing than from any library, and that the books of Hippocrates and Gale n should be burned.78 The Rational and Learned Doctors of the universities saw h ow disastrous this would be for their kind of medicine, so they prevented him fr om getting a teaching position and burned his books. Paracelsus held that medici ne was a gift 73 74 75 76 77 78 See Commentarii in librum secundum Historiae mundi C. Plinii conscripta a Iacobo Milichio, The Hague (Petrus Brubacchius), 1535. This work represents Milichs lec tures at Wittenberg. The text and its editions are also discussed by Bruce Eastw ood, Plinian astronomy in the Middle Ages and Renaissance, in French and Greenaway , Science in the Early Roman Empire, pp. 197235, at p. 218. Lohr, Metaphysics, p. 6 21. See also chapter 6, below. This view is summarised in the work of the later teacher of logic in Leiden, Adriaan Heereboord, who had considerable in uence in c ontemporary Cambridge. See his Ermeneia [Ermhneia] Logica: seu Explicatio tum pe r Notas tum per Exempla Synopsis Logicae Burgersdicianae . . . accedit ejusdem A uctoris Praxis Logica, Leiden (David a Lodensteyn and Severyn Matthysz), 1650. See Vivian Nutton, Wittenberg anatomy, in Ole Peter Grell and Andrew Cunningham, eds., Medicine and the Reformation, London (Routledge), 1993, pp. 1132. See Roger French, Anatomical Education in a Scottish University, 1620. An Annotated trans lation of the Lecture Notes of John Moir, Edinburgh (MacInnes and Whytt), 1974. See Copenhaver, Astrology and magic, p. 290.

The weakening of the Latin tradition 149 from God, and that doctors were born, not made. God sent diseases, but also cure s; and it was the true doctor who could recognise from signs the abundant natura l remedies that God had provided so that the poor and unlettered could help them selves. The scientia of medicine was not to be acquired from authority, but exis ted in the natural objects themselves as much as in the mind of the doctor. Like many Protestants, Paracelsus was suspicious of the priestly monopoly of knowled ge, and published much of his medical thought in the vernacular, as others were translating the Bible. As a champion of medicine for the people, he argued that any doctor accepting a retained position the Rational and Learned Doctors preferr ed mode of practice was betraying his obligations to use medicine for the common good.79 In short, Paracelsus was a gure outside the universities and standard ac ademic medical training; he and his many metal-based remedies proved attractive to medical men in a similar position, and they became a group that grew in power and came to rival university doctors. There are other aspects of Renaissance me dicine that can be related to the change of attitude to authority and religion. When the arguments over Vesalius and his attitude to Galen had died down a chang e came over anatomy. To some extent there was a return to a study of function, w hich had not played a large part in Vesalius morphological studies. But there was also the loss of the classicism of Vesalius, who had answered Galen in Galenic terms. Before Vesalius it was possible to write a professional anatomy in the sc hools, as Zerbi did, or an aggressively Hellenist anatomy, as Benedetti did, but later in the century references to ancient founts of knowledge often included t he hermetic. In a period of new religious sensibilities the human body was now t he image of God, or His temple. This was not Galens demiurge, but the Christian G od as Creator. Anatomists worked literally in anatomy theatres but also in the t heatre of creation, a stage on which the properties revealed the working of God in Creation. In more general terms, the Hellenists, in attempting to restore a pri sca scientia by returning to pre- or non-Christian Greek writings, could be seen as more pagan than Western Christian.80 Like the anatomists, the natural histor ians used the term theatre in a similar way. A surprisingly large number of them w ere Protestant or had reformist backgrounds. It was for them a religious duty to explore the world 79 80 See Charles Webster, Paracelsus: medicine as popular protest, in Grell and Cunning ham, eds., Medicine and the Reformation, pp. 5777, at p. 66. Perhaps, having lost their own church and state, the new Greek state they called for involved the di sestablishment of the Western church. See Geanakoplos, Sibling Byzantine and Weste rn Cultures, p. 248.

150 The Latin tradition that God had made, whose stamp was on all natural objects. This was seeing for o neself rather than accepting the authority of another, reading the book of natur e alongside the book of revealed knowledge. Systematic knowledge of the worlds pl ants and animals related directly to medical knowledge but it was not itself lea rned and rational in the senses in which we are using the terms. It was up to th e elite doctor to bring it into his domain, to medicalise it. In contrast to the reformers, the Catholics reaf rmed the validity of their learned tradition. It is well known that the Jesuits, particularly of Coimbra, studied Aristotles natural philosophy with a new passion and vigour, but there were also movements that re lated more directly to medicine. It is equally well known that Paracelsus was gi ven by Catholics the insulting title of Luther medicorum, and to Bellarmine the whole of the reform movement was a plague. Medical men were particularly worryin g to the Inquisition because Padua was tolerant of Protestant students, providin g they kept quiet. Medical men were also used to discussing things across a wide range of disciplines, which reminds us of their long education, with its disput ations, maturity and their ability to perform many functions for the rich and po werful. University physicians were, after all, learned; and they had the freedom to visit and talk to patients. In Venice in 1568, the Inquisition brought to li ght a full Protestant conventicle which met in apothecaries and barbers shops.81 t h e f re n c h d i s e a s e A century and a half after the plague arrived in E urope there came another epidemic. It started in 1495, when Charles VIII of Fran ce led an army into Italy to besiege Naples and Ferdinand and Isabella sent a Sp anish army to protect the city. This new epidemic was like no other that Europe had seen before. The French called it the Italian or Neapolitan Disease. In Engl and the disease was popularly known as the Pox. But in educated circles througho ut Europe, the phenomenon was widely referred to as the French Disease (morbus gal licus). Unlike the plague, which came in successive waves and killed its victims quickly, the French Disease lingered painfully in its sufferers and made them h ideously dis gured. As with the plague, the empirics took their opportunity and so ld speci cs and secret remedies. The doctors complained, but this time their claim to be practising 81 Richard Palmer, Physicians and the Inquisition in sixteenth-century Venice, in Gre ll and Cunningham, eds., Medicine and the Reformation, pp. 11833, at pp. 118, 120 , 121.

The weakening of the Latin tradition 151 a superior kind of medicine fell on some unwilling ears. We have noticed that Pa racelsus denied the validity of traditional medicine, and Ulrich von Hutten, an angry and literate sufferer of the French Disease, bitterly complained of the do ctors inability to cure him.82 There was, in other words, a threat to the authori ty of the Rational and Learned Doctor. This went hand in hand with other changes in society. We have seen that the doctors preferred form of practice was to be r etained in a household to guide regimen and study the idiosyncrasies that led hi s patients into this or that disorder.83 But epidemics came quickly to large num bers and seemed to be the same in all, and the doctors were not certain what to do. When towns signed contracts with physicians it was the result of a feeling o f responsibility for the health of the population; the situation owed something to a revival of Roman Law and Aristotelian political thought.84 The doctor was e xpressly required to remain in town during epidemics, but it was clear that ther e was little he could do in the face of the French Disease. It was religious cha rity that built hospitals, often called, signi cantly enough, the incurabili.85 It was the city authorities who organised quarantine or turned people from the gat es.86 There was, in fact, a civic notion of disease, which, in however small a w ay, detracted from the authority of the learned doctor. This is no place for a p otted history of the hospital,87 primarily because it was late in his history th at the Rational and Learned Doctor learned to take advantage of them. But hospit als are of interest here because they were medical centres that were partly in l ay control and they helped to weaken the authority of the doctor. Elite universi ty doctors knew from early on that 82 83 84 85 86 87 Ulrich von Hutten, De guaiaci medicina et morbo gallico Liber unus, Mainz (J. Sc heffer), 1519. In the 1540s John Caius, the Italian-educated English humanist ph ysician, welcomed the fact that the English gentry and the court were using doct ors properly, by retaining them; in other words, the doctors had successfully es tablished this expectation in the minds of their well-to-do patients. See Nuttons introduction to Vivian Nutton, ed., Medicine at the Courts of Europe, 15001837, London (Routledge), 1990, p. 3. As Nutton points out, once established as a reta ined physician, the learned and rational doctor had less need to publish. If he did, it was appropriate that he wrote on the diseases particular to courts. See Werner Friedrich K mmel, De Morbis Aulicis: on diseases found u at court in Nutton, ed., Medicine at the Courts of Europe, pp. 1548. See Garca-Ballester, Medical ethi cs in transition, p. 50. See Arrizabalaga et al., The Great Pox. On the ethics of charity and medical skill see also Chiara e Crisciani, Valeurs ethiques et savoi r mdical entre le XIVe et le XIVe si cle, History and Philosophy e of the Life Sci ences, 5 (1983) 3352. Milan was in the forefront of such civic actions. See Carmi chael, Epidemics and state medicine in fteenth-century Milan. The hospital has rece ntly become a focus of interest to historians, with a growing literature, though no attempt will be made to cover it here. For an introduction to the earlier We stern history of the topic see John Henderson, Piety and Charity in late Medieva l Florence, Oxford (Clarendon Press), 1994.

152 The Latin tradition Haly Abbas had recommended doctors to visit (Islamic) hospitals, learn about cas es and diseases and talk to other doctors; and the Hospitaller knights built ref uges where medical care was available.88 By the end of the thirteenth century th ere were hospitals with doctors in Marseilles and Siena.89 To a certain extent t he doctors were medicalising the hospital (as they medicalised empirical remedie s); and the new duties of recording the causes of death90 called for methods of medical rationalisation not so appropriate for the retained or visiting doctor. Perhaps it was when the big Italian hospitals became associated with a wider civ ic pride91 that the elite doctor saw the advantages of working in them. Even roy al physicians did so. To return to the French Disease, and in particular the spe cialist hospitals that were founded to treat it, the problem for the doctors was that, like the plague, it did not have a proper name. Some of them felt that re al names, given to diseases by the ancients, in some way expressed the essence o f the disease. More generally, the absence of a name prevented the disease from being located in the medical literature. Like the plague too, it could not be cap itulated to the appropriate chapter of Avicennas Canon. The Hellenists, who ignore d this text, could not believe that the disease had not existed in antiquity, or had not been adequately described by the ancients. They consequently searched t hrough Hippocrates and Galen, blaming the barbarity of the Middle Ages for the l oss of the name and description of the disease. At the very least they needed to know what kind of disease it was, so that the medical theory of complexion and the appropriate therapy of evacuation could be used. Again the doctors disagreed , and the Arabists, the Hellenists and the establishment school doctors had radica lly different ideas and aired them in disputations in the universities and in th e courts of the great. Some said it was indeed a new disease, brought by sailors from the New World, where its natural remedy was also to be found in the form o f holy wood or guaiac. In Germany, the Fuggers, who had control of the guaiac trad e, contrived to promote its use in medical texts. Others said that the only trea tment was mercury, which made the patients sweat 88 89 90 91 For the Hospitallers see Jessalynn Bird, Medicine for body and soul: Jacques de V itrys sermons to Hospitallers and their charges, in Peter Biller and Joseph Ziegle r, eds., Religion and Medicine in the Middle Ages, University of York (York Medi eval Press), 2001, pp. 91108 and the texts that follow. For hospitals in Byzantiu m see David Bennet, Medical practice and manuscripts in Byzantium, in Peregrine Ho rden and Emilie Savage-Smith, eds., The Year 1000. Medical Practice at the end o f the rst Millennium [Social History of Medicine, 13 (2000)], pp. 279291, at p. 28 8. See Agrimi and Crisciani, Charity and aid in medieval Christian civilization, p p. 188, 191. Carmichael, Epidemics and state medicine in fteenth-century Milan, p. 226. See Agrimi and Crisciani, Charity and aid in medieval Christian civilization, p. 190.

The weakening of the Latin tradition 153 a great deal. The fact that the disease also seemed to be Gods punishment for bla sphemy did not prevent a German inspection team from going to Spain to study the guaiac method.92 The doctors were aware of their failure to agree and of the da mage to their reputation. Some even admitted that the empirics might by chance h ave hit on a successful treatment. But this was a preliminary to doing what the doctors did very well: they medicalised things. An empirical remedy was drawn in to the apparatus of theory and the doctors claimed that only they could administ er it properly, by considering the age, sex, disposition and habits of the patie nt; only they could determine the quantities that made the remedies effective bu t not dangerous. At the heart of the matter was the difference between the theor y of medicine and its actual practice. Although theory and practice had been separat e categories since late Alexandria,93 and had become institutionally separate in Bologna in the rst half of the fourteenth century, most writings on practice wer e on what we might call the theory of practice. Manual practice was taught by ex ample and experience and accordingly left fewer records. In considering this dif ference it becomes clear that one of the main reasons for writing a medical text was to promote the author. Even surgical texts, which we might expect to be sev erely practical, were written partly for status.94 Sometimes the operations desc ribed had not been undertaken or observed by the author, and in some cases they seem to have been reconstructions of operations described by the ancients. Theor etical texts re ected well on the author and his university, and often contained m atter that explicitly concerned the intellect or imagination only, without any p ossible application to practice.95 92 93 94 95 See Arrizabalaga et al., The Great Pox, p. 100. See Andrew Cunningham, The theory /practice division of medicine: two late-Alexandrian legacies, in Teizo Ogawa, ed ., History of Traditional Medicine (Proceedings of the 1st and 2nd International Symposia on the Comparative History of Medicine East and West), Osaka, 1986, pp . 30324. According to Jacquart, Medical scholasticism, the division was made in Par is in the late thirteenth century, before Bologna. See Siraisi, Medieval and Ear ly Renaissance Medicine, p. 162. See also chapter 4, above. Gentiles plague tract was written for the students and for the glory of Perugia; and his exercises on quanti cation are in part purely intellectual. See Roger French, Canonical Medici ne. Gentile da Foligno and Scholasticism, Leiden (Brill), 2001, ch. 6, and chapt er 4 above.

pa rt i i i The Crisis

chapter 6 The crisis of theory All the order of teaching is troubled and the doctrine of Physick is endeavrd an d learned altogether preposterously and confusedly, without any certain method.1 With these words Jacobus de Back reported the confusion in the schools at the co llapse of traditional natural philosophy. He had taken his MD in Franeker in 161 6, when medicine and natural philosophy were still sisters, as they had been thr oughout the Latin tradition.2 But by the 1630s not only were philosophers seeing a battle between Aristotelianism and the mechanical philosophy, but within medi cine some of the major doctrines of Hippocrates and Galen had been shown to be w rong. De Back felt the pull of old loyalties and declared that he still belonged to the ancient physicians; but clearly they were going to need another re-evalu ation to show that they still had authority in a changed society. How had this c risis come about? Rather than retell a traditional story of a revolution in natu ral philosophy, let us look at its relation to medicine from the point of view o f the Rational and Learned Doctor, who still wanted to be successful. 1 2 The Anatomical Exercises of Dr William Harvey . . . with the Preface of Zacharia h Wood . . . to which is added Dr James De Back, His Discourse on the heart . . . London, 1653; the English translation is of de Backs original discourse of 1648 . For a view of the economic and political crisis in medicine in London, see Cha rles Webster, William Harvey and the crisis of medicine in Jacobean England, in Je rome J. Bylebyl, ed., William Harvey and his Age. The Professional and Social co ntext of the Discovery of the circulation, Baltimore (The Johns Hopkins Universi ty Press), 1979, pp. 127. Scholastics such as Pietro dAbano used the phrase, deriv ed from the well-known commentary on De Sectis by John of Alexandria (as we saw in chapter 3): philosophia et medicine duae sorores sunt. It was a famous dictum of the medieval doctor: see Cornelius OBoyle, Discussions on the nature of medici ne at the university of Paris, ca. 1300, in John van Engen, ed., Learning Institu tionalized. Teaching in the Medieval University, Notre Dame, Indiana (University of Notre Dame Press), 2000, pp. 197227. It is part of the rational and learned d octors message about the nature of his medicine. 157

158 The crisis epidemics change medicine The two great epidemics, the plague and the French Disease, left marks on Europe an medicine.3 While the Learned and Rational Doctors struggled to get to grips w ith these new and unknown, or at least improperly labelled diseases, laymen took practical measures such as quarantine and isolation of the affected, and built hospitals to contain them. The theory of medicine centred on the individual and his constitution and circumstances (the naturals and non-naturals). Epidemics re versed this. The disease was now a person. Its approach could be charted, from c ity to city, and when it arrived it killed or maimed a large proportion of the p opulation, and did so largely in the same way, irrespective of individual differ ences. As an entity, it went from one person to another. Like an unwelcome visit or, the person of the plague went away and returned at intervals. The person of the French Disease was an unwanted guest who stayed too long; so long in fact th at many doctors of the sixteenth century thought that it was growing old and fee ble and would shortly die.4 co n tag i o n The theory of complexion could not ad equately explain these epidemics. A central issue was contagion. It was clear es pecially to the layman5 that both epidemics spread from person to person. For re ligious reasons, this perception was not possible in Arabic medicine, which stil l had great authority in the medicine of the schools.6 That epidemics could be t ransmitted by clothes or merchandise added to the dif culties of explaining them o n the basis of the traditional elementary qualities, which were part of the indi viduals environment and acted directly on him. To pursue our image of the French Disease as a person, some doctors began to think that 3 4 5 6 Some measure of this is the huge quantity of medical literature generated by the plague and the almost equally large number of treatises on the French Disease. This led in our period to attempts to collect and publish all the relevant liter ature, to try to capture the natural history of the disease as a thing. See Jean A struc, De Morbis Venereis libri sex, Paris (Widow of P. du Mesnil for G. Cavelie r), 1736. Jon Arrizabalaga, John Henderson and Roger French, The Great Pox. The French Disease in Renaissance Europe, New Haven (Yale University Press), 1997, e sp. ch. 10. On the lay reaction to epidemics see Sheldon Watts, Epidemics and Hi story. Disease, Power and Imperialism, New Haven (Yale University Press), 1997. But see Lawrence I. Conrad, A ninth-century Muslim scholars discussion of contagio n, in Lawrence I. Conrad and Dominik Wujastyk, eds., Contagion. Perspectives from Pre-Modern Societies, Aldershot (Ashgate), 2000, pp. 16377. See also in the same volume Vivian Nutton, Did the Greeks have a word for it?, pp. 13762 and Francois-O livier Touati, Contagion and leprosy: myth, ideas and evolution in medieval minds and societies, pp. 179201.

The crisis of theory 159 it had a material basis, the matter of disease. Postmortem dissection had been p ractised since the thirteenth century to discover causes of death, and the disse ctor relied on a knowledge of the normal body in order to identify what was path ological; but in the sixteenth century those who dissected victims of the French Disease were generally looking for an intrusive substance. Some found a white o r viscous matter close to the bones, where so much pain had been felt (some call ed it virus, slime).7 The wide and rapid spread of both epidemics was explained in some quarters as part of Gods punishment.8 Perhaps He had used secondary causes, such as corruption of the air from celestial sources that were open to astrolog ical interpretation. But then it was disputed whether air, as an element, was ca pable of being corrupted. Astrology too was coming under question in the early s ixteenth century by in uential scholars who objected on humanist and Hellenist gro unds to its determinism and implications for human and divine free will.9 It is to similar sources that we must turn to follow the story of how medicine changed over the sixteenth century. p l ato n i c m e d i c i n e It is partly a story of neo-Platonism. This was not the neo-Platonism of Pico and Ficino, neither of whom lived into the sixteenth century, but a medical neo-Platonism that seems es pecially suited to deal with the problem of contagion. Common to both kinds, how ever, was a deliberately pious (rather than traditionally philosophical) concept of a down- ow of divine power and doctrines of cosmic sympathies, whereby earthly things responded to celestial forces. From the middle to the end of the sixteen th century and across many elds writings began to appear in a new genre. The cent ral word was subtlety. Subtlety provided an explanation of the world that was an i ncreasingly attractive alternative to the traditional and largely Aristotelian w orld-view of the schools. In fact it contributed a great deal to the ultimate co llapse of that system, a collapse that precipitated the crisis in the theory of medicine with which this chapter is concerned. We shall see how the doctors, who had relied on this philosophy for their theory, and on their theory for their r eputation as being rational and learned, coped with the crisis. 7 8 9 Astruc, De Morbis Venereis, cites several sixteenth-century authors who use the term virus. An example is the physician to Philip, Elector to the Palatinate, Co nrad Schellig ( . 1496) who, at his request, drew up a consilium against the pox: In pustulas malas Morbum quem Malum de Francia vulgus appelat . . . Salubre Cons ilium, Heidelberg, 14956. See Giovanni Pico della Mirandola in chapter 5, above.

160 The crisis Subtlety was used to denote natural powers of things that did not work in an obvio us way. Sometimes these powers were unknowable and thus occult at the same time as being natural. Sometimes they were cosmic sympathies or the action of God; but in general the term was used in conscious opposition to what now became known as the manifest qualities, the elementary qualities of traditional natural philosoph y. These now looked coarse in operation and there were many things they could no t explain. What caused the magnet to attract iron? What travelled from the elect ric eel up through the net or spear of the sherman and stupe ed his arm? Why were s ome plants so antipathetic to others that they would never grow together? In med icine, the amount of substance and therefore the qualities it could bear that pa ssed from a mad dog or a poisonous animal to the human body was small, out of al l proportion to the effect it had, and a mechanism involving manifest qualities seemed out of the question. Girolamo Cardano (150176) not only wrote on subtlety, but believed that of the four manifest qualities two, cold and dry, were merely opposites of the other two and did not act on their own.10 Traditional natural philosophy could not work on such a basis and those who sought subtlety had to nd other foundations. Some did with con dence. In Paris, Jean Fernel (1506/758)11 kne w that the learned physicians claim to superiority over the apothecary (and there fore his reputation) lay in his knowledge of causes. Traditional doctors had use d the same arguments for the same purposes, but Fernel is not referring to Arist otelian causes. In a prefatory letter he addresses his king with an optimism abo ut Renaissance society that justi ed a break with the past: printed books, the com pass, the discovery of the New World, all seemed to make the world of the ancien ts narrow and limited. For these reasons the old philosophers should not be slav ishly followed; in any case, they were pagan.12 10 11 12 On Cardano see Nancy Siraisi, The Clock and the Mirror. Girolamo Cardano and Ren aissance Medicine, Princeton (Princeton University Press), 1997, pp. 6, 7, 119 a nd 159 (which deals with Fernel and Cardano). It can be argued that another form of subtlety was represented by the strange and wonderful things seen in the cours e of a long practice, that is, medical events not covered by the canons of Galen ic medicine and its natural philosophy. Possibly new diseases came into this cat egory. On personal experience, especially the mirabilia of Antonio Beniveni and Cardano, see also Siraisi, Remarkable disease, remarkable cures, and personal experi ence in Renaissance medical texts, in her Medicine and the Italian Universities, 12501600, Leiden (Brill), 2001. On the date of Fernels birth, see the still useful biography by Sir Charles Sherrington, The Endeavour of Jean Fernel. With a List of the Editions of his Writings, Cambridge (Cambridge University Press), 1946, p. 136. Fernel deals with subtlety in his De Abditis Rerum Causis. The two books with this title are in the collected works: I have used the edition of Geneva, 1643, the Universa Medicina, published by P. Chout. e

The crisis of theory 161 In practice, Fernel relies on a Renaissance interpretation of the alternative an cient philosophy, Platonism. This does not mean he has forgotten what he said to the king, for his neo-Platonism is not very closely related to what Plato wrote . In the rst place, it could be made pious in a Christian kind of way. It was als o a culture of a self-perceived elite, like that of the earlier Hellenists. Fern el expresses himself in the form of a Platonic dialogue, and the new natural phi losophy is discussed by the speakers in a sodality, a characteristically Renaiss ance gathering of like-minded people.13 Their ideal philosophy is mathematically demonstrative, a very non-Aristotelian ideal. The subtlety that Fernel invoked in his medical writing to explain contagion was the doctrine of whole substance ac tion. This was a concept used by Galen to explain how certain medicines, and poi sons, acted on the body, perhaps in an unknown way, by virtue of their completen ess as natural objects. It was a mode of action that did not depend on the manif est qualities and it was where Galen, as a medical man, departed from Aristoteli an principles. Fernel turned the principle round and argued that contagion acted on the whole substance of the body in a way that could not necessarily be under stood. This was the nub: the manifest qualities were observable to the sense and open to reason, while Fernels subtle or occult actions were not necessarily rational in the same way. The stories of the electric eel and the magnet come from Galen , as examples of whole substance action, and it was natural for Fernel to turn to them in discussing contagion. Fernel was not prepared to abandon traditional nat ural philosophy and still less the theory of medicine. Medicines still worked by manifest qualities, and diseases were categorised in a Galenic way according to the similar and organic parts. To reject such things and rely wholly on irratio nal and unknowable causes would have been to lose one of the learned doctors prin cipal claims to be superior to more empirical practitioners, and, as we have see n, Fernel was aware of this. In dealing with the treatment of the lues venerea ( Fernel naturally did not call it the French Disease) he accordingly deals with the manifest qualities of the guaiac wood in an orthodox way, and one of the purpos es of doing so was to show that although this was a remedy discovered empiricall y, only the Rational and Learned Doctor could understand its action and construc t a proper course of treatment. A major reason behind the unknowability of subtl e actions for Fernel was that they were Gods action. The laws of nature had been laid down directly by God, they produced a general sympathy between natural thin gs 13 For example, Martin Pollich of Mellerstadt, who annotated Mondino and disputed b itterly with Simon Pistoris in Leipzig about the nature of the French Disease, b elonged to the Sodalitas Literaria Rhenana of the humanist Conrad Celtis (1459150 8). See Arrizabalaga et al., The Great Pox. p. 94.

162 The crisis and they were good. Diseases too were natural and divine in this way, like magne tism and the action of rhubarb in purging bile: inexplicable perhaps, or inexpre ssible in words, but universally acknowledged.14 To deny the divinity of these t hings, says Fernel, is to lack faith.15 The links between epidemics, contagion, subtlety and neo-Platonism are demonstrated also by Fernels countryman and commen tator Jean Riolan (the Elder, c. 15381605).16 He thought Fernel was too extreme, for example in his metaphysical description of the diseases of the similar parts, but his account of contemporary neo-Platonic medicine is as revealing as Fernels use of it. Riolan too held that there were diseases of whole substance which did n ot act by manifest qualities but by a poisonous quality. He preferred to call th em diseases of form because they attacked the formal principles, formalia principia, of life. The model is epidemics, spread by poisonous contagion. When he declare s that the ancients did not know of these, he reminds us of the European experie nce of epidemics of the previous two centuries or so. One feature of the plague and the French Disease that came to have considerable intellectual impact on Eur opean medicine was the widespread idea that they were new diseases and that anci ent medicine was not necessarily able to cope with them. Like Fernel, Riolan is con dent that the medicine of his time is progressing (like all the arts, from rud e beginnings) and that this newly recognised kind of disease counts as a discove ry which will be improved upon. But Riolan cannot bring himself to say that the ancients did not know of these diseases. He adopts the common strategy of claimi ng that the knowledge was there, if hidden or incomplete. Clearly, the ancients described and distinguished epidemics, endemics, pestilences, contagions and poi sonous diseases and other diseases of form (Riolan does not say they knew the Fren ch Disease) but remained in ignorance of the causes, believing all diseases to b e intemperies, disordered complexion.17 14 15 16 17 For Fernels reliance on the senses when faced with the inexplicable, see Laurence Brockliss, Seeing and believing: contrasting attitudes towards observational aut onomy among French Galenists in the rst half of the seventeenth century, in W. F. Bynum and Roy Porter, Medicine and the Five Senses, Cambridge (Cambridge Univers ity Press), 1993, pp. 6084. For a comparison of Fernel and Cardano on these matte rs, see Siraisi, The Clock and the Mirror, p. 159. See his Opera cum Physica, tu m Medica, Frankfurt (D. Zacharias Palthenius), 1611, which contains (ch. 9) his commentary on Fernels De Abditis Rerum Causis; and his Praelectiones in Libros Fe rnelii Physiologicos, et de Abditis Rerum Caussis, Paris (Hadrian Perier), 1601. Riolan, Opera, p. 95, even claims to have found in Hippocrates and Alexander of Aphrodisias words that correspond to his own notion of a poisonous ef uvium, viru s, that was responsible for contagion. They were not ignorant of the poisonous qua lity that endangers life, but their knowledge of it was not dioti in Riolans time it was fashionable to use this Greek term in place of the medieval Latin propte r quid , reasoned knowledge; its opposite was quia, simple knowledge of fact.

The crisis of theory 163 Neo-Platonic medicine provided an alternative to traditional medical theory and is very much part of the story of the decline of traditional natural philosophy. Riolan nds it particularly appropriate in dealing with contagion, the issue at t he centre of the new diseases. He insists that all diseases are either manifest or occult. The manifest are traditional Galenic diseases where the senses and reas on follow the actions of the manifest qualities, and Riolan has no need to aband on this authority in his learned and rational medicine. Occult diseases are, in general, poisonous; they work by the mechanisms Riolan has already described, an d they relate mainly to the new diseases and contagion. In explaining contagion Ri olan invokes the new rationality. Contagion is twofold, he says. One kind is for mal, potential and qualitative. These are Aristotelian terms, not out of place i n traditional theory: they are physical attributes. Physical contact is by trans mission of quality and does not need contiguous surfaces: the magnet attracts ir on at a distance; the peony placed on a patients neck affects but does not touch the brain. The second kind of contact in contagion is corporeal, actual and quant itative: these are mathematical.18 This kind of contact is when the surfaces of t he two things touch, as a craftsman works his materials. It is also a link to ne o-Platonic medicine, for it re ects the importance of mathematics in the Platonic world-view. While the Aristotelians did not give much importance to mathematics, the neo-Platonists talked of mathematical demonstration and mathematical forms: a ll the medical men educated in the schools of the Platonists, says Riolan, prefe r mathematical to physical (that is, Aristotelian) forms in being freer from mat ter and closer to the metaphysical. Neo-Platonic medicine as described by Riolan shared some features with the earlier neo-Platonism of Ficino and others, parti cularly the in uence of the heavens. Riolan agreed with them that there was someth ing transnatural in diseases which involved celestial power and opened up a new ki nd of rationality. Ultimately, it was God and the Intelligences who sent rst prin ciples to matter in which a potentiality had been prepared by secondary causes. The sun, for example, does not send souls to bodies19 but excites souls to appea r in prepared matter. The medium carries the message, not the result; semen is i nanimate but prepares for an animated foetus. This is part of subtlety, and Riol an interprets the story of the electric eel to explain why the shermans net (or sp ear) does not become stupe ed like his arm because its matter is not capable of st upefaction: it is the unaltered medium. In Riolans account of neo-Platonic medicine there are 18 Riolan, Opera, p. 102. 19 That is, unlike the Arabic dator formarum. Ibid., p. 102.

164 The crisis the celestial correspondences that appeared in the writings of the fteenthcentury neo-Platonists. Categories of earthly things have a sort of celestial archetype , a certain First, which gives power to them.20 In this way numbers, although expr essed in arti cial gures, are potent. So are words, both spoken and written; Riolan uses the terms of old systems of allegory, in which words surround the inner me ssage.21 In the same way appropriate arti cial shapes will form alliances with the descending powers. It followed that the neo-Platonist doctors of Riolans day bel ieved that diseases could be treated with amulets, accompanied by appropriate wo rds.22 Riolan says that the Peripatetics derided this, claiming that the practic e was a series of tricks by imposters, superstitiously believing in ceremonial m agic. Riolan observes that the theologians too were opposed to the use of amulet s, because their effect was achieved by the work of cacodemones, perhaps those d emons with special knowledge of natural things.23 Clearly, neo-Platonic doctors were using an alternative natural philosophy to enhance the reputation of the in tellectual component of their medicine. s u bt l e t y a n d s e e d s Experienc e with epidemics that led to a perception of disease as a person, an invasive enti ty, called into being another kind of explanation of contagion. This was that th e disease had seeds, which could pass from one person to another. They could als o lie dormant in clothes and merchandise, becoming viable on contact with a new victim; a clear indication of experience gained from the transmission of disease along trade routes. Like other kinds of subtlety, the idea of seeds of disease could be used without abandoning the doctrine of manifest qualities, because it was a special case argument, limited to the rapid spread and cross-infection of ep idemics. But, again like other forms of subtlety, in the cases where it applied, it was radically different from Aristotelian natural philosophy, and helped to loosen its grip. Sometimes the seeds were seen as atoms, and the promulgators of this view took authority from the poem of Lucretius, rediscovered as recently a s the previous century. Ancient atomism claimed that the world was composed of a toms moving without purpose in a void, and was rejected by Aristotle precisely b ecause of the absence of purpose. 20 22 23 21 Ibid., p. 104: volucria. Ibid., p. 105. The men who used amulets in tertian fevers were called circulatores. Ibid., p. 106. Riolan (ibid., p. 105) d oes not enlarge on the similarities between prayer and incantations. Words to st op the ow of blood included Sanguis mane in te sicut Christus ferit in se; Sangui s mane, in tua vena, sicut Christus in sua poena; Sanguis mane xus, sicut Christu s fuit cruci xus.

The crisis of theory 165 For him the irreducible components of the world were the four elements, but atom s were a quite different kind of irreducibility, for they were the smallest poss ible units of existence, incapable of subdivision. For the Latin humanists Lucre tius was an attractive gure, for he wrote in verse, and pulled philosophy into th e Humanists arena; as a Latin writer he could be used in defence of the Res Latin a. Fracastoros Syphilis (1531) illustrates this. It identi es the poet as a man who although medically trained in the schools was distant from them and their Arist otelian natural philosophy. Fracastoro declares himself as a Humanist by choosin g to write in verse, and the setting of his topic is that of the ancients, with their pantheon and uncreated, eternal world. The title gave the name to the Fren ch Disease that we still use, which is a measure of the popularity of Fracastoros work. Later, he wrote separately on sympathy, as a form of subtlety, and on con tagion, both giving a philosophical justi cation for the poem. It is a world-view very different from the Aristotelianism of the schools, and closer to the neo-Pl atonism of Fernel. The whole world sympathises: the needle of the compass has a sympathy to the pole, angry bulls become calm when tied to g trees, adamant is so ftened only with goats blood. Like Fernel, Fracastoro celebrates the modern mirac le of the compass, unknown to the ancients, and is anxious to see the world expl ained in a new way. But Fracastoros sympathies are not purposeful actions or expr essions of a natural appetite, for matter is passive; nor is it directed by some thing that does have a purpose or nal cause. Final cause, of course, is Aristotelia n language, and Fracastoro often uses the terms of traditional natural philosoph y, sometimes investing them with new meanings, but often allowing them to stand. It is as if Aristotelian natural philosophy had penetrated too deep to be remov ed at a stroke. This residual Aristotelianism was often too condensed to re ect ac curately what Aristotle had said, and it was sometimes these debased doctrines t hat came to be criticised most. An example is nature abhors a vacuum, which implie s a conscious choice on the part of nature, where nature is, perhaps, a rational d emiurge. Fracastoro was well enough read to know that such an idea was not Arist otelian, and he has standard arguments against the existence of a vacuum. Indeed , the topic is central, for the nal cause of universal sympathy was that a vacuum should not exist. But Fracastoro cannot give an answer to the question of what it is that resists the separation of two contiguous sympathising surfaces in cir cumstances where a vacuum would form. Applying his rst principles to contagion, F racastoro explains that it is a special kind of sympathy, mediated by particles, the smallest possible parts

166 The crisis into which a body can be divided. These are seeds of the disease, to be identi ed with the white matter found close to the nerves and joints in postmortems. The p articles are partly Lucretian atoms and partly medieval species: images of objects radiating off their surfaces and impinging on our senses. In the case of Daniel Sennert (15721637), the great medical teacher in the Protestant university of Wi ttenberg, consideration of contagion led to a reformulation of natural philosoph y. In 1607 he began to teach on occult diseases and poisons, where the amount of t he infective agent or poison was so small that it could not act by the four prim ary or manifest qualities. Sennert claimed to be within the medical and philosop hical traditions (it was his enemies, he said, who were neoterics and hence spok e in paradoxes) and he spent most of his working life within a university, yet i t is clear that traditional Aristotelianism and Galenism were no longer satisfac tory. Contagion, primarily of the French Disease and the plague,24 led Sennert i nto the whole business of subtleties the action of the magnet, the electric eel, the poison of a rabid dog and of noxious animals, the action of rhubarb in purg ing, whole substance action, sympathies and atoms. Although he does not deny the t raditional actions of the manifest qualities, he says that in physica (he means natural philosophy, not medicine) nothing is more damnable than the attempt to d erive all causes from the elementary qualities.25 He saw describing the subtle q ualities as a new research exercise,26 begun by Fernel, Cardano, Fracastoro, J. C. Scaliger, Thomas Erastus and others. Sennert was writing at a very Protestant university in troubled and sensitive religious times. It is clear that one of t he advantages of departing from the manifest qualities of Aristotle into the rea lm of subtle qualities was that some occult qualities, that is, unknown or unknowa ble, could be attributed directly to the action of God, whose activity was so pl ainly absent from Aristotles natural philosophy.27 f o rc e s o f co n s e rvat i s m a n d c h a n g e Historians normally like to tell a story that seems to be going somewhere, where the signposts are signi cant changes in peoples beliefs and behaviour. 24 25 27 Daniel Sennert, Opera Omnia in tres tomos distincta: Operum Tomus I [-III], Pari s (Societas), 1641, p. 1013. 26 Ibid., pp. 966, 967. Ibid., p. 694. On Thomas Er astus and the divine origin of some qualities, see Brian P. Copenhaver, Astrology and magic, in Quentin Skinner and Eckhard Kessler, eds., The Cambridge History o f Renaissance Philosophy, Cambridge (Cambridge University Press), 1988, pp. 26430 0, at p. 286.

The crisis of theory 167 But we also need to know why other people did not change. We have already seen t hat in their guild-like corporations, Learned and Rational Doctors were, in the sense we have identi ed, successful: they determined what the best medicine was an d helped to shape the expectations of their contemporaries. For all the novelty and attacks on ancient belief by Renaissance gures, there were many more doctors who preferred to do and think in the same way as their predecessors in the Latin tradition of medicine. Hellenists and Humanists thus shared with their predeces sors a desire to understand the ancients, but of course their method was differe nt, to listen to the ancients in another way. An example here is Leonard Fuchs (15 0166), who explains that his purpose was to correct the mistakes of recent writer s and restore the prisca medicine of the ancients. In his address he expects Hil dric, Duke of Wirtemberg, to institute true religion, piety and learning, and he makes a strong argument for their linkage. Learning, of course, was especially hi s own vision of medicine.28 Securing preferment from Hildric, Fuchs set out his ideal medicine in a work called The Institutes.29 The work is designed for stude nts, and he speaks of the danger of young minds being perverted by new ideas. Fo llowing Galen, he says that diseases are complexional or the result of bad struc ture or the solution of continuity. Subtle causes were not classical enough for Fuchs.30 To look ahead for a moment, it has been pointed out that the Canon of A vicenna remained on the statutes of some universities until the Enlightenment,31 and the appearance of an edition of the work in Arabic in 1593 indicates that, to some, progress in medicine centred upon a tighter reading of the traditional sources.32 Bolognese graduates in medicine swore until 1671 to be faithful to Ga len and Aristotle,33 and in 1652 even the violently neoteric Englishman Nicholas Culpeper felt no need to justify 28 29 30 31 32 33 Leonhard Fuchs, Paradoxorum Medicinae libri tres, Basel (J. Bebellius), 1535. In stitutionum Medicinae ad Hippocratis, Galeni, aliorumque veterum scripta recte i ntelligenda mire utiles libri quinque, Leiden (J. Faure for Thomas Guerinus), 15 55. See especially the dedicatory letter. He was now a professor at T bingen, app arently as a result of impressing Hildric. u For Fuchs Institutes I have used the Basel (Oporinus), 1583 edn, pp. 522, 793. Another example of a classicising phy sician is Laurent Joubert (152983), Medicinae Practicae priores libri tres, Genev a, 1572, who begins by saying that all diseases come from distemper or bad struc ture (and not, therefore, from occult qualities). See Nancy G Siraisi, Avicenna in Renaissance Italy. The Canon and Medical Teaching in Italian Universities aft er 1500, Princeton (Princeton University Press), 1987. There were at least sixty full or partial new editions of the Canon between 1500 and 1674 (Siraisi, p. 3) . See Owsei Temkin, Galenism. Rise and Fall of a Medical Philosophy, Ithaca and London (Cornell University Press), 1973, p. 128; but according to Siraisi, Avice nna, pp. 14, 143, the effect on medical teaching was negligible. Temkin, Galenis m, p. 168.

168 The crisis his translation of Galens Tegni (now called the Ars Parva).34 A hundred years aft er the Bolognese oaths were nally abandoned, graduation exercises in Oxford inclu ded the candidate giving six solemn lectures on works by Galen.35 It is likely t hat these statutory prescriptions were vehicles for modern discussions, perhaps on how to interpret Hippocrates and Galen (on whom the Regius Professor had to l ecture),36 but their persistence indicates that in a corporation continuity mean t stability. We shall return to the persistence of Galenism in a later chapter; here we must return to the changes in natural philosophy that had direct repercu ssions on medicine. Two names well known in the history of philosophy concern us rst: Bernadino Telesio (150988) and Francesco Patrizi da Cherso (152997). Telesio was opposed to both Galen and Aristotle, denying, for example, that the soul was the form of the body or that it was the result of the complexion of the body. H is training was in philosophy and mathematics (in Padua) which gave him little cl assroom faith in physical philosophy or medicine. He was a man of the schools onl y in the sense of setting up his own academy to teach his own philosophy.37 Part of it was a scepticism about attaining a full knowledge of things, a knowledge that drew largely on sense experience. For him the active forces of the world we re heat and cold, and all the parts of the universe were sentient. His De Rerum Natura (1565) was put on the Index in 1593 as heretically new (it was the year i n which the rst Arabic edition of Avicennas Canon appeared in print).38 Patrizi wa s even less a man of the schools, acting as secretary to the Venetian nobility a nd travelling widely. He adopted Platonism, developed a metaphysics of light and proposed in 1591 a new philosophy that he hoped would serve as an ideology for the Catholic Church and reunite Christendom. 34 35 36 37 38 Indeed, it was the value of bringing Galens theory to bear on practice that convi nced Culpeper of the need for an English version. Culpeper is a microcosm of opp osition to traditional medicine. He fulminates against the College of Physicians for its monopoly and its secretive use of Latin and against the Catholics for r elated practices in religion. He defends Paracelsus and astrology as the Book of Nature, and although rejecting the rusty old Authors of traditional medicine, he presents the Galenic text as Primmer to learn Physick by, Galens last epitome of al l he wrote. Nicholas Culpeper, Galens Art of Physick, London (Peter Cole), 1652, the address to the reader. See Parecbolae sive Excerpta e Corpore Statutorum Un iversitatis Oxoniensis, Oxford (Clarendon Press), 1771, p. 54. Parecbolae, p. 18 . The Oxford statutes also specify medical disputations. When the candidate lect ured on Galens De Temperamentis, De Differentiis Febrium, De Usu Partium or De Lo cis Affectis he gave (as in the Middle Ages) three days notice by an announcement on the walls of All Souls and Oriel colleges. Temkin, Galenism, p. 145. See Pau l F. Grendler, Printing and censorship, in Skinner and Kessler, eds., Cambridge Hi story of Renaissance Philosophy, pp. 2553, at p. 47.

The crisis of theory 169 For Patrizi, then, religion and philosophy were almost the same thing, or at lea st were mutually supportive. In a period of religious unrest it was necessary on all sides that this should be so, and Aristotles natural philosophy did not alwa ys meet with approval. Certainly the Jesuits, such as those in Coimbra, develope d a sophisticated and detailed Aristotelianism as part of reinforcing the tradit ional learned tradition of the church. On the other hand, some Protestants thoug ht that for related reasons Aristotle needed reforming as the church had needed reforming. In Oxford at the end of the sixteenth century, Aristotles natural phil osophy was taught from handbooks in an abbreviated form that in fact made critic ism easier; it was also rather defensive.39 It is useful to look at the relation ship between medicine and philosophy from a third point of view, that of the the ologian. While systematic theologies40 of the mid-sixteenth century can draw rea dily on the synthesis between GalenicHippocratic medicine and Aristotelian natura l philosophy that had been evolving since the thirteenth century, by the early s eventeenth century it was clear from without that this synthesis could come apar t. The relationship between natural philosophy, medicine and religion was close and also complex, and we should not over-emphasise the differences between the r eligious groups. Natural philosophy in the early seventeenth century remained Ar istotelian in a Protestant university like Cambridge, but its textbooks are repl ete with references to Coimbran and other Jesuits.41 Lutherans, more often than Calvinists, took readily to the book of nature as a road to God, and from the exam ple set by Melanchthon, Aristotle was studied in many Lutheran universities. Som etimes Lutheran theologians refused to pronounce on a matter that Luther had not dealt with, and turned it over to philosophy.42 The study of the soul was an es sential part of Melanchthons programme, and he encouraged the use of the new anat omy of Vesalius in conjunction with it. The result 39 40 41 42 For example, that of John Case, Ancilla Philosophiae, seu Epitome in Octo Libris Physicorum Aristotelis, Oxford (J. Barnesius), 1599. A similar textbook availab le in Cambridge was that of Johannes Magirus (d. 1596), a teacher of natural phi losophy in Marburg. Both were opposed to Petrus Ramus, who had denied the Aristo telian doctrine that nature was an internal principle of motion. See Magirus, Phys iologiae Peripateticae, Wittenberg (Johannes Bernerus), 1609. For example, Hugo of Strassburg, Compendium totius Theologicae Veritatis (collated by Johannes de Combis), Venice, 1554. In general, Aristotelian scholarship was acceptable to th e different Christian confessions. See Luce Giard, Remapping knowledge, reshaping institutions, in Stephen Pumphrey, Paolo Rossi and Maurice Slawinski, eds., Scie nce, Culture and Popular Belief in Renaissance Europe, Manchester (Manchester Un iversity Press), 1991, pp. 1947, at p. 43. When Sennert wanted reassurance on the question of whether animals had souls he wrote to a number of German theology f aculties, some of which replied that it was a matter of philosophy only, for Lut her had not pronounced on the topic. See Daniel Sennert, Opera Omnia, pp. 118.

170 The crisis in some universities was the teaching of anatomy in the arts course, where stude nts began their training in the truths of their religion.43 This complex situati on is illustrated by the systematic and Calvinist De Veritate Religionis Christi anae of Philippe de Mornay, published in Leiden in the early seventeenth century .44 It is directed expressly at the atheists, Epicureans, heathens, Jews and Musl ims. Often these are literary categories, as in the case of Renaissance medical m en who had reinvented Galens enemies as their own (as we saw). But here they are part of de Mornays real world: there is a new as well as an old Aristotle and Pla to; there are Pythagoreans and Academics. They are the pseudophysici, who lie ab out the names of natural things and talk too much about Nature, calling themselv es her Disciples, Interpreters, Disquisitors or Dissectors, each to his own sect . These are the new natural philosophers, and de Mornays major complaint is about the modern Epicureans, who deny the providence and jurisdiction of God. That th e atoms moved without purpose in their void had been as offensive to Aristotle a s it was to the church, and de Mornay contradicts it with an assertion that God is the governor of everything and does nothing in vain, a phrase with Galenic and Aristotelian overtones. But de Mornays God is not Galens demiurge or Aristotles nat ural purpose, which both rearrange extant matter, but a Creator ex nihilo. He kn ows that nothing comes out of nothing is an axiom of the schools that condenses an Aristotelian argument, and he knows too that to attack it excites resentment in the schools. Another dif cult Aristotelian doctrine was the eternity of the world . By the early seventeenth century this was increasingly seen as a heathen belie f ethnicus and was a criticism of Aristotle at least as strong as it had been in the early thirteenth century. De Mornay attacks it with the argument that the h uman arts (especially medicine) have a history, demonstrating growth from rude b eginnings early in the history of the world.45 As in the opinion of other Renais sance gures we have met, excellence was the modern result of development, not the full recovery of ancient opinion. The model for de Mornay was perhaps church do ctrine, which began to take perfect form only with the birth of Christ: like so many others in defence or justi cation of a modern novelty or perfection, de Morna y argues that the doctrine of the Trinity was known, but imperfectly, to the old philosophers.46 His 43 44 45 46 See chapter 5, above. I have used the edition published in Leiden in 1605 by And reas Cloucquius. De Mornay, Veritate, pp. 121, 133. Clearly, if religious truths have had a development to reach a perfection, whether Jesuit or Calvinist, defe nding such positions lends urgency to a theory of development. Ibid., p. 79.

The crisis of theory 171 words have a Renaissance con dence and the new piety of the time. Like Fernel and Riolan, he talks of the magnetic compass as a modern perfection which in his tim e made possible the circumnavigation of the globe.47 His piety leads us in anoth er direction that is important for us. The newly explorable globe and the New Wo rld are now open to be civilised in the forward progress of all the arts (from o ld humble origins). The barbarity of Canada, Patagonia, Brazil and Greenland wil l be replaced by the civilisation we know. But this is not a divided Christendom : de Mornay does not set Calvinists, Lutherans or Catholics against each other a nd insists that what is common to the heathen and the Jew (and by implication al l Christians) is that nature is the same to them and provides a common philosoph y and common principles.48 This is nature as an expression of God as the rector of the world and is, in fact, the nature of Natural Law. We should pause here to r e ect on the changes in the relationship between medicine, philosophy and religion . The older Humanists, Hellenists and the searchers after the ancient wisdom of Hermes were, in some sense, looking for a golden age of knowledge to which they could again give birth in a Renaissance, just as the older scholastics had hoped to repair prelapsarian knowledge. But we have now seen a number of examples whe re the new knowledge and arts of the sixteenth and seventeenth centuries reduced the lustre of the ancient world. In whatever elds the modern world was superior to the ancient, its story was one of development from ruder beginnings. Progress became desirable and history became progressive. While Humanist and Hellenist h istories of medicine often stopped with Galen, those written in and beyond the s eventeenth century (such as that of Leclerc in 1699) often sought to justify mod ern medicine. A progressive view of history was perhaps sharpened by religious s ensibilities. First, in the seventeenth century, perhaps in line with a piety of neo-Platonic 49 or Paracelsian origins, the old medical authors began to look p agan. Both Aristotle and Galen looked heathen especially to chemists.50 Second, th e Reformation had made both Catholics and Protestants aware of the superiority o f their own form of religion. Quite expressly, the learned tradition of the Cath olic church was marked by progress, built up by the church over the centuries. Q uite as clearly to Protestants, the Reformation was progress away from decadence . We have seen that medicine could never be totally separated from religion; it is signi cant that the quotation with which this chapter began is an English trans lation from the 47 49 Ibid., p. 4 of preface (not paginated). See also Siraisi, Clock and Mirror, p. 1 59. 48 Ibid., p. 4 of the preface. 50 Temkin, Galenism, pp. 164, 167.

172 The crisis Latin text of a Dutchman. In political, educational and religious terms there wa s some sympathy between Interregnum England and the United Provinces, and the co ntroversy over the circulation of the blood was most vigorous and most favourabl e in both places. Progressive history has seen the intellectual changes of the s eventeenth century as new beginnings, but we have to remember that this is a sel ective view, centring on England. Leclerc records that in his day there were man y Galenic physicians, and we shall see in the next chapter that perfectly tradit ional texts, and new attempts to rehabilitate Hippocrates, were produced well in to the eighteenth century. b aco n i a n e x pe r i m e n ta l ph i lo s o ph y We have now glanced at a number of challenges to traditional philosophy, from me dical men or others whose criticisms helped to lessen the bond between medicine and philosophy. By far the two most important gures in this respect were Francis Bacon (15611626) and Ren Descartes (15961650) e who were both used extensively by d octors who had to face the collapse of traditional natural philosophy. Bacon was a lawyer (he became solicitorgeneral in 1607 and lord chancellor in 1618) and r epresented a professional grouping separate from the theologians, philosophers a nd medical men. His chief complaint against traditional natural philosophy was t hat it did not reveal the truth of the natural world, and had no means of doing so. His answer to the problem was to work out a method that would lead to the tr uth. He did not construct a system that would replace that of Aristotle but made suggestions about procedure that were widely read. This is no place to go into the details of Bacons proposals for natural philosophy.51 Its salient points were rstly that the method was collaborative. No single mind could hope to gather eno ugh information. Perhaps his model was legal, for his attention was given to ass aying witness reports of the natural world. The method was inductive and experimen tal, quite the opposite of traditional natural philosophy. Whether or not medici ne was also a model, doctors could see in the inductive method a re ection of thei r enduring concern with the rival claims of observation and reason in medicine. Likewise, the medical experiment especially vivisection had a long history, exte nding back through Vesalius to Galen and Herophilus. Learned doctors also knew t he rationalist Galens appreciation of empirical 51 For Bacon, see Stephen Gaukroger, Francis Bacon and the Transformation of EarlyModern Philosophy, Cambridge (Cambridge University Press), 2001.

The crisis of theory 173 observation and of Aristotles collected historiae and recognised at least the pri nciples of Bacons programme. It was a programme designed to replace not only Aris totles natural philosophy, but the logic that introduced and supported it. Aristo tles logical works were collectively known as the Organon, the instrument of ration al thought. Bacons Novum Organum of 1620 was to supply the rational method that w as complementary to such works as the Advancement of Learning (1605) and its big ger Latin version, the De Dignitate et Augmentis Scientiarum of 1623. Together, these were ways of generating knowledge we would call it research and it was to be useful knowledge, for practical ends. Again, the medical men, who all agreed that medicine was a practical and useful business, however much it was also a th eoretical scientia, recognised the link between intellectual procedures and prin ciples, and practical application.52 Although in contradistinction to traditiona l natural philosophy, Bacons method was to generate practical and truer knowledge of the natural world, yet he saw that the old philosophy had a social function almost independent of its content, or truth-value: as long as everyone agreed wi th it, it contributed to the stability of society. c a rt e s i a n m e c h a n i s m Descartes attack on traditional natural philosophy was fundamentally differ ent from that of Bacon. Again (because this is not a history of philosophy), spa ce does not permit a detailed analysis of it and we can note only those parts th at related more or less directly to medicine.53 Descartes was educated badly by the Jesuits: that is, they did not convince him of the things that Jesuits usual ly did convince people of. In pulling down the house of knowledge and starting a gain, Descartes could not at rst even believe in the existence of himself or of G od. This scandalised later theologians (which had a direct effect on his attempt s to promote his philosophy). Arguing that a falsity cannot be imposed upon a sc eptic, he proved himself to exist (dubito ergo sum would be a better rendering o f the traditional phrase) and then that God existed. Because God was not a decei ver, argued Descartes, any clear and simple idea that Descartes entertained must be 52 53 Medical men would not, however, agree that Hippocrates, still widely respected a s the Father of Medicine, was a quack offering a few sophisms sheltered from correc tion by their curt ambiguity: Bacons rejection of the ancients was complete. See G aukroger, Francis Bacon, pp. 1067. In general see G. A. Lindeboom, Descartes and Medicine, Amsterdam (Rodopi), 1979. On Descartes search for medical knowledge (an nounced as his nal task at the end of the Discourse on Method), see his Oeuvres, ed. C. Adam and P. Tannery, Paris, 18961913, vol 3, pp. 443, 4567, 459, 462.

174 The crisis true. His clear and simple ideas about the natural world were mainly that it con sisted of particles in motion. They were all in contact (there was no void) and so the doctrine was not strictly atomism, although it could not be wholly untouc hed by the contemporary interest in Lucretius. Together, atoms constituted matte r, which God had created as extended unthinking substance; God had also created motion, and thirdly, the soul, which was unextended thinking substance. The term soul had none of the intellectual baggage of anima, no connotations of Greek phil osophy that included the powers of nutrition, motion, growth, generation and so on.54 All these faculties were accounted for mechanically, by the motion of the particles. This had two important consequences for medicine. The rst was that bec ause all motion was by impact or pressure of particles there could be no power o f attraction. Galenic medicine had made much of the power of hollow organs to at tract, retain, digest and expel, linking these powers to the three kinds of bres that made up hollow organs and faculties of the soul that controlled these organ s. Attraction also looked impossible to the new philosophers because it appeared to be action at a distance, without any means of exercising itself. In this res pect Descartes doctrine was also radically different from the different kinds of neo-Platonism we have glanced at, for the neo-Platonic world was full of sympath ies, antipathies and macromicrocosmic relationships across distances and explaine d by the sentience of the parts or a ow of spiritus. The neo-Platonic magnet or com pass needle sympathised with iron or the pole and was celebrated for the fact, a s well as for being an example of the superiority of modern inventions (as we sa w with Fernel and others). The medical man knew of sympathies in the body, one o f which was explained by the doctrine of community of origin where two parts felt each others pain by reason of an embryonic connection, lost in the adult body. In contrast, the mechanical or corpuscular magnet demanded an explanation in terms of a ow of strangely shaped corpuscles. The second consequence of the mechanical phi losophy, particularly that of Descartes, for medicine was that because the parti cles moved mechanically by contact, there was no purpose in nature. To be sure, God had designed the world rationally, but so that it ran like a machine. This c ut directly 54 The theologians, long since accommodated to traditional medical-philosophical ac counts of the hearts action, were indignant at the loss of the traditional facult ies of the soul in the heart. One of them was Libert Froidment (15871653), to who m Descartes had sent a review copy of the Discourse on Method . Froidment replie d with a traditional account of the soul (Fromondus, Philosophiae Christianae de Anima libri quatuor, Louvain (Hieronymus Nempaeus), 1649) and was not wholly op posed to the notion of circulation of the blood.

The crisis of theory 175 through the complex system of medical causality in which the similar parts of the body had an action and the organs a purpose and a use, all subsumed under the purp ose of enabling the animal to live and live well. Secondly, the mechanical philo sophy also destroyed Aristotles nature, the purposeful actions of the animal to ful l its potentiality and achieve its full adult form. Thirdly, it did nothing to re inforce the Galenic and Platonic notion of a rational and providential demiurge. Lastly, it ran counter to what was an apparently Aristotelian dictum that nature abhors a vacuum. We have seen that Aristotle had a number of reasons for saying that no such thing as a vacuum existed, but this dictum is a late compression an d alteration of what he had said. Renaissance engineers thought that water follo wed the rising piston in what we would call a suction pump in order to stop the formation of a vacuum; this is what nature abhorred, and the purposefulness of t he action seemed like local sentience acting in an appropriate way to prevent it . The new philosophers could not agree with this, nor accept that suction in a suc tion pump or medical cupping glass or syringe was a kind of attraction, and riva l theories were constructed to explain how it was all done by particles. w i l l i a m h a rvey ( 1 5 7 8 1 6 5 7 ) The discovery of the circulation Harvey was as rational and learned as any doctor of the time. Yet, if we adhere to the prog ramme and terms adopted in this book, he was also a failure. People thought him mad and his practice fell away. A peer wrote to his daughter warning her that it was a mistake to have a physician with too much imagination. His opponents reas onably pointed out that the doctrine of circulation would destroy not only the t heory of medicine but also the major therapeutic technique of selective blood-le tting. They considered that traditional theory and practice had served them well enough and that change was destructive. In our terms the medicine they professe d and practised had evolved expectations on the part of patients that the doctor had helped to form and was largely able to meet. It need hardly be added that H arveys failure is not a question of his clinical effectiveness, about which we ca n form no idea.55 55 See Jerome J. Bylebyl, ed., William Harvey and his Age. The Professional and Soc ial Context of the Circulation, Baltimore (The Johns Hopkins University Press), 1979.

176 The crisis While there is not the space here to tell Harveys story in detail, there are neve rtheless things we must note because the discovery of the circulation was a majo r factor in the loss of traditional theory and the consequent dif culties of the d octors. It is something of a paradox that Harvey was a traditionalist and a grea t admirer of the ancients, especially Aristotle, at a time when they were coming increasingly under attack and when his own work was eagerly adopted by the oppo nents of Aristotelianism. Harvey made the acquaintance of late Renaissance Arist otelianism in Cambridge. In Padua, where he took his medical degree in 1602, Ari stotle was treated differently. Harveys teacher, Fabricius of Aquapendente, was i nterested in Aristotles works on animals. He reconstructed what he took to be Ari stotles method and applied it to organs and organ-systems of animals with the pur pose of generating new knowledge about them.56 Returning to England, Harvey beca me a fellow of the College of Physicians. The college had a monopoly of the prac tice of internal medicine in London, and the qualifying procedures for candidate s for membership were strict: essentially, an examination in Galenism. The colle ge also expected its members to know the works of Hippocrates, and to be able to conduct a dissection of the human body. Harvey was elected to the Lumleian lect ureship in anatomy and gave his rst lecture in 1616. The endowment of the lecture ship was intended for a cycle of lectures for medical and surgical purposes, whi ch were to be given partly in English but Harveys lectures were in Latin and not surgical. His anatomy was, in fact, philosophical: when justifying or explaining their business, anatomists commonly gave a short list of the purposes of anatom y, on which its use to medicine generally came third or fourth. In rst place was either the religious purpose of demonstrating the work of the Creator, or the us es to philosophy. Harveys philosophy was that of Aristotle and Fabricius, togethe r with the experimental method of the medical tradition through from Galen to th e Italian anatomist Realdo Colombo (151659). When he came to deal with the heart, Harvey found some terminological confusion in the work of Colombo, which he dec ided to clarify by experimental vivisections of animals. It was a question of id entifying correctly the diastolic and systolic phases of the hearts motion, when it is expanding and when it is 56 See A. R. Cunningham, Fabricius and the Aristotle project in anatomical teaching an d research at Padua, in A. Wear, R. K. French and I. M. Lonie, The Medical Renais sance of the Sixteenth Century, Cambridge (Cambridge University Press), 1985, pp . 195222; on Padua in general see J. J. Bylebyl, The school of Padua: humanistic m edicine in the sixteenth century, in Charles Webster, ed., Health, Medicine and M ortality in the Sixteenth Century, Cambridge (Cambridge University Press), 1979, pp. 33570.

The crisis of theory 177 contracting. Galen had argued that the heart expanded forcibly, sucking blood ou t of the vena cava, and that the aorta then expanded forcibly, sucking blood fro m the relaxing heart and making the arterial pulse. But in the living animal, Ha rvey could not see expansion and contraction, only a forcible elevation of the h eart followed by a relaxation. He decided on theoretical grounds that the forcib le elevation of the heart was its proper motion, the one most directly concerned w ith its function; and experimentally (by puncturing an artery) he showed that th e elevation of the heart was a forcible contraction that expelled blood into the passive arteries, making the pulse. Harvey was proud of his discovery of the fo rceful systole, which he saw as correcting an error that had been part of the me dical tradition since before Galen, and he taught it in the lectures. Naturally, in a Galenic institution he found opposition and was compelled to carry out fur ther vivisections to provide additional evidence. To make the case for an active systole he emphasised the force and amount of the blood emerging from the heart . He made a modest estimate of the difference in volume between a relaxed and a contracted ventricle, which corresponded with the amount of blood ejected at eve ry beat. But when he added up the amounts of blood emerging over an hour or a wh ole day from a heart beating about 70 times a minute he saw that it was impossib ly large. Such a quantity of arterial blood could not be absorbed by the body, a s Galen said it was, nor could the venous blood entering the heart from the live r be produced in suf cient quantity from food, as Galenic theory maintained. It wa s a moment of crisis. Harveys new doctrine of forceful systole seemed at risk, ye t his demonstrations seemed incontrovertible. Then he remembered the recent disc overy of valves in the veins, the purpose of which seemed to be to slow down the centrifugal ow of blood to prevent it from accumulating in the legs. But Harvey and Colombo had already decided that valves such as those in the heart imposed a unidirectional ow and did not allow a partial leakage in the reverse direction ( as Galen claimed of the valves of the heart): if the valves in the veins were re al valves, they controlled the centripetal ow of blood, from the tissues back to the heart. Institutional Galenism Harvey made his discovery of the circulation i n about 1618 and taught it in the anatomy lectures for about nine years before p ublishing De Motu Cordis in 1628. In that time he disputed the thesis with his c olleagues in the manner of a university, with the president of the College of Ph ysicians

178 The crisis acting as praeses, the adjudicating master. The book itself is also formally str uctured as an academic exercise in a way that would meet the expectations of an educated readership across Europe.57 The new doctrines and the book met with a v ery mixed reception. The college was justi ably nervous that it would be seen as e ndorsing the book, and took steps to distance itself from it. Parigiano, who was a member of the Venetian College of Physicians, and an outspoken opponent of Ha rvey, did indeed regard the book as expressing the London Colleges opinion, and w as sarcastic about what could be seen and heard in London but not in Venice. The London College was concerned that so great a novelty would destroy the image of learned Galenism with which they maintained their reputation. They were already in con ict with doctors who professed a chemical medicine and who resented the mo nopoly of the college, and they disliked men who talked in terms of the particle s and mechanism of nature. In other words, for a long time the college wore a Ga lenic mask for professional purposes. Harvey, like Bacon, saw that the old philo sophy, however wrong, at least generated unity of belief. In a similar way, Harv ey, as censor of the college, examined candidates on their Galenism even after h e had discovered the circulation. He saw that his opponent in Paris, the great a natomist Jean Riolan (the Younger), also maintained a Galenism for reasons conne cted to the professional reputation of the Paris faculty.58 It seems likely that in Montpellier they also maintained a face of corporate Galenism until at least 1650, when Lazarus Riverius was called on to resign for teaching the circulatio n.59 57 58 59 For the view that the book was written in two halves, the rst before he had made the discovery, see Jerome J. Bylebyl, The growth of Harveys De Motu Cordis, Bulleti n of the History of Medicine, 47 (1973) 42770. But the formal nature of an academ ic exercise meant that the discovery was presented in its proper place; likewise Harveys treatise on animal motion deals with the necessary preliminaries before mentioning muscle, about half way through. For an extended discussion of the point and its associated secondary literature, see Roger French, William Harveys Natur al Philosophy, Cambridge (Cambridge University Press), 1994, ch. 5. As Harvey sa id, Riolan could be seen as speaking not personally, but of cially: It was doubtles s tting for the Dean of the College of Paris to keep Galens medicine in good repai r . . . lest (as he says) the precepts and dogmata of the physicians be disturbe d, and lest the pathology which has obtained for so many years, with the agreeme nt of the physicians . . . be corrupted. Harvey to Schlegel, 1651: Harvey, The Ci rculation of the Blood and other Writings, trans. Kenneth J. Franklin, London (D ent: Everymans Library), 1963, p. 185. See also Harold Cook, Institutional structu res and personal belief in the London College of Physicians, in Ole Grell and And rew Cunningham, eds., Religio Medici. Medicine and Religion in Seventeenth-Centu ry England, Aldershot (Scolar Press), 1996, pp. 91114. See William Richard Lefanu , Jean Martet, a French follower of Harvey, in E. Ashworth Underwood, ed., Science , Medicine and History. Essays on the Evolution of Scienti c Thought and Medical P ractice written in honour of Charles Singer, 2 vols., Oxford (Oxford University Press), 1953, vol. 2, pp. 3340.

The crisis of theory co n t rove r s i e s 179 If we look forward for a moment and outline the fortunes of Harveys doctrines of the forceful systole and the circulation of the blood in the period before he di ed, there are obvious signs of a division of opinion along religious lines. Abou t two dozen men were concerned enough to express their approval in print. Almost all of them were from northern Europe and most often Protestant. Robert Fludd, Thomas Bartholin, Johannes Walaeus and his student Roger Drake, Jacobus de Back, George Ent, Albert Kyper, Anton Vesling, Herman Conring and Olaus Rudbeck are s ome of the better known names; Descartes and Henricus Regius (whom we shall meet later) are exceptions in the sense that their radical philosophy could not read ily be given a religious position. In Louvain, the Catholic Vobiscus Fortunatus Plemp (160171) changed his mind, at rst rejecting the circulation and then becomin g its defender. At rst he was a stout defender of Arabic and Latin medicine, tran slating parts of the Canon. He regarded the Hippocratic works as equivalent to t he Bible in containing revealed knowledge; Avicenna is the Aquinas of medicine, bringing order to earlier diffuse works (of Galen and Augustine). He called his textbook the foundations of medicine;60 yet in its second edition he supported Har vey. What had happened was that he had read Harvey properly and disengaged the d octrine of circulation from Cartesian mechanism, a much more offensive novelty. This exposed Harveys experiments as persuasive. Harveys opponents were generally f rom the south and most often seem to have been Catholic. Only about ten of them wrote opinions signi cant enough for us to make judgements about. The most voluble were Parigiano and Riolan, whom we have met. Parigiano the Venetian brought his religion to bear directly on his medicine and regarded Harvey with distaste. Hi s anatomy began with the brain of man as the seat of the Christian immortal soul , which generated the body. The perfection of the body was a re ection of the glor y of God. Parigiano could therefore see no point whatsoever in descending with H arvey into the realms of vile, disgusting and imperfect animals which poisoned t he senses and intellect and were at such a great distance from mans almost divine perfection. Harveys Aristotle project and experiments were of no importance.61 I n contrast, Marco Aurelio Severino, 60 61 V. F. Plemp, Fundamenta Medicinae, Louvain (Hieronymus Nempaeus), 1654 ( rst editi on before 1644). William Harvey, De Motu Cordis et Sanguinis in Animalibus, Anat omica Exercitatio. Cum Refutationibus Aemylii Romani, Philosophi, ac Medici Vene ti et Jacobi Primirosii in Londonensi Collegio doctoris, Leiden (Ioannes Maire), 1639.

180 The crisis an Italian with Reformist tendencies, not only agreed with Harvey but set forth a whole new philosophy zootomia based on dissection and experiment.62 In Catholi c eyes there was a clear connection between the new heresy of the reformers and novelties in medicine and philosophy. What the heresy was attempting to destroy was the learned tradition of the church. Because of the authority of the church this tradition had extended to all learning, including that of medicine and phil osophy, that is, what we are calling in this book the Latin medical tradition. W e have seen that the CounterReformation came to stress the learned tradition in the sixteenth century, and here it is useful to glance at a gure who counted for a good deal in the seventeenth. It is Robert Bellarmine, a Jesuit, member of the Inquisition and friend of Galileo. As a theologian he was a controversialist; f or example, he disputed with James I of England on the subject of the divine rig ht of kings (which, it was generally held in England and France, could enable th e Royal Touch to cure scrophula). In rebutting the theologies of Luther, Calvin and Zwingli, Bellarmine gives force to the learned tradition: revelation is the written word of God, tradition the unwritten. Tradition is Gods word expressed by the apostles and, notably, by the church. The latter ecclesiastical tradition, sa ys Bellarmine, has the same force as decrees and constitutions of the church. Th us the humanly written tradition has divine authority, the point uppermost in Be llarmines mind when directing this argument against the Protestants who thought t hat the revealed knowledge of the Bible was enough.63 The authority of the tradi tion went back ultimately to the transfer of Roman power to the church;64 it gai ned its greatest philosophical strength from the Aristotelianism of Aquinas. For Bellarmine, even the councils of the church have the four Aristotelian causes.6 5 There is a sense in which Bellarmine sees that the Protestants had replaced tra dition with nature as a second book in which Gods words might be read. He devotes li ttle space to nature. Indeed, the rst question in naturals, he says, is whether faith is needed to recognise a natural truth. Is not the human mind so damaged by sin as to be unable by natural forces alone to recognise any natural, mechanical tr uth?66 He allows that natural cognition, which is also theoretical or mechanical i n belonging 62 63 64 The story of the reaction to Harveys doctrines across Europe is given in French, William Harveys Natural Philosophy and need not be repeated here. Roberti Bellarm ini Politiani S.R.E. Cardinalis Solida Christianae Fidei Demonstratio, Antwerp ( Martinus Nutius), 1611, p. 24. The volume was put together by Baldvinus Iunius f rom various controversies. 65 Ibid., p. 156. 66 Ibid., p. 782. Ibid., p. 143.

The crisis of theory 181 to the lowest level of human activity, is akin to the productive arts. At the in termediate level is moral cognition and at the highest, supernatural, supplied o nly by revelation. While some Protestants saw the hand of God in the fabric of t he human body as clearly as Caesars face appeared on coins, or felt themselves in a theatre of creation where God was so close that it was almost possible to rea ch out and touch him, it remained a major question for Bellarmine whether the li ght of reason, without the special help of grace, could prove the existence and singleness of God. Bellarmines book was assembled from his arguments in controver sies. Topics such as the perfection of Christ and his descent into hell were con troversies, and the term passed readily into other disciplines. In medicine by t he seventeenth century there were controversies that at least potentially weaken ed the traditional system from within. One such concerned whether venous blood p assed through the interventricular septum of the heart and became arterial, as G alen had claimed. This particular controversy had been created by Realdo Colombo and Michael Servetus in the previous century. They had thought that the septum was not pervious and that blood instead went through the lungs from right to lef t ventricle. Servetus thought that it was in the lungs that the divine spirit en tered the blood, but Calvin had him burned, along with his book, and the subsequ ent controversy centred on Colombo. Before Harvey there was a controversy about the lacteals,67 and the controversy over the circulation ended in Harveys favour largely when an interesting new controversy on the lymphatic vessels68 eclipsed it. In some sense a controversy replaced the disputed question as a device for g enerating knowledge. Contenders often published series of pamphlets of increasin g bitterness in a way that was not possible in the Middle Ages, and medical cont roversies often involved experiments. Controversies naturally appeared in medica l topics where there were religious or philosophical differences between the par ties. These differences were an aspect of the collapse of the Latin tradition, o f which we are concerned with the philosophical and hence medical component. Con troversies also reveal a new aspect of the universities in the seventeenth centu ry. While medical students were generally there to obtain professional quali catio ns, the same was not true of all arts students. It has 67 68 The problem of the lacteal vessels, described by Gaspare Aselli in 1622, was tha t they seemed to be involved in the process of converting food into blood, yet c ontained only a milky liquid and did not share the function of the portal vein, which was thought to convey chyle from the intestines to the liver (where blood was made). The lymphatics were described by Olaus Rudbeck, who had been born in the year Harvey published De Motu Cordis. See Sten Lindroth, Harvey, Descartes an d the young Olaus Rudbeck, Journal of the History of Medicine and Allied Sciences , 12 (1957) 20919.

182 The crisis often been pointed out that the new prosperous middle classes in England, for ex ample, might send their sons to Oxford and Cambridge as nishing schools; and in a later chapter we shall look at gentlemanly education in the Italian universitie s. It was not always necessary for such men in England to obtain the degree from the university, and they could enter into what was essentially a private contra ct with their college tutor. These students included those sometimes called the virtuosi at the time of the scienti c revolution and, not needing to adhere to unive rsity statutes, they could take up experimental and mechanical philosophy with e nthusiasm, thus weakening traditional philosophy. In medicine, students were fas cinated by the novelties in controversies and their teachers felt obliged to res olve such questions. They might do so by experiment, followed by disputation and even the construction of a textbook. m e c h a n i s m a n d c i rc u l at i o n The controversies over the circulation of the blood and Cartesian mechanism be came closely related in a paradoxical way. Descartes read Harveys book in about 1 630 and decided that Harveys doctrine of the circulation was the ideal vehicle fo r his own mechanism, from the single motion of the circulation of blood he could derive, by particle-to-particle impulsion, all the other motions of the body. A ware that he might be attacked like Galileo, Descartes tended to be circumspect in expressing his notions of mechanism, but in his Discourse on Method he was un usually con dent and forthright about the motion of the heart and blood. It was a centrepiece of his mechanism and he said that if his account were not true, the whole of his philosophy would fail. It was paradoxical, then, that Harveys doctri ne should be carried to many readers on the back of Descartes new philosophy, whi ch was entirely foreign to Harvey, that staunch admirer of Aristotle. But Descar tes disagreed with Harvey in one important respect. Descartes could not allow th at the heart contracted forcibly Harveys rst discovery because it implied that the parts of the heart were attracting one another, illicit in the new philosophy. He proposed therefore that blood entering the heart drop by drop was vapourised by the heat of the heart and expanded, forcing its way across the valves before condensing in the aorta. Again, many people rst met the idea of the circulation i n this form and treated it as a part of the new mechanical philosophy. We can fo rm some idea of their response because Descartes sent out review copies of the D iscourse and engaged in correspondence with his reviewers. Some rejected mechani sm

The crisis of theory 183 entirely, arguing that the soul played its traditional role in moving the heart. 69 Others argued that the heat of the heart was entirely insuf cient to vapourise the blood. Others made vivisectional experiments, showing that pieces of a livin g heart contracted in circumstances that made in ation impossible. Descartes was d riven to make experiments himself and modi ed the doctrine of in ation, which became something closer to an intestinal fermentation. Descartes had ambitions. He had constructed a new philosophy of nature and wanted to become the New Philosopher to replace Aristotle. Like Bacon, he saw that this natural philosophy had to be supported by a new form of rationality in the same way as Aristotles natural phi losophy rested on the logical works that the student met earlier in the arts cou rse. Descartes also saw that arts-course philosophy in its turn supported medici ne. His own philosophy could not, of course, support traditional medicine with i ts Galenic and Aristotelian theory, and Descartes began to construct a mechanica l medicine on his own principles. It seems that he was constructing a package of academic subjects of the same curricular shape as the traditional philosophy and medicine that he was trying to displace. This is suggested too by the fact that Descartes chose a medical man in his bid to insert his own philosophy into the u niversities. This man was Henricus Regius in Utrecht, who had written to Descart es expressing admiration of the new philosophy, and the mechanism they used was the disputation. As in the Middle Ages this consisted of the promulgation and de fence of a thesis, but contemporary discussions about the nature of university d isputations indicate that arguments drawn from sensory observation were consider ed valid.70 Indeed, some university masters engaged in the controversy over the circulation of the blood by defending theses they had developed in formal disput ations and veri ed by vivisection. Descartes was not a university teacher and need ed Regius to propose the theses. Normally Descartes made the suggestion, Regius drew up a formal thesis for Descartes approval and the thesis was accordingly off ered for disputation. Sometimes Descartes would listen from a concealed room. Th e Utrecht theologians were not at all happy that there should be in their univer sity these echoes of a philosophy that had begun with a doubt as to the existenc e of God. Then Regius went too far. His topic was the Cartesian 69 70 As we have seen, an example is Libert Froidmont, a teacher of Plemp. See also De scartes, Oeuvres, ed. Adam and Tannery, vol. 1, p. 399 (Plemp to Descartes). See Adriaan Heerebord, Ermeneia [Ermhneia] Logica: seu Explicatio tum per Notas tum per Exempla Synopsis Logicae Burgersdicianae . . . accedit ejusdem Auctoris Pra xis Logica, Leiden (David a Lodensteyn and Severyn Matthysz), 1650.

184 The crisis distinction between soul as unextended thinking substance and matter as extended non-thinking substance. The thesis he tried to sustain was that man was a being in which matter the body and soul were united accidentally rather than essentiall y. Moreover, this time Regius had not sought Descartes approval. Descartes was ho rri ed, the theologians were scandalised and the students rioted. The university b anned philosophical novelties and ordered that Aristotle should be the basis of all philosophical disputation: above all, Aristotle was safe.

chapter 7 Resolutions i n t ro d u c t i o n Few histories of medicine are without an evolutionary app roach. Histories adopting this approach are not now generally whiggish, but they i nvariably give much attention to signposts indicating the direction of the road and bearing legends such as mechanism or circulation. Many of these directional mile stones are clustered in England and the United Provinces of Holland, and, even i n the seventeenth century, medical mechanism could be seen by a major gure in Par is as so much modern Dutch nonsense.1 But as we have seen, Learned and Rational Doctors were successful in the familiar territory of traditional natural philoso phy where they did not need signposts or milestones. This was mostly the case in Catholic countries such as Italy and Spain,2 and we have glanced at some probab le religious reasons for this. In Spain in particular, the universities were hap py to do without the new doctrines from England and Holland, and viewed with sus picion the instrument of their dissemination, the tertulia, which were private a ssociations. In 1700 the rector of the University of Seville wrote to his counte rpart in Osuna urging the destruction of a tertulia. These organisations co-oper ated, he said, with the object of destroying the Aristotelianism and Galenism of the schools.3 There were also political and economic circumstances that seem to bear on the matter. The economic centre of gravity of Europe was moving north. Spain was nding it dif cult to sustain its colonial empire, which had grown so rapi dly in the early sixteenth century, almost as if the conquerors of South America were the descendants of the 1 2 3 See J. Riolan (the Younger), Opuscula Anatomica Nova. Quae nunc primum in lucem prodeunt. Instauratio magna Physicae et Medicinae per Novam Doctrinam de Motu Ci rculatorio in Sanguinis in Corde, London (M. Flesher), 1649, p. 49. On the posit ion of the new philosophy in Spain, see W. G. L. Randles, The Unmaking of the Me dieval Christian Cosmos, 15001760. From Solid Heavens to Boundless ther, Aldershot (Ashgate), 1999, p. 168. Much of his rhetoric was directed against the new Roya l Society of Medicine in Seville. Randles, Christian Cosmos, p. 204. 185

186 The crisis re-conquerors of Muslim Spain. Italy was slowly losing its economic dominance. B ut a century or more later it was England, now increasingly prosperous, that was colonising North America; and at the same time Holland, having released itself from Spanish rule, was becoming a rich maritime trading nation, also with overse as possessions. Leiden supplanted Padua as the premier medical school of Europe and it taught medicine of a new kind, gathered from the novelties mechanism, che mistry and circulation among them that were seen as actual or potential heresies further south. t h e c r i s i s i n ph i lo s o ph y It was in the north that the doctors faced the crisis of the collapse of natural philosophy. Even in the universities Aristotle ultimately lost his position as The Philosopher, and his moral and natural philosophy was replaced by the disciplines of natural law (see below). The law of nature and nations was cultivated by Protestants because the y had rejected Canon Law, and the customary law of the north differed widely from Civil Law; moreover, the law of nations was useful in commerce with nation states of differing natures. The law of nature could be accommodated to some form of me chanism,4 but since it was all, ultimately, the law of God, this was not content ious. Indeed, it was the divinity of nature that made natural philosophy possibl e. The broad spread of scepticism, often called Pyrrhonism, which extended from Gassendi to Boyle, denied explanations of nature that rested on the intellectual system of a single man, whether Aristotle or Descartes.5 Experimental observation s, especially when repeated in front of witnesses, could be relied on, but infer ences drawn from them were limited to probable knowledge: there was no demonstrabl e knowledge, nothing propter quid. Yet no one could deny that the natural world was Gods handiwork, or that God was rational and bene cent. This is what made the s tudy of natural things attractive and instructive: the rationality of any philos ophy of nature lay in the natural world itself. 4 5 See, for example, Martin Heinrich Otto, Elementa Iuris Naturae et Gentium una cu m Delineatione Iuris Positivi Universalis, Halle, 1738. Natural actions in man a re those that occur mechanically from the structure and force given to the body by God. Halle was the Pietist university of Friedrich Hoffmann (see below) where Christian Wolf wrote an Institutiones of natural law in 1750. See his Jus Genti um Methodo Scienti ca Pertractum, 2 vols., Oxford (Clarendon Press), 1934. As obse rved by J-B. Pittion, Scepticism and medicine in the Renaissance, in Richard H. Po pkin and Charles B. Schmitt, eds., Scepticism from the Renaissance to Enlightenm ent, Weisbaden (O. Harrassowitz), 1987, pp. 10332, at p. 105, medicine had its ow n internal history of scepticism, drawn largely from Sextus Empiricus, which bec ame popular again in the late sixteenth century.

Resolutions 187 The doctors were compelled to consider what they had indignantly rejected for ce nturies, namely that medicine was an empirical art, not a rational scientia. It was argued by Nathaniel Highmore that demonstration, the traditional mark of a scie nce, belonged only to geometry and was impossible in medicine. Highmore was Engli sh and was attacking James Primrose, Harveys opponent, whose system was the traditi onal Aristotelian/Galenic synthesis. Highmore uses the language of the experimen ters, saying that knowledge is only probable.6 In France, Pierre Gassendi assert ed that the whole business of medicine was conjectural, even the circulation of the blood.7 In Holland the professor of medicine at Leiden (where there had been troubles similar to those at Utrecht over the Cartesian system) was Albert Kype r, who declared that medicine was not part of reasoned knowledge, but an art, de pending on experience and observation. Now, while the practitioner had lost the support of traditional natural philosophy in telling a good story to his patient s, a teacher stood to lose much more. If medicine really was an art of experienc e and observation, it could hardly be taught in a classroom, with words and the usual formal devices of exposition. Kyper had no wish to remove medicine from th e universities and make himself and his kind redundant, and he struggled to come to terms with the implications of his belief. Indeed, he wrote a textbook to sh ow that medicine was an autonomous art, separate from the systems of Descartes a nd Aristotle.8 His purpose was to guide his students out of the crisis of philos ophy, to steer, in his words, between Scylla and Charybdis. Traditional medical learning was a hindrance, not a help, and one of his aphorisms was that a learned doctor is a bad practitioner.9 This was, of course, exactly the opposite of what university doctors had been claiming since the Middle Ages, and is a sure sign of the crisis of the middle of the seventeenth century. There were other reasons for the crisis being felt so sharply in Holland, for as Kyper explains in his d edication, having thrown off the yoke of Spanish and Catholic rule, now is the t ime to cultivate true religion and true knowledge. 6 7 8 9 Nathaniel Highmore, Corporis Humani Disquisitio Anatomica, The Hague (Samuel Bro un), 1651, p. 149: Ars Medica non est demonstrationibus ornata . . . nobis suf cia t ex probabili ratiocinari. See also Steven Shapin and Simon Schaffer, Leviathan and the Air-Pump: Hobbes, Boyle, and the Experimental Life, Princeton (Princeto n University Press), 1985. Pierre Gassendi, Discours Sceptique sur la passage du Chyle & sur le Mouvement du Coeur, Leiden (Jean Maire), 1648, p. 56. Gassendi d id not put his name on the title-page, giving only the initials S. S., but the i dentity of the author was known for example to Jean Riolan, Notationes in tractu m clarissimi D. D. Petri Gassendi . . . de Circulatione Sanguinis, Paris, n.d. A lbert Kyper, Institutiones Medicae, ad Hypothesin de Circulari Sanguinis Motu co mpositae. Subiungitur ejusdem Transsumpta Medica, quibus continentur Medicinae F undamenta, Amsterdam (Joannes Janssonius), 1654. Doctus theoreticus est infelix practicus. See the address to the reader in the Transsumpta.

188 The crisis The Rational and Learned Doctor faced other problems in the middle and second ha lf of the seventeenth century. As the towns and their money economies expanded t here was more opportunity for middle-class patients to seek out other kinds of m edical practitioner, out of reach of the professional colleges. The London Colle ge of Physicians remained comparatively small, a strategy that worked to the adv antage of the fellows in previous centuries, but which now diminished their powe r.10 Apothecaries and surgeons had professional groupings which grew in power. I n 1704 the House of Lords decided that an apothecary could practise internal med icine, thereby challenging the colleges old monopoly. As in Paris, the college ma intained the professional face of Galenism while Galen was falling rapidly from favour elsewhere. In England, royal patronage of the college ended abruptly with the Interregnum, and its regulatory power dropped off precipitously.11 Indeed, it was dif cult to regulate medicine when it could not be said with certainty what i ts principles were. In 1678, for example, the favourite of the viceroy of Naples was killed by a chemical remedy administered by a Galenist. When the viceroy as ked the profession for guidance, he was told that medicine was so confused that regulation was impossible. It was without rational principles and was not a scie ntia.12 c re at i n g a n ew o rt h o d ox y Kyper chose to call his book the In stitutes of Medicine, a title often used when a particular form of medicine was to be presented in attempting to lay down a new orthodoxy.13 What Kyper did was to grasp a few principles which seemed still to be true in natural philosophy an d bring them over into medicine. This was precisely the strategy of the medieval d octors who had declared that medicine was an extension of natural philosophy and that the doctor began where the philosopher nished. It will be recalled 10 11 12 13 On the earlier history of the college, see Sir George Clark, A History of the Ro yal College of Physicians of London, vol. 1, Oxford (Clarendon Press for the Col lege), 1964. For an introduction to the topic, see Toby Gelfand, The history of t he medical profession, in W. F. Bynum and Roy Porter, eds., Companion Encyclopedi a of the History of Medicine, 2 vols., London (Routledge), 1993; vol. 2, pp. 111 950, at p. 1126. See Nancy Struever, Lionardo di Capoas Parere (1681): a legal opin ion on the use of Aristotle in medicine, in Constance Blackwell and Sachiko Kusuk awa, eds., Philosophy in the Sixteenth and Seventeenth Centuries. Conversations with Aristotle, Aldershot (Ashgate), 1999, pp. 32266, at p. 322. Di Capoa, like o thers in uncertain times, wrote a short history of medicine, complaining how the fall of philosophy had brought down medicine too. A new orthodoxy could, of cou rse, be a reassertion of an old one, as in the Institutes of the Hellenist Fuchs (see chapter 6) and the anatomical Institutes of Vesalius teacher Guinter of And ernacht: Institutionum Anatomicarum secundum Galeni Sententiam, ad Candidatos Me dicinae, Paris (Simon Colinaeus), 1536.

Resolutions 189 that part of the programme was that such philosophical axioms could not and shou ld not be questioned by the medical man. Kyper was in a dif cult position because the old philosophy was discredited and the new was not widespread, detailed or c onsistent among its proponents. He preferred to speak of physica rather than phi losophia, no doubt to avoid connotations of systems. One of his axioms was the cir culation of the blood. Another was that repeated sensory observation can add up to a universal statement of truth. Part of his strategy was to use some of the t erms of Aristotles philosophy, which although discredited as a system, still reta ined some force of meaning for educated men. Thus, ef cient causality seemed expli cable, while nal causality was impossible. Like Boyle, he saw that nature had an underlying rationality because it was Gods creation: in the absence of a philosop hical system, this gave coherence and order to the world, even to a sceptic. Kyp er is largely traditional on the powers of the soul in the body, and, while sidi ng with the moderns in giving attention to the solid parts of the body rather th an the humours, his account of details such as the humidum radicale are medieval . He stoutly defends the validity and durability of medical healing procedures d espite the changes in theory. While the medievals had discussed the difference b etween knowledge propter quid (largely demonstrated knowledge derived from somet hing else) and knowledge quia (simple knowledge of a thing), Kyper uses the more fashionable to dioti and to oti, giving the dignity of erudition, and his appro val, to simple experiential knowledge. This enables him to say that the theory o f medicine, with all its faults, is an attempt to understand the human body in g eneral, while the practical art of medicine is a study of particulars in individ uals.14 t h e ph y s i c i a n s l e a r n i n g There were two areas of traditio nal medical learning that survived, in a diminished form, the crisis of medical theory. The rst was knowledge of the powers of natural substances. This was the m ost widespread form of medical learning, and even in the days of high theory doc tors were always anxious to learn of new substances or new properties. One of th e reasons why Philip II of Spain sent a doctor to South America in the rst half o f the sixteenth century was to explore the new drugs of the New World, and colon ial doctors in North America also examined Indian medicine.15 Indeed, by 14 15 The Transsumpta are separately paginated: this is his Prolegomena, p. 3. See, fo r example, Jean de Lry, History of a Voyage to the Land of Brazil, trans. Janet W hatley, Berkeley e (University of California Press), 1990.

190 The crisis the middle of the seventeenth century so populous were the Americas, with their European culture and medicine, that the northern European crisis in philosophy n ow seems somewhat parochial. What the knowledge of the powers of substances had lost was the theoretical apparatus, the intension and remission of qualities, th e doctrine of change of substantial form in the fermentation of compounds and the mathematics of dosage. The second survival of the crisis was anatomy.16 This rel ied upon sensory observation, experience and experiment, so it suited the scepti cal temper of the experimenters and did not necessarily lead to a theoretical sy stem of medicine. Indeed, anatomy in the experimental sense became something of a slogan for the new philosophers, for example for those of the Royal Society. Wha t anatomy lost in the process was the hierarchy of action, use and utility of th e similar and compound parts, the nal causality that had determined true knowledg e of a part, and the faculties of the vital and sensitive aspects of the soul (i n particular the faculty of attraction). In short, anatomy became morphological, with an increasing interest in ne structure. In this form, without its theory, a natomy came to be more closely associated with surgery, particularly where taugh t in private schools outside the universities. But academic anatomy also drew su pport from the microscope, which revealed structure at an unexpected level. Whil e gross anatomy was sometimes called simple anatomy, it extended not only to ne str ucture including bres but to vital anatomy, chemistry.17 empiricism We have seen th at a number of men thought that medicine was, or should be, after all, an empiri cal art, not a theoretical scientia. This would have made them empirics, the kin d of practitioner that the university-trained doctor had denigrated for centurie s. But there were ways out. One could, like Kyper, grasp some of the few certain ties left in philosophy and rebuild medicine from them, in a rather traditional way. Another escape route was to return to Hippocrates, the Father of Medicine. He had been (by mutual agreement) without many of the sciences and arts that lat er and weaker medical minds needed to understand the great medical wisdom that u nderlay Hippocratic texts such as the Aphorisms and Prognosis. But it was also g enerally agreed that Hippocrates, although patient, observational and 16 17 Medical educators saw anatomy not merely as a survivor of the crisis but as an a rea of growth, particularly when identi ed with microscopic studies. See J. Antoni us Vulpius, Opuscula Philosophica, 3rd edn, Padua, 1744, p. 208. Struever, Di Cap oa, p. 331.

Resolutions 191 even experimental, was not an empiric. Many doctors of the seventeenth century a nd later could call themselves Hippocratics without the odium of empiricism. Ind eed, Hippocratic texts remained popular down to the nineteenth century, in contr ast to the declining publication of theoretical Galenic texts. It was possible t o be a non-empirical Hippocratic by deciding that what had made Hippocrates grea t was his method. This is what was believed by Thomas Sydenham (162489), who was sometimes known as the English Hippocrates and who eschewed theory.18 He held that the proper method of medicine was twofold: collecting a history of diseases and e stablishing a method of cure. Hippocrates is the only ancient author he mentions in his preface19 and it is clear that in part his inspiration comes from the Hi ppocratic case-histories and the circumstances of the patient given in Airs, Wat ers and Places. But Sydenham is more explicit he declared that a history of a dise ase is also what was set out by Francis Bacon in the method of gathering natural histories. Bacon was a useful resource for those caught up in the crisis of the oretical medicine, for he had set out a detailed and in uential procedure for disc overy while the old theory and, institutionally at least, the old philosophy was intact. Sydenhams quotation from Bacon explains how a true natural history is wi thout fables, philology, disputes or quotations, matters not t for the institutes of philosophy that is, in fact, a proposal for a new orthodoxy. What a true Hippo craticBaconian history would reveal, said Sydenham in essence, was the identity o f disease. As he himself put it, diseases ought to be reduced to certain kinds, in the same way as botanists treat plants. This heralds an important change in m edicine. We have seen that the preferred kind of practice of the Rational and Le arned Doctor was contractual or retained service over a period of time to a comm unity or an individual. We also saw that epidemics like the Black Death and Fren ch Disease did not suit this kind of practice at all and that, as a result, dise ases acquired a weightier ontology. Sydenham is now saying not only that disease s are things, but that they have similarities and differences that enable them t o be classi ed in the manner of physical objects. He stresses that this classi catio n should be done in the Baconian way, for previous classi cations had been made on ly to support hypotheses 18 19 Sydenham is generally associated with his friend John Locke and sensory epistemo logy. See also W. F. Bynum and Roy Porter, eds., Medicine and the Five Senses, C ambridge (Cambridge University Press), 1993, introduction. There is a biography by Kenneth Dewhurst, Dr Thomas Sydenham (16241689). His Life and Original Writing s, Berkeley (University of California Press), 1966. Thomas Sydenham, The entire Works of Dr Thomas Sydenham, newly made English from the Originals, ed. John Swa n, London (Edward Cave), 1742, preface.

192 The crisis (he is perhaps thinking of types of tumour named after the predominant vitiated humour). Sydenham believed (with Bacon) that by building up a history from repea ted observations, constant symptoms could be distinguished from accidental and ( with Hippocrates) that histories are to be correlated with the seasons, for some diseases follow the seasons by a secret tendency of nature. Histories also gave i ndications of cure, largely by trial and error.20 This is consistent with Sydenh ams belief that no deeper cause than the most immediate is discoverable; and it i s also consistent with the language of the experimenters about matters of fact (ra ther than of theory) and probable knowledge. Sydenham was aware of Boyles beliefs.2 1 Sydenhams distrust of theory was shared by his friend, the philosopher John Loc ke, who also practised medicine. Both drew from seventeenthcentury scepticism bu t lived to see a new assertiveness about theory as an answer to the crisis of tr aditional natural philosophy. Theories, that are for the most part but a sort of waking Dreams . . . I wonder, that after the Pattern Dr Sydenham has set them of a better Way, Men should return again to that Romance Way of Physick.22 Probably Sydenhams ontological concept of disease was related to the nature of his practi ce. Perhaps for political reasons (he was a Parliamentarian who practised medici ne after the Restoration) his work was mainly among the poor. He had to see many of them to make up his income, and they suffered much from epidemic fevers. It was the opposite of being retained and the individual meant less than the diseas e; possibly too he had greater freedom to experiment with his remedies. denial T he changes in philosophy were viewed differently across Europe. In Paris the gre at anatomist Riolan ercely defended Galen, as his predecessors had done. It was h e who had tetchily remarked that mechanism was a newfangled Dutch invention. Ult imately he was compelled to agree because by now most learned men had agreed on the changes in medicine, but he tried to claw back his reputation by claiming th eir discovery for himself. Indeed, he claimed that he was about to reformulate n atural philosophy itself 20 21 22 He thought that Hippocrates rules for removing diseases were given in the Aphoris ms and Prognosis. See Andrew Cunningham, Thomas Sydenham: epidemics, experiment a nd the Good Old Cause , in Roger French and Andrew Wear, eds., The Medical Revoluti on of the Seventeenth Century, Cambridge (Cambridge University Press), 1989, pp. 16490, at p. 180. See Kenneth Dewhurst, John Locke (16321704) Physician and Philo sopher. A Medical Biography, London (Wellcome), 1963, p. 310.

Resolutions 193 in a Grand Instauration. But he was by now an old man and it amounted to little; and it fell on deaf ears. At the other end of France, in common with most Medit erranean countries, the new philosophy looked distant and heretical. Montpellier had for centuries been a famous medical school and men could go there to be tra ined in rational and learned medicine of the traditional sort. It worked for the m as it had done before: in the terms we are using they were successful. In the 1650s the dean of the regius professors there was Lazarus Riverius (15891655), wh o found it desirable to restate traditional medicine in an Institutes, a term wh ose circumstances we have met before. This had a long publishing history: it rst appeared in print in 1640 and new editions were brought out regularly until 1737 when the nal edition appeared in the form of Riverius collected works.23 The appe arance of so many editions implies a good market for the book and many readers, but little more can be read into this in terms of historical signi cance if the ed itions contain nothing new. (Sir) Thomas Browne went to Riverius lectures in Mont pellier in 1630,24 when the Latin tradition of medicine had hardly been challeng ed; Riverius kept it alive for over a century. By the 1650s Riverius was well aw are of the changes in philosophy and medicine in other parts of Europe, but for him scepticism and its implications counted for nothing. He asserted that medici ne was indeed a scientia, capable of demonstration. His was no Hellenist or Huma nist revival of ancient learning but a continuation of the medieval tradition. H e takes up the medieval question of whether medicine is an art or science and ar gues on both sides, as a scholastic would. Yes, in being directed to a practical goal, medicine is a productive art; yet on the other hand, it has principles, a xioms and demonstrations, founded on nature herself. When he says that these pri nciples are more certain even than those of natural philosophy (physica) itself, which are derived from a faith in senses, it is likely that he was thinking of contemporary natural philosophy further north, where its practitioners were refu sing to elaborate systems out of sensory experience. For Riverius, medicine was a separate and older discipline than this, with a superior means of demonstration and with its own noble subject, the human body. Unlike the arts, medicine was le arned and was to be acquired by much reading and the institutio of the doctors, a phrase that encapsulates the authority of the medical tradition and which 23 24 Lazarus Riverius, Opera Medica Universa, Geneva, 1737. Riverius is said to have accepted the circulation of the blood by 1650. See Charles W. Bodemer, Materialis tic and Neoplatonic in uences in embryology in Allen G. Debus, ed., Medicine in Sev enteenth Century England. A Symposium held at UCLA in Honor of C. D. OMalley, Ber keley (University of California Press), 1974, pp. 183235, at p. 199.

194 The crisis was built into the title of his book. He uses demonstration not only in its Aristo telian sense but also in a geometrical way (by contrast, the English empiricists thought that the term demonstration could be used only in a geometrical sense): l ike medicine, geometry was certain knowledge and was only secondarily practical, in measuring the earth. In its long life Riverius book came to be presented in a different way. After Riverius death in 1655, Daniel Horstius contributed an addr ess in 1668. The edition of 1737 contains editorial matter designed to temper th e eagerness of Riverius Galenism, which by now looked medieval, at least in Enlig htenment Geneva. By then it needed explaining why Riverius had used Aristotles di scussion in the Metaphysics about the relationships between the disciplines to a rgue that medicine was a full scientia. It needed explaining why Riverius built up the content of his medicine in the traditional and compositive way from the f our elements, their qualities, complexions, humours and the seven naturals. It cer tainly needed explaining why Riverius resurrected the huge debate of the late Mi ddle Ages about the perfect balance of qualities in complexion and the highly ma thematical distinction between ad pondus and ad justitiam complexions. Riverius was not being simply medieval, for he dismisses (in the manner of the schools) t he attacks on the theory of elementary qualities made by Telesio and Cardano, si gnificant enemies of Aristotelian natural philosophy. There can be little doubt that Riverius very complete Galenism was a reply to such attacks. Later editions of Riverius book contain two signi cant editorial insertions. One is a little tract on medical deontology written by the emperors physician.25 It comes with the app rovals of a theologian and a medical man and is expressly designed to inform the Catholic doctor of his medical and religious duties. It gives the attributes of the good physician and the disciplines with which he must be familiar. Of these , philosophy is by far the most important, and it may be that this tract was tho ught suitable for Riverius text, because its philosophy is as traditional as Rive rius Galenism. The cause seems to have been the same, that is, that the northern crisis in philosophy and its effect on medicine could be avoided by denying it. Medical principles, says the emperors doctor, are the arcana of philosophy; philo sophy is the uterine sister of medicine, offering a light to it. Without it medic ine is more like a bloodless corpse than a living body, a branch torn from a tre e.26 This relationship between philosophy and medicine had been an axiom since th e early Middle Ages, but the reference to the 25 26 F. C. Weinhart, Medicus Of ciosus, without date or place; separately paginated. Phi losophia medicinae soror germana & uterina est, facem et praeferens. Medicus Of cio sus, p. 3.

Resolutions 195 damage done to medicine by the absence of philosophy applies to the crisis of th e late seventeenth century. Medicine without philosophy becomes enervated, all d iscussion recedes from truth, axioms are impossible to prove, proofs are offered that prove nothing, monstrous novelties appear, the parts of medicine lose thei r order and the result is a bad method of cure. The Good Doctor, whose medicine is rationalis, must be a student in the arena of theory before becoming an athle te in practice. Again we may suppose that the publisher saw a market for the lat e editions of Riverius work on a traditional medicine supported upon a traditiona l philosophy. But perhaps he wanted to hedge his bets with a second editorial ad dition that addressed once more the old question of whether medicine was an art or a science. But the answer is new, with arguments drawn from writers of the la te seventeenth century: Marcello Malpighi, Lorenzo Bellini and even Friedrich Ho ffmann. Now are given the views of Boyle on the importance of the senses and the dangers of intellectual systems. Demonstration now carries a Baconian as well as other meanings. The purpose is not to deny the traditionalism of Riverius or the truths of traditional philosophy, for we hear of Aristotles discussion of the re lationship between the productive arts and the intellectual sciences, and there is a very rationalist discussion of demonstration and utility, partly in connection with the rst aphorism, always a nexus when such things are discussed. No, the ove rall purpose is once more to escape the medical consequences of the fragmentatio n of philosophy: medicine as an art cannot be damaged by changes in philosophica l fashion. The author provides in explanation the image of a man faced with a bu rning house: when you are trying to put out the ames with water there is little p oint in asking whether they consist of Democritean atoms or Aristotelian substan tial forms. t h e lo n d o n co l l e g e o f ph y s i c i a n s a n d t h o m a s w i l l i s Institutional Galenism is well illustrated by the London College of Physicians. It had been founded in the sixteenth century by Henry VIII on a s uggestion of John Caius and was inspired by the Italian professional colleges. I ts task was to control the practice of physic, and by the time of Charles I it h ad begun to look to parliament like a royal monopoly. The City of London was gro wing in size and power and in 1630 it gave formal recognition to the Apothecarie s Company, which four years later directly refused to be controlled by the Colleg e of Physicians. As a royal foundation the college lost more of its power in the Civil War and Interregnum, and at the Restoration its new charter was less favo urable than the old. These were

196 The crisis local English circumstances, on which much has been written and the story does n ot need to be repeated here.27 But they coincided with the story of the scienti c r evolution in which many contemporaries saw the importance of what was happening i n England. One of these was the formation of groups of like-minded philosophers culminating in the Royal Society. The members shared a belief in a philosophy wh ich was variously mechanical, corpuscular, experimental or anatomical, and they pursued research topics that arose from Harveys work and that of Continental mech anists such as Giovanni Borelli and Malpighi. The College of Physicians, in cont rast, had a professional need to be Galenic, the measure of the authority and ef fectiveness of university medicine since the Middle Ages: the statutes of 1647, for example, betray no departure from GalenicHippocratic ideals.28 But the colleg e felt acutely the intellectual rivalry of the Royal Society and the professiona l rivalry of the Apothecaries Company and the Society of Chemical Physicians, bot h growing in power. The college remained small at a time when London was growing rapidly, and to offset criticism in 1664 it admitted a large number of honorary fellows, a new category of membership. In a bald statement of professional ethic s it told them exactly what to do to promote and defend the reputation of the col lege.29 But it was of little use. When the plague came in the following year, mo st of the physicians left town, leaving the medical market free to the apothecar ies, and the following year the Fire of London burned down the college building and it had no funds to rebuild. The college could no longer defend a Galenic med icine and turned to mechanism in about 1680. The members had defended themselves against the criticism of the chemists by claiming that they had already adopted a number of chemical remedies (which did not necessarily con ict with Galenic the ory). They had also answered Boyles criticism of their traditional theory by clai ming that the practice of traditional medicine worked better than any medicine b ased on the new philosophy. The argument for effectiveness had always been part of the Rational and Learned Doctors 27 28 29 See in the rst instance Theodore M. Brown, The Mechanical Philosophy and the Anima l Oeconomy. A Study in the Development of English Physiology in the Seventeenth a nd early Eighteenth Century, New York (Arno Press), 1981. Browns introduction to Domenico Bertoloni Meli, ed., Malpighi: Anatomist and Physician, Florence (L. S. Olschki), 1997, sums up the changes in the eld and its literature. Brown, Mechan ical Philosophy, p. 138. As in earlier schemes of medical ethics, the honorary f ellows were forbidden to converse with empirics or enemies of the college, but to work for the honour and advantage of the College. Above all, the new fellows were not to publicly argue with any licensed physician, that is, of the rational and learned elite, a point of medical ethics for centuries. See Brown, Mechanical Ph ilosophy, p. 144.

Resolutions 197 armoury, but now it was time to link it to the new philosophy. This was done lar gely in the way set out by Thomas Willis (162075). Willis showed the physicians t hat they could maintain a largely traditional practice of medicine by constructi ng mechanical reasons for it. This was another way of resolving the crisis: rest ore some of the dignity to practical medicine and show that now the reasons for its success are better known. Willis rational pharmaceutics thus have a mechanical rationality in which his learning draws strength from contemporary philosophy.30 His mechanism is a solidist one, with much attention given to bres (which can, for example, provoke vomiting when irritated).31 He nds it necessary to defend medic ine, reminding the reader that it should be among the most noble of the sciences . But, in mathematics and mechanics, experiment, experience or chance lead more readily to causes than in medicine. Medicine was rst handled by empirics, he says , and then stolen by mountebanks and the little old ladies (who so constantly pl agued the Rational and Learned Doctor). The result was that it became a mysterio us rite, an inexplicable matter in which no reasoning could be found.32 Mounteban k here is a rendering in English of agyrta, apparently a term recorded only in Br itish seventeenth-century sources, so it is a very speci c insult for those who pr actised the wrong kind of medicine or criticised the right kind. His language ge ts stronger. The literate cynics who criticise medicine are no doubt the philosoph ical sceptics who refused to admit systems and causes, and the vilissimi quique e plebis faece are the literal equivalent of those neoterics whom (Aubrey tells us) Harvey called shitt-breeches.33 It clearly re ects the disputes between the Gale nists and the mechanists, between the mechanists themselves, and between the che mists and everyone else. Pseudochemists, Willis calls them. The of cial pharmacopoei a of the college was the battleground with the apothecaries, who nally refused to follow it: Willis is moving in a highly charged political atmosphere. In princi ple, Willis mechanical account of the actions of materia medica is taken in conjunc tion with anatomy, a surviving part of traditional medicine, and he gives an acc ount of the major regions of the body where the remedies act. In practice this m eans that he categorises medicine in the conventional way as purges, vomits, diu retics 30 31 32 33 Thomas Willis, Pharmaceutice Rationalis sive Diatriba de Medicamentorum Operatio nibus in Humano Corpore, The Hague (Arnout Leers), 1675. Leers was part of the E nglishDutch connection, specialising in English medical works and publishing four of the seven editions of Harvey in Holland. Willis, Pharmaceutice Rationalis, p . 46. Ars tamen medendi licet primo ab Empiricis tradita, & ab Agyrtis quibusque & mulierculis passim arrepta, usque tamen quasi mysterii ritu, in cuius rationes minime inquirere fas esset, inexplicata permansit. The preface to the reader. Se e Geoffrey Keynes, The Life of William Harvey, Oxford (Clarendon Press), 1978, p . 434.

198 The crisis and so on. Discussion of how they act mechanically is not a major part of Willis treatment. The context of Willis projected programme of giving new philosophical muscle to fairly conventional medical therapy was the attempt by of cials of the c ollege and iatromechanical authors to rebuild the physicians decaying income, powe r and prestige.34 Willis career illustrates a number of themes of this book. He wa s born into a family of the middling sort, the class who supplied the bulk of le arned and rational physicians, for gentry did not become doctors35 (although we shall see that doctors tried to become gentry). His lifetime saw the crisis in t raditional natural philosophy and the attempts by the physicians to resolve it. His medical education was, like Sydenhams, interrupted by the English Civil War a nd he may have had less than six months formal training; he certainly developed a taste for chemical explanations. He also lived at a time of great competition i n the medical marketplace. While the earlier professional colleges and faculties had exercised some form of numerus clausus to protect the status and market sha re of the learned physician, it seems that medical quali cations were easier to co me by in Willis time. Many French universities had two levels of the same medical degree, the lower being pretty much a purchase made by foreigners who would not practise within the faculties jurisdiction. Aberdeen frankly sold its degrees on the recommendation of two established practitioners.36 Some of these foreign de grees could be traded-in for an Oxford or Cambridge degree and so make possible a membership of the London College for candidates with a less than rigorous medi cal education. Moreover, the king or bishops could confer the degree of MD.37 Co mpetition meant that not even fellowship of the London College always led to suc cess: Nathanial Hodges, for example, an Oxford-educated fellow in Willis time, di ed in a debtors prison.38 Other things were needed to secure a practice and make money. In the rapidly changing economic and social conditions of seventeenth-cen tury London, physicians found that attention to dress and manners could be 34 35 36 37 38 Brown, Mechanical Philosophy, p. 124. Willis still has spirits and humours, alth ough of a new kind. His listing of the formulae for remedies connects to the pha rmacopoeia and looks rather traditional, including mithradatium (p. 257) and the theriac of Andromachus (p. 167). Theriac and mithradatium remained in the Edinb urgh Dispensatory until 1756 and their last vestige did not disappear from the P aris Codex until 1908. See David L. Cowen, Expunctum est mithradatium, in his Phar macopoeias and Related Literature in Britain and America, 16181847, Aldershot (As hgate), 2001, item III. On Willis and Boyle see Kenneth Dewhurst, Thomas Williss Oxford Lectures, Oxford (Sandford Publications), 1980. See Roger French, Medical teaching in Aberdeen: from the foundation of the university to the middle of the seventeenth century, History of Universities, 3 (1983) 12757. Harold J. Cook, The Regulation of Medical Practice in London under the Stuarts, 16071704, PhD disser tation University of Michigan, 1981, p. 32. Ibid., p. 43.

Resolutions 199 useful. Appointment to a hospital or a faculty had a certain cachet and for the physician (even without an MD) who made it to court respect was inevitable. Curi ng a famous gure often led to a secure word-of-mouth reputation, and securing a w ealthy patron was just as good (John Locke left Oxford without taking his medica l degree to work for Lord Ashley).39 These were not, however, the sort of opport unities that presented themselves to many doctors. Rather, they would be obliged to sit in fashionable coffeehouses or visit the local market casting Waters, that is, inspecting urine samples.40 Willis himself was a piss prophet in Abingdon mar ket, where he travelled from his rooms in Christ Church, Oxford, on a shared hor se on Mondays. In 1646 he was a bachelor, not a doctor of medicine (and may have counted his army service as university terms). His patients were largely poor c ountryfolk until a series of epidemics struck Oxford in 1658. He capitalised on this by writing a largely chemical theoretical tract on fevers.41 Like Harvey, h e married wisely, and into Royalist circles, and was rewarded at the Restoration by being made Sedleian Professor of Natural Philosophy and by being given the d egree of MD at the insistence of Charles II. The Sedleian chair was rst occupied in 1620, when traditional natural philosophy was still undisturbed, and the stat utes of 1636 governing it specify that the Aristotelian libri naturales were to be lectured upon in an entirely traditional way. Willis, however, gave lectures that centred on medical topics in the chemical manner.42 But still Aristotle rep resented continuity and authority and with Charles II enjoyed a triumphant and e ven divine Restoration (especially at Willis college, Christ Church).43 Outside t he university, in contrast, Willis kind of medicine made him very rich and famous . Of all these devices to secure a reputation perhaps the most effective was to write a book. This was certainly Richard Meads advice: Should you have an itching to make your name known by writing a book, choose one that will be business and money-making, like fevers, smallpox; address it to a great man or get your fello w doctors who agree to commend each others books by letters.44 t h e i ta l i a n co l l e g e s a n d g e n t l e m a n ly m e d i c i n e Medical men at the uni versities of Paris and Montpellier had their own academic reasons for resisting the new philosophy; in Italy learned medical men had additional professional rea sons for wishing to retain Galenic 39 41 42 43 40 Dewhurst, Williss Oxford Lectures, p. 9. Ibid., pp. 34, 35. Diatri bae duae Medico-Philosophicae, London (Thomas Roycroft), 1659. His later De Anim a Brutorum is partly an expansion of these lectures. 44 Cook, Regulation, p. 35. Dewhurst, Williss Oxford Lectures, p. 39.

200 The crisis medicine. Through the sixteenth century the medical colleges had been extending their power over the old guilds, which often included apothecaries and surgeons. The protomedicato and the colleges were able to extend monopolistic control of internal medicine, including licensing and examination. The physicians, separate d from the apothecaries and surgeons, were assimilated into the upper classes. W hile the guilds had an open policy on matriculation, the colleges operated a num erus clausus which made them literally more exclusive, each member with a greate r share of the monopoly. Cities and universities both had medical colleges and w ere jealous of their privileges, refusing to admit the theoretically universal d egree of master from other universities and cities. The Milanese College was ini tially open only to the local patricians45 and that in Bologna was restricted to Bolognese citizens. Inevitably medical dynasties grew and rami ed through both ki nds of college and the faculty. The college of Pavia in 1667 obtained a privileg e from the emperor that made all its members Counts Palatine, and the social sta nding of some physicians was so great that they did not practise medicine. Moreo ver, the older physicians had greater power and all in all these ancients adhered closely to Galen and Avicenna. The moderns lectured illicitly and formed their own academies but did not defeat the ancients until the middle of the eighteenth ce ntury.46 When university statutes continued into the eighteenth century to speci fy the texts of Aristotle and Galen they were often taken as a framework into wh ich to t another kind of discussion. Our example here is Johannes Vulpius, a teac her of arts in that famous home of Aristotelianism and medicine, Padua. His acad emic oration on physica of c. 1727 gives a picture of a manner of discussing the se things in what was still a CounterReformation climate (the permission to publ ish explains that the book contains nothing against the Catholic faith).47 The t one of the whole is one of studied elegance, and Vulpius sometimes provides a Gr eek version of his Latin. This is classical education, with instruction in prope r language as important as the subject matter of philosophy and medicine. It is also a liberal education, of the kind that many doctors in the eighteenth centur y undertook to make themselves gentlemen. It was an obvious strategy to adopt, 45 46 47 See Ann G. Carmichael, Epidemics and state medicine in fteenth-century Milan, in Ro ger French, Jon Arrizabalaga, Andrew Cunningham and Luis Garca-Ballester, eds., M edicine from the Black Death to the French Disease, Aldershot (Ashgate), 1998, p p. 22147, at p. 222. See David Gentilcore, The organisation of medical practice in Malpighis Italy, in Bertoloni Meli, ed., Malpighi, 75110. Vulpius, Opuscula Philos ophica; the rst scholion on Aristotle carries the date 1727 (p. 73).

Resolutions 201 for a rich medical market was provided by the newly prosperous urban middle clas ses, who concerned themselves with civility and gentility; in Prussia there were galant doctors and patients. When disputes occurred between English practitioners the most serious crime was to break the gentlemanly code.48 It was a question o f behaviour, not clinical success or failure, and the doctors reputation was his success. For Vulpius there were, of course, practical advantages in having a kno wledge of nature, for it enabled one to lead the good and blessed life; and unde rstanding the nature of the body helped the physician to apply effective remedie s in cases of illness.49 Vulpius taught physica by order of the Venetian Senate and the triumvirate of letters. Physica was a new name for natural philosophy, and its purpose, as of old, was to explain Aristotles works: Vulpius had to give lectu res on De Caelo et Mundo and on De Generatione et Corruptione with the tradition al purpose of preparing students for medicine, law or theology.50 Indeed, physic a is a close sister, in the old way, of medicine, and the physician begins where the philosopher nished.51 But in spite of all these traditional features, Vulpiu s uses the statutes as a framework to discuss all manner of philosophical and me dical subjects. He writes as a historian reporting at a distance from his subjec t. There is no urgency to discover the physical truth in the disputes between th e Cartesians and the Newtonians, or whether there is a vacuum or not. He prefers Newton and John Keill, seen as geometers, to Descartes, the past dictator of phil osophy, and he defends Galen against the attacks of ignorant little men of weak character.52 The overall educational purpose is to teach the young gentlemen to understand enough about the body and the natural world (which God had constructe d as its dwelling place) for them to live in peace within it, in accordance with divine order. Clearly, the doctor could gain status by placing himself in the g enteel classes. But if Italian Galenists were also striving after gentility, the n the search for this new social status cannot, in itself, be interpreted as a s trategy for escaping from the collapse of philosophy (although that remains a po ssibility in the northern countries). It seems rather that new urban prosperity helped to generate a polite or genteel Enlightenment in the early eighteenth century and that doctors such as George Cheyne 48 49 51 52 See David Harley, Honour and property: the structure of professional disputes in eighteenth-century English medicine, in Andrew Cunningham and Roger French, eds., The Medical Enlightenment of the Eighteenth Century, Cambridge (Cambridge Unive rsity Press), 1990, pp. 13864. 50 Ibid., p. 24. Vulpius, Opuscula, p. 22. Ibid., p. 97. He gives particular attention to the role of anatomy. Ibid., p. 197.

202 The crisis (16731743) practised an appropriate medicine. He saw that a rigid and complex New tonianism was beyond the intellectual taste and abilities of his fashionable pat ients at Bath and elsewhere.53 A rising Bristol surgeon spoke of an imposing exte rior of the physician: He moved in a measured step and affected a meditating abstr action of countenance with a pomposity of diction and manner which served to kee p the vulgar at a respectable distance The doctors Peruke alone was enough in its elf to command respect.54 In Italy for the sake of dignity the physician was obli ged to keep a carriage; he wore a fur-lined gown, velvet cap, black gloves and a gold ring.55 As we have seen, these were the items to which he had become entit led at graduation and they remained symbols of his profession through the sevent eenth century.56 In 1696 Prospero Mandioso published a theatre of biographies of p apal physicians, showing that they were men of good learning and good families. Like most contemporary assessments, clinical excellence was not a big criterion of the good doctor.57 From the days of Melchior Adams collection of biographies o f German doctors,58 gentlemanly behaviour, cultural achievement and contacts wer e more tangible attributes.59 Adams collection was paralleled by the publication in Amsterdam of Zacutus Lusitanus De Medicorum Principum Historia libri sex by He nricus Laurentius in 1629. Lusitanus was a sixteenth-century Portuguese converso and this gives us information on the European network of such minorities.60 Ada ms and Zacutos works are examples of a genre of medical literature that came to in clude medical histories and 53 54 55 56 57 58 59 60 See Akihito Suzuki, Anti-Lockean enlightenment? Mind and body in early eighteenth -century English medicine, in Roy Porter, ed., Medicine in the Enlightenment, Ams terdam (Rodopi), 1995 (The Wellcome Institute Series in the History of Medicine) , pp. 33659, at p. 330. Quoted by Mary E. Fissell, Patients, Power, and the Poor in Eighteenth-Century Bristol, Cambridge (Cambridge University Press), 1991, p. 62. See David Gentilcore, The organisation of medical practice in Malpighis Italy, in Bertoloni Meli, ed., Malpighi, pp. 75110, at p. 78. The guilded stirrups and h orse-blanket were otherwise used only by princes and prelates. Richard Palmer, Me dicine at the papal court in the sixteenth century, in Vivian Nutton, ed., Medici ne at the Courts of Europe, 15001837, London (Routledge), 1990, pp. 4778, at p. 49 . I am grateful to Nancy Siraisi for drawing my attention to Adams Vitae Germanor um Medicorum, Heidelberg (J. Rosa), 1620. Collections of biographies of the famo us, often made to glorify a particular city, were made in the Middle Ages. While of course patients chose their doctors on the basis of their clinical reputatio ns, what interested the biographers was not the low-level and mundane business o f medical practice but the intellectual achievements of the biographee in medica l theory and philosophy. See Nancy Siraisi, The physicians task: medical reputatio ns in humanist collective biographies, in her Medicine and the Italian Universiti es 12501600, Leiden (Brill), 2001, pp. 15783. See Luis Garca-Ballester, The Inquisit ion and minority medical practitioners in counter reformation Spain. Judaizing an d Morisco practitioners, 15601610, in Ole Peter Grell and Andrew Cunningham, eds., Medicine and the Reformation, London (Routledge), 1993, pp. 15691, at p. 166.

Resolutions 203 bio-bibliographies of the seventeenth and eighteenth centuries. Patrons, towns a nd universities sought out doctors with wide erudition: the learned and gentlema nly physician was, above all, an educated man and could turn his hands to many t hings for an important master. Physicians educated at Kings College, Cambridge in the Middle Ages went abroad to further their education, apparently to qualify t hem for careers in something other than medicine.61 Harvey went on foreign embas sies for his king; and some of his contemporaries were essentially Protestant se cret agents.62 In the smaller German courts physicians took on a range of jobs s uch as administration and ambassadorial activity; many had studied mathematics a nd could make astrological forecasts and oversaw building and engineering.63 The important thing was that the learned and gentlemanly doctor had been educated i n a university approved of by his patron, whether Catholic or Protestant. Many o f these things lead back to the question asked in the Introduction: in what sens es could a doctor be called successful? In what way did he meet or even create t he expectations of society? Proud chroniclers writing about their Italian cities often included the names of the great and the good. Thus Filippo Matteo eulogis ed Florence and its early medical men including Taddeo, Dino, Turisanus and Tomm aso del Garbo. Filippo points to intellectual excellence in interpreting old and developing new texts by which rich and famous patients are attracted; the super iority of intellect over practice in Filippos view, such a frequent topic within medicine, emphasises the point made at the beginning of this book that clinical criteria can hardly, if ever, be used to measure medical practice.64 Another exa mple is Bartolomeo Fazio of Genoa (d. 1547) who wrote a collective biography in which he said of medicine, For what is higher than the investigation and the know ledge of the cause of those very things by which the whole of nature is containe d?65 Nothing could better express what has, in this book, been called the Good St ory by which the Rational and Learned Doctor in the Latin tradition related the patients symptoms 61 62 63 64 65 I am grateful to Peter Jones, Librarian of Kings College, for this information. H ugh Trevor-Roper, The court physician and Paracelsianism, in Nutton, Courts, pp. 7 994. For example, Theodore de Mayerne was a secret agent. He bought a castle and used it as a listening post for Protestant Europe (p. 92). See Bruce T. Moran, Pr ince-practitioning and the direction of medical roles at the German court: Mauri ce of Hesse-Kassel and his physicians, in Nutton, Courts, pp. 95116. See Nancy Sir aisi, The Physicians task: medical reputations in humanist collective biographies, in her Medicine and the Italian Universities, pp. 15783. Quoted by Nancy Siraisi, The Physicians task , p. 176.

204 The crisis and disease, with their Galenic physical reasons, to the very basis of the Arist otelian world-view. The ancient superiority of intellect soon to be dismissed as a system is also very notable. t h e e n d o f t h e l at i n t r a d i t i o n I t is notable that the gentlemanly physician continued to read his sources in Lat in and even in Greek. As late as the nineteenth century the big editions of Gale n and Hippocrates by K hn and Littr appeared in Greek, with u e Latin and French v ersions respectively standing opposite. But the working doctor who published for status or preferment increasingly turned to his vernacular language. This was t he end of the Latin tradition which has been a theme of this book and it is wort hwhile glancing at it in a little more detail as the story draws to a close. Lat in had been in common use throughout Europe because it was the learned language of the undivided church. It was the medium in which Aristotle, Hippocrates and G alen were read. It became the language of philosophy and of the theory of medici ne. Its technical terms carried a wide range of connotations that the Rational a nd Learned Physician knew well. But, with the crisis of traditional philosophy, the continued use of the old terms could be confusing, for they related to a net work of meanings in a discredited system and many authors seem to have opted to ex press themselves in the vernacular. In Harveys time writing in Latin was a way of securing a Europe-wide readership, which is what Harvey was aiming at. In his n otes for his anatomy lectures he sometimes used English: the point was that the general principles of his Aristotelian natural philosophy could be expressed wit h the full authority of formal Latin, but when he wanted an arresting image or a nalogy to convince and stay in the mind of his audience, he used English. Harveys opponents, Primrose and Riolan, used Latin for its authority in its reasoning a nd learning, and in contemporary terms their arguments were extensive and powerf ul. Newton too addressed a European audience in Latin; his was high philosophy a nd needed a formal language despite (like Harveys) containing radical novelties. But Boyle and sceptics such as Gassendi, both distrusting past systems of natural philosophy, made extensive use of their vernaculars; Descartes, with a new syste m designed to replace the old, broke with the old by using French. Experimental observations, such as Harveys sensory images, were best expressed in English with out any philosophical baggage. Medical teaching in the newer universities such a s Edinburgh was often in the vernacular from the early eighteenth century, altho ugh to reach an international studentship Latin

Resolutions 205 was necessary (as in Boerhaaves Leiden). Writers of reference works such as Halle r (see chapter 8) also used Latin for related reasons. c h e m i s t ry a n d m e d i c i n e Chemical medicine cannot form a direct part of this story because its practitioners were not learned and rational in the senses we have adopted66 (and because it has attracted a good share of historical attention).67 The inter est of chemical medicine for us is that it was a real challenge professional and intellectual to traditional medicine at a time when its theory had faltered; it was part of the crisis and for some, a resolution. The chemists sought their in spiration from Paracelsus and the Hermetic tradition, where Hermes was thought t o be contemporary with Moses or Abraham. This was not only a dignity of age device , but a claim of piety where the ancient Greek philosophers were expressly seen as pagan. In making the world, they believed, God had created powerful natural s ubstances recognisable by signs to the Godly physician. While Paracelsus had rej ected all of Greek medical theory, the chemists of the seventeenth century rejec ted the claims of contemporaries that geometry (and anatomy) had the force of de monstration; they preferred some form of numerology (and a system of celestial, sympathetic anatomy). As an attack on an established tradition, chemical medicin e was often preached by Protestants.68 In Galenic Paris, it was bitterly attacke d in the early seventeenth century by the Galenic Riolans, father and son, but M ontpellier was much more tolerant. The second stage in the growth of chemical me dicine is attributable to the work of Jean Baptiste van Helmont (15771644), whose doctrines were an effective challenge not only to traditional medicine but to t he new mechanical philosophy. An indignant church defended its own by locking hi m up for a while.69 But prudent 66 67 68 69 Where it was supported by the princely patron of a university, it almost became rational and learned. See Trevor-Roper, The court physician. While Paracelsus neve r got or wanted patronage, his followers shed the revolutionary image and were s ometimes supported by princes. The duke of Neuburg had a Paracelsian as his cour t physician before 1545. By 1570 Latin Paracelsianism was becoming respectable, and Maurice of Hesse, patron of Marburg university, appointed a Paracelsian, Joh an Hartmann (15681631). This was the beginning of chemiatria as an academic disci pline. See in particular the works of Allen G. Debus, especially The French Para celsians. The Chemical Challenge to Medical and Scienti c Tradition in Early Moder n France, Cambridge (Cambridge University Press), 1991; and Paracelsianism and th e diffusion of the chemical philosophy in early modern Europe, in Ole Grell, ed., Paracelsus. The Man and his Reputation. His Ideas and their Transformation, Lei den (Brill), 1998, pp. 22544. In France, by the Huguenots. When Henry of Navarre assumed control of Paris in 1593 the chemists were favoured. See Debus, The Fren ch Paracelsians, p. 48. Debus, The French Paracelsians, p. 106.

206 The crisis doctors of the traditional kind could accommodate some chemistry. It was entirel y possible within the structure of Galenic and Hippocratic medical theory to sea rch out new drugs, justi ed perhaps by the theoretical claim than modern man was w eaker than the ancients and needed stronger remedies. A powerful incentive in th e Spanish explorations of the Indies was the desire to nd new medicines.70 In par ticular, attention was given to metals, which did not feature in the old categor y of simples: mercury was used for the French Disease and there were constant sq uabbles over the uses and dangers of antimony. Broadly speaking, the chemists di scussed actions in liquids: fermentations, acids reacting with alkalis, and inte stinal motion in general. Distillation was central, for it seemed to be a way of extracting the essence of a medicine from the grossness of its matter. The noti on of puri cation in this often had Reformist overtones, nowhere more so than with the Rosicrucians, for whom the alembic was a parable for the whole world. While doctors of the traditional and mechanist persuasion could adopt a number of spa gyrical remedies from the chemists, they often saw chemical medicine as a new sys tem, on offer from the chemists only as a whole. When Georgio Baglivi was attacke d by Jacob Le Mort, the Leiden teacher of chemistry, a commentator observed that the tyranny of chemistry was that it had lovers but no friends.71 Consequently even doctors who were prepared to accept a good deal from the chemists, such as Antoine Deidier in Montpellier, thought that the whole chemical package was vulga r.72 Hoffmann thought it was grandiloquent but medically useless.73 Perhaps the m ost pronounced form of medical chemistry was that of van Helmont and it was cons picuous in England, where traditional natural philosophy had failed so signally. Helmontians sought a new and not mechanical natural philosophy on which to buil d a new medicine. In 1665 Marchamont Nedham, like Noah Biggs before him, spoke o f tearing down the old building of medicine and beginning again from different a nd deeper foundations, knowing that nothing new could be grafted on to old begin nings.74 The identities of philosophy and medicine had changed, but 70 71 72 73 74 See, for example, Robert Fludd, Clavis Philosophiae et Alchymiae Fluddianae, Fra nkfurt (Guilhelmus Fitzerus), 1633. It considers itself to be despised when no lo nger adored; it has slaves but no listeners: the anonymous writer of the preface to Georgius Baglivi, Opera Omnia Medico-Practica, et Anatomica, 15th edn, Venice , 1723. Antonius Deidier, Institutiones Medicae Theoricae, Physiologiam et Patho logicam Complectens, Paris (Carolus-Mauritius dHoury), 1731, p. 7. These are the novatores Chymici, p. 3. See the preface (1728) to volume 1 of the collected wor ks: Friedrich Hoffmann, Opera Omnia Physico-Medica, vol. 1, Geneva (The Brothers De Tournes), 1748. See Andrew Wear, Knowledge and Practice in English Medicine, 15501680, Cambridge (Cambridge University Press), 2000, p. 363.

Resolutions 207 the argument was the same as it had been since the Middle Ages: Natural Philosoph y is the Basis or the main Fundamental of Medicine: for where Philosophy ends, t here Medicine is to be enterprised.75 n ew i n s tau r at i o n s The Baconian In stauration By the end of the seventeenth century there were, then, a number of w ays of resolving the crisis of the fragmentation of traditional philosophy. But one general question remained in medicine: what weight was to be given to ancien t opinion? On the one hand, many held that the old authors were still authoritie s. Moreover, however convincing personal observation was, it was a particular, n ot a universal, and it had to be communicated to others. If it was experimental, then others would need the apparatus or need to do the vivisection. Scepticism in any case forbade the assembly of observations to make an argument that dealt with causes. The problem of ancient authority and the collapse of traditional me dical theory is exempli ed by Giorgio Baglivi (16681707). He is an important gure in our story and begins a new chapter within it, one in which physicians began to construct a new theory of medicine. His book, published near the end of the seve nteenth century, had gone through fteen editions by 1723: clearly he had found a huge market and his doctrines were in uential. We must look at it in a little more detail, but in short his story is one of a man who found medical theory chaotic and turned instead to practice. He could in this way retain Hippocrates as the Father of Medicine, while rejecting much Greek theory. He decided that his pract ical medicine would be a question of studying diseases as entities in a Baconian way, compiling histories of them over a long period of time (for the art is long and life is short). The aim of this method was to produce aphorisms, modelled on the Hippocratic, but which Baglivi held were capable of giving the causes of di sease, as many of the old rational systems did. Baglivi was not hampered 75 Noah Biggs (1651), quoted by Wear, Knowledge and Practice, p. 364. In England th e instauration of a new chemical medicine was conditioned by the Civil War, and it is not the present purpose to go over ground that has attracted so much histo rical attention. Important are Charles Websters The Great Instauration. Science, Medicine and Reform, 16261660, London (Duckworth), 1975; and the works of Allen D ebus, particularly his English Paracelsians, London (Oldbourne), 1965. The topic and its literature are usefully reviewed in Wear, Knowledge and Practice, esp. chs. 8 and 9. The chemists took advantage of the plague of 1665 in London, which killed about a fth of the population: they saw it as a trial of their own Godly medicine against the atheistical (i.e. philosophical) medicine of the Galenists. See Ole Grell, Plague, prayer and physic, in Grell and Cunningham, eds., Religio Medici, pp. 20427, at p. 204.

208 The crisis by scepticism, which had been an intellectual guarantee against systems for Boyl e. Indeed, descent into scepticism was now seen as a fault, for scepticism was now Pyrrhonianism, which limited the intellect and was moreover pagan: for Baglivi as for Boyle it was the Christian God as Creator who ultimately assured the ration ality and coherence of nature. Writing in 1696, he tells the reader of his studi es in Naples, his travels along the Dalmatian coast and his attention to practic al medicine in a number of Italian universities. Nothing was agreed as to the pr inciples of medicine among the men who taught him. Many of his contemporaries ha d abandoned the pristine (prisca) wisdom of medicine and left it a shaky structu re. There were rumours of great novelties; in some universities they were so muc h opposed to the ancient authors that they said it belittled the human mind to r ead the works of Galen. In others the theories of the ancients were anxiously an d religiously observed and new discoveries were constantly attacked. Often, in t he uncertainty, practice was reduced to purging, bleeding and vesication. In all universities Baglivi found contention, ill will and imprudence among the medica l men. Worst of all, Hippocates himself, medicinam Parentem suam, et magistram, was defamed as uncertain and fraudulent, both privately and publicly. Faced with an almost in nite variety of opinion, confused and uncertain, what was he to do? The rst thing was to recall that the ultimate purpose of medicine was practical. The disputes of his training were matters of words, the fallacies of explodable v anities of systems, things that did not direct his actions when he decided to vis it Italian hospitals to make notes of diseases. Like many others, he decided in the face of uncertainty to be led by the light of reason and experience. But, of course, it was to be reason and experience of a particular kind, historically l ocal. It was, in short, a method that was both Christian and Baconian. Baglivis Ch ristian philosopher was the man who saw God as the Creator of the world and natur e as expressions of His will. No philosophical scepticism could deny this, and, as with Boyle, it provided the rationality and coherence of the natural world. I n his preface, Baglivi addresses the pope and prays to Deus Optimus Maximus that reason and experience will in this way bring peace to the warring doctors of th e Christian Republic.76 Baglivi saw the parallel between the fractious medical m en of his day and the arguing philosophers described by Bacon: Baglivis programme amounted to a Medical Instauration.77 Its Organon, a method of acquiring useful knowledge, was to be personal observation over a long 76 77 sed solo praeeunte Rationis, et Experientiae lumine. Georgii Baglivi, Opera Omnia Medico-Practica, et Anatomica, 15th edn, Venice, 1723; Baglivis preface. Baglivi, Opera, p. 78.

Resolutions 209 period. Baglivi is emphatic that this should be done simply, even simple mindedl y, thus avoiding all distractions of theory or systems. Here Baglivi is most exp licitly Baconian: the collection of observations is a history (historia) of diseas e, and Baglivi quotes the passage that seemed to have a particular attraction fo r medical men, in which Bacon writes that in the construction of a natural histo ry it serves no purpose to include stories, citations of the authors, antiquitie s, controversies, superstitions, ornaments or etymologies; and above all, says B acon, include no systems. Use plain language, says Baglivi, and omit no detail, however slight. The doctor during this process, he adds, is a witness, not a jud ge; a historographus who needs no other scientia or reading to help him in compi ling his history. The history is composed of a rich and fertile forest of particul ars: Baglivi uses the Baconian term sylva.78 Putting the history together could take years. Baglivi wanted the doctor to look out for diseases as an entity, so that by noting every day the vehemence, circumstances and outcome of the disease , the history became chronological as well as simply descriptive. Baglivi though t that a doctor practising this method might collect 1,0002,000 observations on a single disease, like colic. The doctor was to note also the effect of remedies and the time and place of observation. When he was told too to make a note of th e constitution of the year it reveals that Baglivi had in mind some causal connect ion between the weather and the disease that owed something to Sydenham and some thing to Hippocrates and which was connected to attempts elsewhere to use the ba rometer medically. These simple observations are in themselves useless, says Bag livi: they are like letters of the alphabet which have to be arranged in signi can t groupings. Baglivi is entering the second stage of his Organon, arranging the observations under common headings and locations. With 2,000 observations on col ic in his notebook, the doctor can now group them into the paired categories of constant and variable (Bacons voice is audible) and diagnostic and prognostic. Ba glivis ideal doctor is now rising above the level of the empiric, and having arra nged his observations, begins to digest them. It was, of course, a major problem for a doctor engaged in empirical observation to avoid being labelled an empiri c, the traditional enemy of the Learned and Rational Doctor. The danger was grea ter when the doctor was unable to substantiate his medicine with an authoritativ e natural philosophy, and in supplying a method of procedure rather than an inte llectual system, Baglivi was coming to the rescue of his colleagues. 78 Baglivi, Opera, p. 111; p. 112 copiosa sylva.

210 The crisis The third stage of his Baconian programme was the digestion of the particulars. Arranging them had shown what was constant; what was not could be rejected as ac cidents. The doubts and cautions that had been entered in the notes while the hi story was being compiled could now be evaluated. Baglivi was aware that inductio n from particulars was imperfect in traditional logic, but he rests comfortably on the authority of Bacon in claiming it as a demonstration based on the senses which illuminates the mind and provides conclusions close to nature. Baglivi bec omes rhetorical here, indicating the centrality of this point in his method, whi ch is a kind of divine re in the mind, illuminating the vast desert of particular s signs, symptoms, causes that lies below as we labour the mountain to the peak of nature; from here we can descend with tranquil mind and a serene view to medi cal practice. It is at the peak of nature that the fourth stage of the programme i s reached, the production of precepts or general axioms: Baglivi speaks of abstra cting or deducing these from the digested particulars. Sometimes he calls them middl e propositions, but he is principally concerned to show that they have the same s tanding and nature as traditional medical aphorisms.79 In this way Baglivi can d efend Hippocrates by interpreting him, as almost everyone did, and strengthen hi s own novelty by enlisting Hippocrates on his side, which was also popular. But Baglivi makes bigger claims for his axioms, for they are not only aphoristic but can reveal causes, which the Hippocratic aphorisms do not. The causes underlie the appearances, provide signs and indicate remedies. Moreover, causes are part of natural philosophy: for all his denigration of other peoples systems and philo sophies, Baglivi admits to a philosophy which supplies the theory of medicine. I t is, to be sure, a different natural philosophy, because it is true, and it is true, says Baglivi, because it is based on experiment and the truth of mathemati cs.80 Baglivi prefers to use nature rather than philosophy so that he can speak of t he laws of nature, being close to nature, at the peak of nature and drawing hist ories from nature. He claims that Hippocrates spoke with the voice of nature, no t of man.81 He also adopts the not uncommon motto that the physician is the serv ant of nature, but only by understanding her.82 Nature 79 80 81 82 Baglivi, Opera, pp. 109, 112. Baglivi approved of experiment as a form of observ ation, and argued that some philosophical systems had failed by being insuf cientl y grounded on experiments: the chemical philosophy, with its acids and alkalis, Gilberts magnetical philosophy, Mayows nitrous air physiology. These too must have a dded to the general picture of uncertainty in natural philosophy. Baglivi, Opera , p. 107. Ibid., p. 1. The rst book of his De Praxi Medica (the rst numbered page of the volume) opens with Medicus naturae Minister, et Interpretes. . . . .

Resolutions 211 was also part of Creation. Baglivi uses the term Christian philosopher to imply th at he saw that God was the Creator of nature and her laws, that Gods rationality was now understood in those laws and that there was thus divine reason not to si nk into scepticism.83 Baglivi prayed that by the use of reason in this way the c urrent battles between doctors in the Christian Republic would come to an end.84 It was here in the method, at the generation of Hippocratic-philosophical axiom s, that Baglivi allowed the ideal doctor to undertake reading for the rst time. H e had been greatly insistent and very rhetorical that the doctor should in no wa y allow his mind to be distracted from the collection of particulars of the hist oria at the beginning of the method. Compiling a history, he said, was a science all of its own, not drawing its principles from elsewhere.85 It was therefore v ery important to do this with a clear mind, far from the in uence of disturbing bo oks. In fact, Baglivi has a formal list of things that have hindered the develop ment of a truly axiomatic medicine. These remind us again of the con icts between the philosophers and the plight of the medical men without a solid theory. They also remind us of Baglivis debt to Bacon, for these are Idols, falsities on which men have spent too much time in the past. Baglivi quotes Bacons view that having despaired of nding truth, men fell into the habit of disputing rather than maint aining a strict enquiry.86 Some of the Idols we have met, such as the propensity to construct systems and the refusal to make observation the beginning of medic ine and to generate axioms in the proper way. In fact, most of Baglivis Idols rel ate to the disrupted state of philosophy in his youth. The Idol of Deriding the Ancients represents Paracelsus and van Helmont, building their systems impertine ntly amid the ruins of the Galenic. The fourth is the Idol of Reading Prepostero us Books. Baglivi is very severe here (for it was, of course, how people got wro ng ideas). There are far too many books anyway, he says, so do not be greedy in reading: too many books are as bad as too much food. Indeed, never read a book u ntil you have a method for doing so; never read a book until you have asked your self Is it true? Too much reading trains the memory instead of the reason, and tak es up the time that should be devoted to experience. Learned 83 84 85 86 One could read (in the appropriate books) what laws God had made for matter. Bag livi, Opera, p. 106. Ibid., p. 1. That is, it is not subalternated, a relationsh ip we met in connection with medieval disciplines. Ibid., p. 9. Baglivi quotes B acon as saying Postquam homines de veritate invenienda semel desperaverint, omnin o omnia unt languidiora, ex quo t ut de ectant potius ad amaenas disputationes, et r erum quasdam peragrationes, quam in severitate inquisitionis se sustineant. Ibid. , p. 5.

212 The crisis doctors are therefore like spiders spinning webs from undigested thought, and Ba glivi, like Kyper before him, argued that the learned doctor makes a bad practit ioner. Too many different opinions drive a man mad or into Pyrrhonism (that is, late seventeenth-century philosophical scepticism). Like other doctors who sough t to bring order into a troubled medical world, Baglivi sketched out a little hi story of medicine, to show how things had gone wrong and to indicate how they mi ght be put right.87 It was appropriate for him (given his conception of aphorism s) to show that Greek medicine was good in practice despite the garrulity of the Greeks in theory. Left without light or leader at the end of the Roman period, me dicine was taken up and distorted by the Arabs, who made it disputatious, like q uarrelsome children. From them medicine was received by the Latins like a wrecke d ship creeping into harbour, and was slowly repaired by men like Fuchs (the Ins titutes) and Fernel. The heroes of the salvage operation were otherwise largely Italian, like most of Baglivis heroes. But no sooner had some purity been restore d to medical practice than new storms arose. The rst was that of the chemists, wh ose three fundamental principles (salt, sulphur and mercury) did not allow for t he proper constructions of histories of disease. Similarly bad for practice were the new philosophies: the Cartesian, atomistic, mechanical and physico-mechanic al. Baglivi has reached the point where he entered the story, and he recalls aga in the troubled period of his youth, when for twenty- ve years, unsupported by wil dly different and highly philosophical theory, medical practice had nothing soli d to rest on.88 Even while writing, Baglivi saw that the principles of medical p ractice were wholly disturbed and that even the most skilled of practitioners di sagreed and were uncertain. His rhetoric ows fast round the inane axioms, false g eneralities, diverse sects and preposterous rules of method, and we can see how his circumstances drove him to concentrate on practice and to a method that was both Baconian and Hippocratic. The Newtonian Instauration While the attraction o f Bacons work was that it presented a method of discovery in place of the system of Aristotle, the case of Newton was 87 88 It is notable that separate histories of medicine (and anatomy) begin to appear in the late seventeenth century, perhaps to give support to a tradition under at tack. Baglivis editor noted from Daniel le Clercs history of medicine how far the chemical philosophy had infected educated minds. Le Clercs (16521728) history was pu blished in 1696. See John C. Burnham, How the Idea of Profession Changed the Wri ting of Medical History, London (Wellcome Institute for the History of Medicine) , 1998, p. ix. Baglivi, Opera, p. 77.

Resolutions 213 different. His authority was unquestionable: he was a stupendiously Great Man.89 H e famously declared that he was not concerned with hypotheses hypotheses non ngo which was his own rejection of the causal systems of the past. The point was tha t he described the regularities of nature, natures laws, without seeking causal exp lanations. In practice, however, his work became a new system, depending on Newt ons name as an authority.90 It was an opportunity for medical men to grasp a natu ral philosophy again to give strength to their theory and practice of medicine. The opportunity was taken rst by Archibald Pitcairne (16521713) who had pupils and followers at Edinburgh, Leiden and Oxford. This group constructed a medical the ory, which they called the principles of mathematical theoretical medicine, which they considered analogous to Newtons own work.91 It was derived partly from the a tomism of Newtons essay on the nature of acids and partly from the queries added to the 1706 edition of the Opticks. By the time the Opticks was revised again in 171718 Newton had begun also to think in terms of subtle uids or ether,92 and his m edical followers had a wide range of explanations for physiological changes. The y were even able to think, once more, in terms of attraction (between the Newton ian atoms) and subtleties, both of which had been strenuously denied by earlier mechanists.93 Newtonian doctors agreed on some of the principles on which the th eory of medicine was now built, but it is unlikely that they shared a complete u nderstanding of all of Newtons philosophy, particularly its mathematical aspects. There is good evidence that one of the attractions of Newtonianism in medicine was that it gave the doctors authority in their efforts to form themselves into a professional body.94 Perhaps the main intellectual attraction of Newtons work w as that it offered the certainty of mathematics. We can recall that earlier in t he century the collapse of traditional natural philosophy had made some doctors declare that demonstration had a place only in mathematics; what the Newtonian Geo rge Cheyne now proposed to do was to restore mathematical certainty to medicine. Writing on fevers he pointed out the sorry state of medicine as a scientia and proposed to reform it. The body was made, 89 90 91 92 93 94 The description is that of George Cheyne: see Anita Guerrini, Isaac Newton, Georg e Cheyne and the Principia Medicinae , in French and Wear, eds., Medical Revolution , pp. 22245, at p. 228. On the relationship between natural philosophy, religion and society, see also M. C. Jacob, The Newtonians and the English Revolution, 16 891720, Hassocks, Sussex (Harvester Press), 1976. Guerrini, Isaac Newton, p. 222. S ee in general G. Cantor and J. Hodge, eds., Conceptions of Ether: Studies in the History of Ether Theories, 17401900, Cambridge (Cambridge University Press), 198 1. However, Pitcairne and Cheyne were hesitant about attraction. Guerrini, Isaac Newton, p. 223.

214 The crisis after all, of uids and vessels, all of which were quanti able and amenable to physi cal and geometrical analysis. The steps to a reformed Principia of medicine incl uded a more thorough knowledge of anatomy (the survivor of the old theory of med icine) and complete mechanical philosophy. Another Scottish member of the circle of Newtonians centred on Pitcairne was John Keill (16711721), who had secured th e post of deputy to the Sedleian professor of natural philosophy at Oxford. He w as a medical man and his lectures, an introduction to the true physics, are full o f Newtonian con dence that medicine is once more equipped with a philosophy of nat ure.95 The point is made with force when Keill identi es the faults of sects of ph ilosophers who have yet to embrace Newton: in our terms the result of the collap se of natural philosophy. His best way of philosophising was to take what was valu able from each sect and dismiss the rest. From the Platonists he takes arithmeti c and geometry, leaving them with their numerology and diagrams to explain essen ces of things. The physici that Keill describes are the descendants of the Arist otelians and he says that to the usual peripatetic array of manifest elementary qualities matter, form, substance and so on they add occult qualities and sympat hies. This latter pair probably represent whole substance action and the effect of poisons, in a medical context. Keill can salvage little from this philosophy an d supposes that its purpose was not to discover causes but to invent and impose names on things and actions. This would certainly be an adequate description of the late school Aristotelianism that survived in the English universities down t o the second half of the seventeenth century.96 It did not set out to explore ca uses but used an ancient and wordy apparatus with manifold connections with othe r parts of intellectual life; certainly its treatment of causes was passive in c omparison to that of the new natural philosophy. Clearly the Aristotelians were the most objectionable kind of philosopher to Keill, but he also distances himse lf from the experimental philosophers. In their experiments, he says, they take notice only of the properties of a body and of actions that are perceptible to t he senses. Keill argues that philosophy in this way has taken only small steps. That is, he saw the restraint that scepticism had imposed upon the imaginations of the experimenters, but also believed that from the true, Newtonian viewpoint, such restraint was no longer needed. (Keill also thought that some experimenter s did draw 95 96 John Keill, Introductio ad Veram Physicam: seu Lectiones Physicae Habitae in Sch ola Naturalis Philosophiae Academiae Anno Domini 1700. I have used the third edn , Oxford, 1725. It seems likely that physica was preferred to philosophia in bei ng less related to system. For example, Daniel Stahl, Axiomata Philosophica, Cambr idge (Rogerius Daniel), 1645 (3rd edn).

Resolutions 215 up theories, and falsi ed the experiments to obtain proof.) The last sect mentione d by Keill are the mechanici. Although the mechanical philosophy is much celebra ted in this age, says Keill, there is little of true mechanics in it. Its propon ents talk of invisible particles, pores, shapes, pathways and battles between ac ids and alkalis. This is Cartesian mechanism with a dash of chemistry, explained on a basis of particles all obeying laws of mechanics. What is wrong with this system according to Keill is that it takes no account of the quantity and propor tion of physical motion or the size, shape and powers of moving bodies. These, t hen, are what Newton added to the common mechanism of his day. The powers of bod ies included attraction, a term Keill uses with con dence, although proscribed by earlier mechanists. He does so because it was simply a description of a motion t hat had intension and remission, that is, it could be measured. Keill also uses q uality and faculty (terms taken from the peripatetic sect) in the same way: gravity is a measurable quality and not a statement about causes. Keill con rms the truth of his Newtonianism with a common device, a little history about how the truth became known. The father of the discipline was Archimedes, who left a monument t o geometry and provided the basis of statics and mechanics. As in most such stor ies, the work of the Father was lost and then recovered by the Restorers, here R oger Bacon and Cardano. Galileos Geometrical Key showed how to look for mechanica l causes. Besides more recent heroes such as Torricelli, Pascal, Boyle, Wallis, Huygens, Halley and his predecessor as Savilian professor in Oxford, Gregory, Ke ill drew attention to the collaborative efforts of the Royal Societies of London and Paris. Of course, vera physica was nally revealed by Newton. solidism Microa natomy and mechanics In traditional medicine disease had been caused by disturba nces in the humours and their elementary qualities, but these had no place in th e new views about nature. Stepping into the space left by the collapse of tradit ional theory, chemical physicians also talked of liquids and their intestinal mo vements and fermentations. But it also proved possible to ll the same space by co nstructing a theory based on the solids of the body. This had a number of source s. The rst was anatomy, which had not been eclipsed as a discipline in the sevent eenth century and which, towards the end of the century, tended towards ne anatom y with the increasing use of the microscope. The discovery of unexpected structu re below the visible level seemed

216 The crisis to support the doctrines of particulate mechanism; it certainly destroyed Aristo tles doctrine that the similar parts were homogeneous. Machines after all were so lid, and some interesting ones in the seventeenth century were made to handle uid s: water and air. Machines were also rationally designed and so were a ready ana logy of the created body. A number of men began to think that the body was indee d a hydraulic machine, a notion that could be seen as having a Newtonian basis. The idea could be used to tackle a problem arising from the discovery of the cir culation of the blood: many medical men took the action of the heart to be one t hat gave the blood projectile motion: it threw the blood into the arteries. Again, in the many experiments performed to con rm the circulation, an artery opened at some distance from the heart also seemed to emit blood in a projectile way. But was this projectile force great enough to throw the blood to the very ends of th e arteries? Would it not soon be lost by the friction of the tortuous vessels? I n the absence of pathological humours and of nervous spirit, attention was incre asingly given to the solids of the body in explanations of how it worked and how it went wrong. After all, it was the solids of the body that controlled the uids . A thorough-going theory of solids could satisfy the physicians need for a natur al philosophy of the body, particularly when it had a direct application to path ology and treatment, for many who felt the loss of the old theory had re-emphasi sed the practical nature of treatment. There was another advantage. The basic un it of the solid parts seemed to be the bre, for example in nerves and muscles, an d the nature of muscular contraction was a problem to many who did not believe D escartes theory of in ation. But it was a motion, and it took place in delimited st ructures: many thought that it could be explained geometrically. This was clear and intelligible and it allowed into medicine the only kind of demonstration, or proof, which was still possible. And, when the new theorists came to think of i t, was it not true that Hippocrates himself had categorised the parts of the bod y into the Contained (the uids), the Containing (solids) and the impetum faciens (that which gave motion)? Hippocrates could generally be relied on to have rst re cognised the beginnings of any new system that later writers elaborated, but thi s was a seminal distinction that served also another group of physicians in the eighteenth century, as we shall see. Earlier we looked brie y at some of the gures who attacked traditional natural philosophy, such as Cardano and Descartes, but we have not touched upon that other hero of the scienti c revolution, Galileo. Unlik e Descartes, Galileo did not have half an eye on a new medicine, but his work ha d an important in uence on the way some doctors thought. In the terms

Resolutions 217 we are using here, Galileo helped to precipitate the crisis in philosophy, but h e also provided some of the materials out of which a new theory could be built. The important gure here is Giovanni Alfonso Borelli (160879) whose early work on f evers was a sort of manifesto for the mechanist cause. Like Galileo he was a mat hematician, and his best-known work (published after his death) sets out in geom etrical form the gross mechanics of the motion of animals. Borellis system was no t totally mechanical (he believed in an essentially vital sentience in the beati ng heart)97 but we are reminded again of the general awareness of the power of d emonstration that geometry possessed in a post-Aristotelian intellectual world. One of Borellis students was Marcello Malpighi (162894), who developed a mechanica l programme within microanatomy. One of the principal advantages of this was tha t it provided an explanation of glandular activity, namely secretion. There was a comparatively small group of men working on related areas, largely concerned w ith bres: Nicholaus Steno on muscles, Bellini following Malpighi and, later, Giov anni Santorini, who broadly agreed that geometry and the level of the microscopi c solid parts could explain the motions of the body.98 In this respect it was a medical business, and these men might be seen as attempting to build a new medic al theory. But it was, more directly, natural philosophy rather than medicine. M alpighis microanatomy was clearly philosophical too in being extended to animals and plants.99 Just as Riolan had complained that Harveys doctrine of circulation was of no medical use whatsoever, so Giovanni Sbaraglia, Malpighis opponent, argu ed that microanatomy and mechanism were irrelevant to the practice of medicine.1 00 At best, he said, the new discoveries were philosophical, not medical; and pr obably function was not dictated by microstructure. Sbaraglia was in a powerful position in Bologna, teaching Galenic medicine, a member of the college and the holder of a chair of anatomy, options not open to Malpighi. Historians have not noticed 97 98 99 100 See Roger French, Sauvages, Whytt and the motion of the heart: aspects of 18th ce ntury animism, Clio Medica, 7 (1972) 3554. The notion of geometrical demonstration was strong in these authors. Steno argued that he was doing for muscles what as tronomers did for the heavens, geographers for the earth and optical writers for the eyes. See Steno on Muscles [Transactions of the American Philosophical Soci ety, 84, Part 1], Philadelphia (The American Philosophical Society), 1994. This is a collection of facsimile materials with translations. In building a system a nd impressing a patron (as Steno was doing) technical terminology was as importa nt as it had been in the Middle Ages. Steno says that the geometry of muscles is . . . ut mediae carnes parallelepipedum constituant, tendines vero oppositi duo prismata tetragona componant (p. 94). See Domenico Bertoloni Meli, The new anato my of Marcello Malpighi, in Bertoloni Meli, ed., Marcello Malpighi, pp. 2362. See Marta Cavazza, The uselessness of anatomy: Mini and Sbaraglia versus Malpighi, in Bertoloni Meli, ed., Marcello Malpighi, pp. 12045.

218 The crisis him until recently because (like Primrose in Harveys case) he was in the shadow o f an innovator. The neoterics themselves, like the Hellenists of the fteenth and sixteenth centuries, formed a self-supporting minority clique, but, outside thei r rhetoric, we can see that the bulk of physicians were conservative, well enoug h satis ed with traditional medicine. Not even the neoterics could assume that the re was anyone in Spain or Portugal who agreed with them. In practising medicine Malpighi himself used traditional remedies that had been used for centuries befo re and would be for a century to come. The same may be said of Bellini, for whom evacuation remained central.101 Even in England the university faculties contin ued to learn, teach and practise conventional medicine throughout the seventeent h century.102 In short, the Italian exercises in mechanism and microanatomy from Borelli to Santorini can be seen as a new and partly mathematical escape from t he scepticism about systems of the later seventeenth century. But it is important to remember that the new Galilean philosophers were in a minority and were made to feel it. Borellis in uence was felt in the Accademia del Cimento, where, however , the superior academic power of the Galenists and Aristotelians emerged by 1670 .103 The majority was not silent, and Michele Liparis Triumph of the Galenists he lped to drive Malpighi back to Bologna from Messina.104 The new philosophers cla imed the principle of the freedom to philosophise and called their philosophy the f ree philosophy: Malpighi uses the phrase libera Philosophia.105 It was also calle d Democritean, which historians generally take to mean atomic.106 But more often it was used to invoke Democritus physicus, whom we met in chapter 1 as the dissecti ng investigator of the secrets of animals. This vision of Democritus had several advantages in the seventeenth century: Democritus was even more ancient than Ar istotle, a venerable to whom veneration could still be given; what was known of his philosophy did not constitute a system and so did not attract scepticism; hi s dissections could be seen as anatomical experiments, which survived the crisis in philosophy and were a major item on the agenda of the new philosophers; he w as traditionally 101 102 103 104 105 106 See Anita Guerrini, The varieties of mechanical medicine, in Bertoloni Meli, ed., Marcello Malpighi, pp. 11128, at p. 123. See Andrew Wear, Medical practice in late seventeenth- and early eighteenth-century England: continuity and union, in Fren ch and Wear, eds., Medical Revolution of the Seventeenth Century, p. 300. Susana G mez L pez, Marcello Malpighi and Atomism, in Bertoloni Meli, ed., Marcello Malpig hi, o o pp. 17589, at p. 177. See Rosario Moscheo, The Galenistarum Triumphus by Mic hele Lipari (1665) : a real edition, not merely a bibliographical illusion, in Be rtoloni Meli, ed., Marcello Malpighi, pp. 31315. See G mez L pez, Atomism, p. 175. o o See Charles Schmitt and Charles Webster, Harvey and M. A. Severino. A neglected medical relationship, Bulletin of the History of Medicine, 45 (1971) 4975.

Resolutions 219

linked to medicine by way of the gure of Hippocrates, still the Father of Medicin e; just as Hippocrates was variously mechanised or rationalised, so could the phi losophy of Democritus be adapted to new versions of the truth. The story of Democ ritus physicus was well known in the seventeenth century, and Thomas Bartholin, for example, refers to it approvingly in his Anatomia (1651)107 and Boyle called Harvey the English Democritus (clearly not a reference to atomism).108 Walter Cha rleton called the College of Physicians Solomons house and its anatomically minded fellows sones of Democritus; Marco Severino made the whole of his new discipline o f zootomy the cutting of animals Democritean.109 Sometimes it was the wells or sprin s of Democritus that could now be drawn upon for new discoveries, and George Ent told Harvey that medical men wondered how it was that the circulation had been h idden in the well of Democritus.110 When Gassendi used the same phrase for the n ew philosophy he may have been thinking of atoms but his main message was that D emocritus philosophy provided an escape from scepticism.111 Above all, of course, it provided an escape from Aristotelianism, the enemies of which revelled in th e legend that Aristotle had burned the books of Democritus so that his own philo sophy would go unchallenged.112 We can turn to Baglivi again as an example of so me of these trends in a solidist interpretation of the body. By the time he came to write on moving bres he had moved to a teaching position in the school of the theory of medicine.113 He wanted to go beyond Baconian historia and the aphoris ms they produce to develop a theory of medicine to use in conjunction with his p ractice. It was to be geometrical because, essentially, God is a geometer and al l created things obey the rules (and because in geometry alone do human beings h ave the power of demonstation).114 And because it is geometrical it is not specul ative theory like those of the past, which were mere ostentations 107 108 109 110 111 112 113 114 See Roger French, William Harveys Natural Philosophy, Cambridge (Cambridge Univer sity Press), 1994, p. 168. See R. A. Hunter and I. Macalpine, William Harvey and Robert Boyle, Notes and Records of the Royal Society, 13 (1958) 114127, at p. 118. Marcus Aurelius Severinus [Severino], Zootomia Democritaea; id est Anatome gene ralis totius Animantium Opi cii, Nuremberg (Literis Endterianis), 1645. G. Ent, Ap ologia pro Circulatione Sanguinis: qua respondetur Aemilio Parisano Medico Venet o, London (Guilhelmus Hope), 1641. See the dedication to Harvey. Gassendi publis hed anonymously, under the initials S. S.: Discours Sceptique sur la passage du Chyle et sur le Mouvement du Coeur, Leiden (Jean Maire), 1648, p. 148. The idea was indignantly rejected by Hermann Conring, Introductio in Naturalem Philosophi am et Naturalium Institutionum liber 1, Helmstadt, 1638 (thesis VII). Specimen Q uatuor Librorum de Fibra Motrice, et Morbosa. It is included in the Opera. Qui co mmunis salutis, Hominumque utilitatis erit cupidus; de Theorica Medicina ex Geom etriae legibus judicabit: Baglivis preface.

220 The crisis of vanity.115 He again gives his story of his youth in the schools amid such ost entations of opposed vanities. They drove him to the practice of medicine and to the writings of Hippocrates, which he claims to have committed to memory.116 He was now impressed with the effectiveness of Hippocratic physical treatment of t he solid parts the frictions, incisions, exercises, vellications and so on. If d iseases were located in the solid parts, that would explain the oriental treatme nt of moxibustion and acupuncture. In the 1690s in Bologna and Rome, Baglivi beg an to look for signs of damage to the solid parts while performing postmortem ex aminations. In hospitals he met cases where head wounds had left the membranes o f the brain exposed, and he knew that if they were touched tremors or convulsion s followed.117 It seemed to him that the dura mater as a membrane was composed o f bres that reached to all parts of the body. Indeed, he held that the dura mater was the controlling centre of the body, sending mechanical motions contraction, relaxation, vibration and the like along the bres; such motions could, in princi ple, be expressed geometrically. He was geometrical in his mode of expression, i ntroducing some experiments in a series of numbered passages called corollaries and postulates.118 The experiments were in some sense too geometrical. Believing that the pulsation of the membranes of the brain caused the beating of the hear t, he was able to quantify the force of the blood by measuring the height to whi ch it spurted when he opened an artery.119 Performing the experiment with two do gs, he argued that the blood emerged in its arc more forcibly in the dog whose dur a mater was simultaneously stimulated. These are experiments to prove, in some ge ometrical way, his theory of the mechanical dominance of the dura and pia mater. But he also did experiments of a more Baconian nature. Most of these were concer ned with introducing foreign substances below the surface of the membranes surro unding the spinal cord, taken as extensions of the membranes of the brain. The p oint was to do many experiments, vary the injected uids and carefully compile a l ist of the similarities and differences in constructing a sort of historia. He e xperimented with cats, dogs, pigs and cattle. He generalised about the results w hen the injected substance came into the class of acids or aromatic spirits. Spi rit of wine injected into a dog made it tremble violently sed cum hilaritate.120 Many other experiments 115 116 117 119 etiamsi partes quasdam alias, et speculativas Medinae [sic] divisiones ignoret, q ue sunt propemodum ostentationes vanitatis, non peritiei in medendo: ibid. Hippoc rates was the Oracle of Medicine, the Dux, Magister and Auspex. 118 Ibid., p. 19 0. Baglivi, Fibra Motrice, p. 169. 120 Baglivi, Fibra Motrice, p. 183. idest quan tum velocitatis momentum.

Resolutions 221 involved injecting substances into the veins of the animal and waiting, Bacon-li ke, for the accidents of the experiment. Baglivi argued forcibly that there should be a great collaborative effort to make a systematic study; and to encourage ot hers to do the experiments he spoke of the incredible joy to be experienced when r ealising that the generalised accidents of experiments with acids included the t remors of the experimental animal, its wailings, the swelling of its stomach, it s stupors, paralysis and incontinence. co n c lu s i o n We have seen that in th ose places where traditional natural philosophy came under attack and collapsed, the Rational and Learned Doctor lost the Good Story he could tell to patients, pupils and the law-makers. There were various solutions to the problem. He could claim a superior and practical method, untainted by systems. He could construct a new story, perhaps stressing the role of experience as superior to a theoreti cal system. He could defend the old philosophy. He could adopt a new philosophy. He could invoke the rationality of the Creator to avoid scepticism and bring ex tra piety into his medicine. He could medicalise parts of the chemical and mecha nical philosophies. He could become a learned gentleman and focus upon a particu lar social class for his services; he could even frame his medicine in response to his patients demands rather than working to produce suitable expectations in h is patient. All went hand in hand with religious, institutional and economic cha nges. As elsewhere in this book, this chapter has not sought to give a systemati c account of the evolution of medicine or to give a magisterial view of the seco ndary literature, which so often seems to point in that direction. Examples of t he strategies employed to escape the crisis are given as attempts to achieve med ical success in the terms set out in the Introduction.121 121 Two modern views on the changing nature of historical studies of medicine may be usefully consulted: Ludmilla Jordanova, The social construction of medical knowl edge, Social History of Medicine, 8 (1995) 36181, and Burnham, Idea of Profession.

chapter 8 Enlightenment, systems and science i n t ro d u c t i o n The scienti c revolution of the seventeenth century has lon g been a centre of interest for historians of science. Traditionally, a major to pic within it was astronomy, the ideal science on account of its being objective , intellectual, based on the senses, uncontaminated with contemporary unscienti c things and pointing rmly to the future. This image and the name scienti c revolution itself are now seen to be constructions of recent historians, but the name has s tuck and we are still invited to see science in the seventeenth century and cele brate its earliest exponents.1 But to many observers at the time, the new doctri nes were a pernicious heresy spread by men who had betrayed the old traditions o f learning and piety. The new doctrines were also a minority opinion, promulgate d by a handful of people limited largely to two European countries, England and Holland. Elsewhere, the men with the greatest vocational need for philosophy wer e the physicians, whose use of it is the subject of this book. When and if they n ally absorbed the new doctrines, it was not until well into the eighteenth centu ry, which makes a European scienti c revolution a thing of the Enlightenment. It is only recently that the role of medicine in these changes has begun to be appreci ated. There are several things we should note. First, as we have seen, the docto rs had a practical use for natural philosophy and treated it as professional kno wledge. Second, medicine had, since the Middle Ages, given attention to the role s of experience and reason. Experience was not only the short life of the rst of th e Hippocratic Aphorisms, it was the experimental procedure of Galen and the Rena issance anatomists such as Zerbi, Berengario, Vesalius, Colombo and Harvey. We h ave seen that anatomy survived the crisis in theory because it was a semi-autonomo us 1 Removing medicine and the biological disciplines from science makes it more justi ab le to talk of a scienti c revolution in the hard sciences. 222

Enlightenment, systems and science 223 discipline based on experience which could supply medical theory but which was n ot an expression of an essential theory of its own. Anatomy had always been a st udy of action as well as morphology and it was the natural word to use for all k inds of experiments on living and dead animals by new and old philosophers. When groups of like-minded men, such as those that preceded the Royal Society, were formalised, anatomy was included among their interests and purposes. It went handin-hand with experiment. Third, medical botany also survived the crisis, and for similar reasons: it was not theoretical, but practical, it was a useful special ism and it depended partly on sensory observation. The fourth thing we need to n ote about medicine and the scienti c revolution was that doctors gured large in eff orts to retain the old philosophy or, where this was impossible, to install a ne w one in its place. Physicians needed a philosophy. Let us take one or two examp les to illustrate these general remarks. We have seen that Aristotle represented stability in the universities of the United Provinces and it was the same in th e German states for a long time. There, the universities were the centre of inte llectual life and were under the control of powerful patrons. Catholic patrons h ad given their universities over to the Jesuits by 1622, but as in the Protestan t universities, Aristotle and disputation were the tools of the educators. Altdo rf was a progressive university, but was rebuked by its patron as late as 1678 for departing from Aristotle. New universities such as Rinteln (founded in 1671) st arted their lives with Aristotle. France, too, was philosophically conservative up to about 1620 and teachers did not know much of what was happening elsewhere. A fter the assassination of Henri IV in 1610 the Counter-Reformation climate led t o the pronouncement in 1624 of the death penalty for departure from the ancient and approved authors. Reaction to the novelties of Fernel was a new Aristotelian ism.2 In Spain and Portugal the Jesuits did much to retain the medical and philo sophical status quo. The climate was Counter-Reformation: the death penalty had been introduced in Spain in 1558 for importing foreign books and the number of S paniards going to unsuitable universities dropped dramatically (just as in Prote stant England in the 1580s and 1590s there was of cial discouragement of travel to Catholic universities).3 In the 1680s 2 3 See L. W. Brockliss, The scienti c revolution in France, in Roy Porter and Mikul Teich , eds., The as Scienti c Revolution in National Context, Cambridge (Cambridge Univ ersity Press), 1992, pp. 5589, at pp. 57, 59. See Harold Cook, Institutional struc tures and personal belief in the London College of Physicians, in Ole Grell and A ndrew Cunningham, eds., Religio Medici. Medicine and Religion in SeventeenthCent ury England , Aldershot (Scolar Press), 1996, pp. 91114, at p. 96.

224 The crisis Juan de Cabriada was attempting to persuade the Galenists of Madrid to accept th at the blood circulated. In the next century there were attempts in Portugal to depose Aristotle as The Philosopher: the agents were converted Jews who had turn ed to medicine and had studied abroad. Progress was slow, aided mostly by an enli ghtened despotic government and the expulsion of the Jesuits in 1759; they were e xpelled from Spain eight years later, amid plans to replace Galen with Boerhaave .4 In other words, by the time the new medicine mechanical in its philosophy bec ame acceptable in the Peninsula, it was well into the Enlightenment. The new med icine involved reorganised bedside teaching, botany and anatomy theatres and it was resisted mostly by the university faculties, which perhaps resented it as a northern import; the professor of practical medicine in Padua (in 1727) complain ed that the northerners did not recognise earlier Italian contributions such as the microscope and thermometer.5 In Spain the medicina Galnica-Ar bica was still s trong in 1768 and it was not until 1771 e a that the university of Salamanca ado pted the ideas of Albrecht von Haller, Herman Boerhaave and his commentator Gera rd van Swieten. It may have helped that van Swieten was Catholic, although it is also the case that many Lutherans and Calvinists resisted the new medicine. But it seems to be the case that the lack of new medical books and the Inquisitions distaste for medical works of Protestant origin helped to defend the old medicin e. Lack of learned journals with book reviews also seems to have played a part. Another factor was relative prosperity. The Spanish economic decline is typi ed by Toledo, the population of which in 1650 was a third of what it had been in 1590 , its industries undermined by cheap imports from the north; where there was gre ater prosperity, the new medicine was adopted more readily.6 The Jews were an im portant element in the Iberian story. They had been expelled very much earlier, but some elected to be baptised and maintain at least an outward appearance of C hristianity. These conversos were often viewed with suspicion by the Christians, who thought that knowledge of medicine and drugs in a Jew would be dangerous; p rofessional medical colleges drew up regulations about blood purity to exclude J ews. Yet Jews could rise to the heights of medicine, as they had in the Middle A ges: 4 5 6 See David Goodman, The scienti c revolution in Spain and Portugal, in Porter and Tei ch, eds., Scienti c Revolution, pp. 158177, at pp. 164, 172, 174. See Jonathan Isra el, Counter-Reformation, economic decline, and the delayed impact of the medical revolution in Catholic Europe, 15501750, in Ole Peter Grell, Andrew Cunningham and Jon Arrizabalaga, eds., Health Care and Poor Relief in Counter-Reformation Euro pe, London (Routledge), 1999, pp. 4055. Ibid., pp. 43, 46.

Enlightenment, systems and science 225

they were successful doctors. There were also more of them in relation to the si ze of the converso population; in the 1570s a local Inquisition had to seek perm ission to use the skilled advice of a converso doctor because they could not nd a n Old Christian physician. Perhaps Jewish physicians were successful because the y were thought to have strange powers derived from their history; and, perhaps b ecause they were numerous and successful, Old Christians avoided medicine to avo id suspicion of being Jewish. At all events, Jews were not subject to the pressu res on philosophy generated by the Reformation and its reaction. Sometimes they were prevented by their elders from studying traditional philosophy until they w ere mature enough to resist its charms (but they were allowed to study medicine) and had no cultural need to preserve Aristotle. Thus the attempts by converso p hysicians to introduce new philosophy and the expulsion of the Jesuits merge the scienti c revolution with the Enlightenment. This age of reason has been characterised as a period when men talked rationally about the Deity rather than promoting con fessional differences. It has also been argued that it was a period in which Eur opean culture was de-Christianised. In philosophy, con dence in human rationality re covered after the severe attack of Pyrrhonism of the previous century. In practi ce, and particularly in medicine, Newtons physics, for all its distance from hypot heses, became a new system. There were perhaps few medical men who fully understo od Newtonian physics, which did not in any case relate as directly to medicine a s traditional natural philosophy had done. Its great attraction was that it was mathematical, for mathematics always seemed to retain the promise of certain, de monstrated, knowledge. e i re n i c a l m e d i c i n e Another way of dealing w ith the dif culties in medicine that resulted from the breakdown of traditional na tural philosophy was to attempt a compromise, a synthesis of the important featu res of different kinds of medical theory. This too could offer a new system in t he age of reason. While the Baconians thought they had a superior method in esch ewing theory, not everyone wanted to go this far. There were still chairs of the ory and practice in the universities, and teachers generally found that they had to give an all-round account of medicine from rst principles. Teachers are neces sarily rationalists, for no collection of curious observations would make a good university medical course. But what should those rst principles be? As the Edinb urgh medical men (see below) and authors like Baglivi pointed out,

226 The crisis there were so many on offer, from the new elements of the chemists to species of mechanism that owed more to particles than to mechanics. One answer was to reac h some sort of middle position, to emphasise what was common to all kinds of the ory. It has already been noted that in troubled times a new stand could be made with the genre of medical literature called the Institutes. It will be instructi ve to look at two such constructions, those of Antoine Deidier and Herman Boerha ave. Deidier (who died in 1746) was an adviser to the French king, a Fellow of t he Royal Society of London and Regius Professor of Medicine at Montpellier, wher e in the previous century Riverius had attempted to halt the tide of novelty wit h his own Galenic Institutiones of 1640. This was no longer possible by the 1730 s, but Didier was unwilling to leave the old authors completely, even Galen. His aim is eirenic, attempting to reconcile differences by emphasising similarities . Often he uses Galenic categories to cover chemical or mechanical explanations. It is Galenic to say that the human body is healthy, ill or neutral,7 but the t erms do not preclude being ill in an up-to-date way. The division of medicine in to physiology, pathology, semiotics, hygiene and therapy is Galenic, but that do es not prevent a superimposed and post-Galenic division of these ve into theory a nd practice. Likewise the Galenic labels of the naturals, non-naturals and contr a-naturals can be attached to categories more recent than Galen. Deidiers broad s trategy is to present traditional medicine as one of the alternatives available in the 1730s, when after all, Riverius Institutes were still in print. Sometimes he is hesitant about ancient authority, and often is surprisingly detailed on do ctrines elaborated in the Middle Ages. The two go together, for Deidier is in pr actice offering disputed questions, the presentation of which in the Middle Ages involved stating as fully as possible the arguments and opinions for and agains t the dubium before making a resolution. Deidier does not always come to a resol ution and his Institutes in part takes on the nature of a review of the literatu re. Thus he gives a Galenic (and even pre-Galenic) account of the elements, thei r qualities and the complexions, and goes on to say that the new chemists8 have radically changed things with the assumption that there are ve elements water, ai r, salt, sulphur and spirit. But the chemists still derive complexions in the ol d way from mixtures of the elements. Spirit is also a term that has not wholly los t its traditional connotations, although the chemists (as Deidier 7 8 The doctrine is found is the Ars Parva, the more modern title of the medieval Te gni. novatores Chymici . Antonius Deidier, Institutiones Medicae Theoricae, Physio logiam et Pathologicam Complectens, Paris (CarolusMauritius dHoury), 1731, p. 3. D eidier had been professor of chemistry at Montpellier in 1697.

Enlightenment, systems and science 227 says) derive it from the fermentation of the blood. The chemists also had humour s, separated from the blood by glands. They have changed only the names, says Deid ier. Moreover, the context of Deidiers presentation of these doctrines is the div ision of the body into solids and liquids. There is a hint of the Hippocratic co ntainedcontainingimpetum faciens division and a clear reference to the modern disc ussion of the hydraulics of the bodily machine. His proem ends characteristicall y: health is a [Hippocratic] balance between individual [Galenic] humours circul ating [in a Harveian way] through their own [rather Newtonian] vessels. He begin s the main body of the text in a characteristic way, too. The Galenic category o f physiology is divided into two smaller and more recent categories of humours and solids. He wants to explain ancient medicine by use of the modern tools of obse rvation and anatomy. He also wants to explain what the chemists believe (but the y are vulgar here and he treats them with scepticism).9 Some of Deidiers exposition surely re ects the long tradition of medicine in Montpellier. From Arnau of Vilan ova to Riverius and perhaps beyond, learned doctors in Montpellier were among th e foremost of school doctors and Deidier may well be drawing from them. Discussi ng humours rst, he makes ne distinctions which look more at home in the world of A rnau or Gentile. He has humours that nourish and others that are expelled. He ha s ros and cambium, terms for bodily uids that look distinctly old fashioned for t he Enlightenment. He distinguishes innate from in owing spirits, concepts central to t he huge discussion of complexion theory of Gentile, about four centuries earlier . Deidier is reviewing the literature, this time historically, for it was in the last century, he says, that solertissimus Harvey showed that it was the same bl ood that circulated and that separate humours could not exist in the traditional way. This made Deidier look with some favour at the chemists assertion that the various uids of the body, like lymph or saliva, were not carried round with the b lood, but generated from it by fermentation and separated in the glands.10 His s cholastic distinctions between the seven different kinds of lymph enables him to explain the ancient separation of spermatic and sanguineous tissues of the body (which depended on their embryological origin). Deidiers personal interpretation s are at the physico-chemical level, in a framework of the solids of the body. T here are no traditional spirits, for the solids control the ow of uids, and suffoc ation has physical causes rather than chemical (the lack of nitrous particles of the air). Fine structure 9 Deidier, Institutiones, p. 7. 10 Ibid., p. 15.

228 The crisis was important for him and he subscribed to the theory that all parts of the futu re animal were present in the egg, even before fertilisation.11 The Institutes o f Boerhaave (16691738) were quite different.12 He taught at a medical school that was comparatively new, without a long tradition of teaching. He learned medicin e there without even going to lectures. Instead, he began a course of self-instr uction by reading through the medical authorities in chronological order. There was no reason for him to doubt that Hippocrates was the Father of Medicine, and it will come as no surprise to us that Boerhaave read in to Hippocrates all that he found best in modern medicine. Thus Hippocrates was the rst dogmatic physician. The term is generally interchangeable with rationalist, and Boerhaave attributes to Hippocrates a knowledge of what had gone on in medicine before him: the rst do ctors were Assyrians, Babylonians, Chaldeans and the Magi, who moved to Egypt an d from there to Greece, especially its islands (and in particular, Cos, the home of Hippocrates). There, medicine developed by systematic comparison of remember ed diseases and remedies, set down in tables on the walls of the temples; analog ical reasoning provided prognosis. The perfection that Hippocrates brought to th is medicine was in Boerhaaves view spoiled by Galen. Not only did Galen bring in Aristotelian principles but he made medicine a lucrative trade, pro table but serv ile. In their turn, the Arabs made it more subtle but no less damnable: for Boer haave the history of medicine was a simple story of the Hellenists recovery of ea rly Greek medicine, on to which the moderns grafted scions from related discipli nes of anatomy, botany and chemistry. It is among these disciplines and their pr actitioners that Boerhaaves Institutes was intended to be eirenical. He was immen sely successful, teaching and in uencing more medical men across Europe than anyon e else. What mattered for a doctors reputation now was whether he had sat at the feet of Boerhaave. Boerhaaves medical system represented, above all, stability in a confused world. In the words of a contemporary, Boerhaave did more services t o medicine than all his Predecessors in the whole World put together; by digestin g a huge Heap of Jargon and indigested Stuff into an intelligible, regular, and rational System.13 Boerhaave read his medical sources as he read the theological, holding that the purest opinions were 11 12 13 Ibid., pp. 141, 152. Herman Boerhaave, Institutiones Medicae in Usus Annuae Exer citationis Domesticos Digestae, Leiden (Boutesteniana), 1727. On Boerhaave in ge neral see G. A. Lindeboom, Herman Boerhaave. The Man and his Work, London (Methu en), 1968. Quoted by Andrew Cunningham, Medicine to calm the mind. Boerhaaves medi cal system, and why it was adopted in Edinburgh, in Andrew Cunningham and Roger F rench, eds., The Medical Enlightenment of the Eighteenth Century, Cambridge (Cam bridge University Press), 1990, pp. 4066, at p. 41.

Enlightenment, systems and science 229 the oldest and that the subsequent corruption had resulted in the medical contro versies (the Heap of Jargon) of his time. His history of medicine jumps from Hip pocrates to Sydenham (the English Hippocrates) whom Boerhaave saw as one of his ow n predecessors in putting matters right. Another predecessor was Boyle, whose re ligious eirenicism had led him to emphasise those things held in common by all C hristians rather than the differences that had provoked such disastrous clashes in the seventeenth century. Boerhaave also had a high regard for Bacon, Harvey a nd Newton, and although neither Harvey nor Newton had much time for the views of Bacon, Boerhaave made them mutually consistent and all heirs of Hippocrates. On ly by following the Father of Medicine could medical sectarianism14 be avoided; of course, hidden in the words of the Father were indications of experiments condu cted in a way recognisable to the seventeenth-century mind, and suggestions of a n underlying philosophy of atoms, vacuum and gravity that had nally been assemble d by Newton. Hippocrates had been a mechanist and a solidist, for the body was d ivided into Contained and Containing. It is notable that Hippocrates had not bee n a chemist of the Paracelsian or Helmontian type, for Boerhaave could only exte nd the peace of his eirenicism to chemistry after it had been purged of its erro rs. n o s o lo g y In the rationalism of the Enlightenment not many doctors care d to claim, as the sceptics had done in the middle of the seventeenth century, t hat medicine was a mere empirical art. But it was clear enough to many of them t hat the troubled state of medical theory had had damaging effects on medical pra ctice, and that practice had been ignored in the battles between the theorists. So it seemed to Johannes de Gorter (16891762), the ordinary professor at Harderwi jk. Like Baglivi, de Gorter complained (in his inaugural oration of 1726) that t he uncertainties of theory had not prepared him for practice. He proposed to put the matter right by a method of arranging and indexing aphorisms, ready for use in practice. This method followed two models. First, the aphorisms were to be c lassi ed in the way that botanists classi ed plants. Part of the botanists interest i n plants had always been medical, and knowledge of the medicinal properties of p lants was a kind of medical knowledge which, like anatomy, had not been damaged by the collapse of traditional natural philosphy. The development of 14 Cunningham, Boerhaaves medical system, p. 50.

230 The crisis botanical gardens is a well-known feature of early modern medicine (botany was o ne of the several chairs that Boerhaave came to hold) and by the end of the seve nteenth century a great deal of thought was being given to how plants should be grouped. The second model (again like Baglivis) was Bacon. De Gorter suggests tha t the aphorisms are drawn from observation and set down without theory: this com prises a sylva, or nursery, and it deals with causes, effects, symptoms and indi cations of cure. Each aphorism is to be numbered and key words to be underlined and indexed. Alphabetic order of the index allows for additions, and the result is a series of genera of diseases subdivided into classes. Twenty-four years of experience modi ed de Gorters method. It was no longer an attempt at a botanical cl assi cation of disease entities, but a mode of access in a practical way to diseas es seen somewhat more traditionally as disturbed function. The ontological conce pt of disease was, however, taken up in several quarters. Francois Boissier de S auvages (170667) had been (from 1722) a student of Deidier and Jean Astruc at Mon tpellier: Astruc was the more mechanical of the two, and Sauvages adopted a Newt onian version of mechanism. In 1730 he was in Paris, beginning to think that dis eases could be categorised like plants. Boerhaave told him it would be a dif cult business, but he pressed ahead with his project, which ultimately helped him to his chair at Montpellier. A new rational system was clearly a step on the career ladder. It seems likely that treating diseases as entities and grouping them by their similarities was encouraged by the destruction of the elaborate and causa l pathological theory of Galen.15 Modern mechanism could supply various accounts of how the body worked, but it had little impact on pathology. Some doctors tho ught in terms of the traditional Galenic humours, some wrote of humours based on the ve chemical elements and many agreed with Baglivi that diseases were seated in the solids of the body. An ontological disease was one taken out of its theoret ical framework and observed in a Baconian way (in Sauvages case, from Baglivis exa mple). Sauvages denied that disease was disordered function in Galens terms, for th at implied a context of causality that was no longer acceptable. Nor was there m eaning in the Galenic categories of non-natural and contra-natural, for all diseases are natural in being natures attempt to rid the body of something noxious. 15 Likewise the quiddity or ontological status of diseases as seen by Helmontians was made possible by the removal of diseases from the Galenic theoretical apparatus (and by attributing them to the archeus of the body). See Andrew Wear, Knowledg e and Practice in English Medicine, 15501680, Cambridge (Cambridge University Pre ss), 2000, p. 370.

Enlightenment, systems and science o n to lo g y o f d i s e a s e 231 It has been a theme of this book that the doctors perception of disease changed r adically from the Middle Ages to the Enlightenment. The medieval view of disease as something that occurred in individuals and was identi able only after long obs ervation was changed by experience of two major epidemics. Instead, disease came to be viewed as a thing that moved indiscriminately from place to place and per son to person. This did not t in well with traditional causal medicine, and when the old theoretical system of causes disappeared physicians felt free to arrange diseases as botanists classi ed plants. The ultimate ontological view of disease came in the nineteenth century, and when medical scientists discovered germs, th e disease was identi ed with the pathogen, the infective organism. This story is q uite outside the range of this book, but it had a number of important effects. T he doctor demonstrated more clearly than before that he could cure some diseases he had clinical success. This gave him authority, including retrospective medic al judgements: many early historians of medicine were doctors and they projected a modern search for pathogens upon old experiences of diseases, symptoms and so on. Let us take an example. Tuberculosis is a modern category of disease, identi ed by means of recognising, in a laboratory, the tubercle bacillus. It is often sa id that the disease was known to the Romantics and Victorians as consumption, whic h was a wasting disease that consumed the body, and from which we cannot exclude o ther wasting diseases. It is even more dif cult to identify twentieth-century tube rculosis and nineteenth-century consumption with seventeenth- and eighteenth-cen tury scrophula, as some historians have tried to do. Scrophula existed in France and in Britain, and the surgeon to Charles II, Richard Wiseman, gave a detailed description of its symptoms, including struma, swellings in the neck, encysted tumours through the body, swollen lips and protruding eyes.16 Scrophula was also known as the Kings Evil because it was held to be curable, even after medicine h ad failed, by the touch of a king. But the king had to be of the true line, orda ined and sancti ed by God: indeed, touching for the Evil strengthened the position of the king and his supporters and was part of the attempts of the Old Pretende r (who touched in Edinburgh in 1715) and of Prince Charles Edward (who did likew ise in Aberdeen in 1745) to regain the throne. The French kings also touched for the Evil until the Revolution, and we should not be surprised that people in bo th countries 16 Richard Wiseman, Severall Chirurgicall Treatises, London (R. Royston), 1676.

232 The crisis ocked around their kings to be touched. As we have seen in other cases, proven cl inical success was, and is, not the issue. Scrophula did not exist in Holland, w here there had been no monarchs since the Dutch ejected the Spanish. Boerhaave d oes not deal with the disease, nor does it seem to occur in van Swietens vast com mentary on his work.17 Struma is there, and some of the other symptoms of Englis h scrophula, but they are unrelated. There was scrophula in Scotland, and when t he Aberdeen In rmary was opened in 1742 there were pressing needs to identify it. The In rmary was a charitable institution, run on a shoestring compared with the E nglish voluntary hospitals, and it was intended as a hospital for acute cases, t o achieve a rapid turnover of patients for ef cient use of funds. Scrophula was ch ronic and therefore excluded; but to satisfy the lay managers of the hospital, t he physician or surgeon had to write down his diagnosis before the patient was a dmitted. He generally took care not to use named diseases (which were so complet ely described in the medical literature) and restricted himself to symptoms: but even then he often failed to recognise a scrophulous symptom or distinguish it from a scorbutic.18 In crypto-Jacobite Aberdeen it was possible to see scrophula ; when a new Leiden-trained physician was appointed to the In rmary the disease va nished from the records.19 This little digression illustrates a number of points . First, it is very dif cult to trace back through time the identity of a modern d isease. The name changes. The description is elusive: either everyone at the tim e knew what it was (plague, pox) and there was no need for description, or the d escription was one of appearances that were signi cant in an etiology entirely dif ferent from our own. Second, the physicians self-justi cation is put to the test wh en he has to commit himself baldly to laymen. Just as the practice of medicine w as changed by the lay and civic response to epidemics, so now the practical and improving urges of the Enlightenment dominate any Good Story the doctor could te ll. Third, towards the end of the period covered in this book, hospital records, which were compiled for reasons of administration and economy, give some sort o f insight into the actual clinical success of the physician. 17 18 19 Gerardus van Swieten, Commentaria in Hermanni Boerhaave Aphorismos de Cognoscend is et Curandis Morbis. I have used the edition of W rzburg, 12 vols., 1787. See a lso the Lexicum Medicum Renovatum, u Leiden (Lutchmans), 1735, of Steven Blankaa rt (Blancardus) which identi es scrophula with struma, without any other symptoms. Because the hospital had only six beds, the descriptions of the patients conditi ons are unusually detailed. The records are in the unpublished sederunt books, t he minutes of the sitting committee of management.

Enlightenment, systems and science t h e e n l i g h t e n e d d o c to r 233 Another way to steer medicine to a new strength in the absence of traditional na tural philosophy was to forget seventeenth-century scepticism about systems and construct a world-view where medicine was again intimately bound up with natural philosophy. Our example here is Friedrich Hoffmann, the primary professor of me dicine at the new university of Halle. Hoffmann is quite explicit that his purpo se is to build up a rational system the very thing the sceptics avoided and that i t is to be used by the rationalis et peritus Medicus, our Rational and Learned D octor. The Good Story that Hoffmanns doctor tells is an entirely con dent one of a natural philosophy that is now certain and stable, an ideal foundation for the t heory and practice of medicine. The main reason for this certainty and stability is that the mechanism that runs the world is nothing other than the laws that G od has established for matter. In a strong sense, Hoffmann has taken Boyles route away from scepticism by declaring that no one can deny Gods rationality in the w orld, His system. Like Baglivi, Hoffmann calls himself a Christian Philosopher. Ho ffmann was born in 1660 and was well aware of the medical and philosophical prob lems of the late seventeenth century. By the time he was seventy-eight and had p ublished the seventh volume of his rational medicine he had created a system that proved enormously popular. He speaks of editions in Italy, Belgium, Switzerland and Germany. The six folio volumes of his collected works, printed in Geneva in a new edition between 1748 and 1753 made him an authority second only to Boerhaa ve. It seems very likely that this success came about because once again he gave medicine a rm basis, not only in natural philosophy but in a kind of Christianit y that was acceptable in any European country. Part of his rational medicine was directed to the countries of north-west Europe, where the climate was different from that of Spain and Italy, and where the religion was Protestant; at the sam e time, the Riformatori (the Catholic censor at the studium in Padua) could nd in his works no threat to the Catholic faith, to princes or to behaviour.20 This w as the standard formula and it indicates that the Catholic church had little obj ection to medical or philosophical novelty (with the exception of Cartesianism, founded on 20 Friedrich Hoffmann, Opera Omnia Physico-Medica, vol. 1, Geneva (The Brothers de Tournes), 1748. The Riformatoris permissions to print (p. xix) are of the usual f orm. Hoffmanns rational and learned doctor appears in the address to the reader, p. xvii. He has his eye on medical conditions in Denmark and Sweden: p. xxvi.

234 The crisis a doubt about the existence of God). What was important was stability, social an d political. Hoffmanns strategy was to develop a largely natural theology that lo cked as rmly into his medicine as into his natural philosophy. That this was an e scape route is indicated by the title he gave to the preface to the whole of his collected works: The Different State and Condition of Medicine and Doctors. He be wailed the fact that despite the dignity of medicine and the nobility of the hum an body, medicine was practised by the plebs and the vulgar. He meant, of course , people with whom he disagreed, whose learning was of the wrong kind. But much worse than wrongly learned doctors were those men, often doctors themselves, who even denied that medicine was rational. These were the men who held, like Alber tus Kyper and Nathaniel Highmore, that medicine was simply an art and that theor y means bad practice. Hoffmann, the great rational systematiser, thought that th is was a monstrous calumny, and he argues energetically that no, medicine is not just a matter of labour, time and experience, and no, it is not a measure of a doctors wisdom and skill that he has many patients. Better a doctor who can think well and straight about disease, even though he has only a few patients, than o ne who looks close to empiricism.21 Hoffmann the rationalist believed that exper ience conformed to reason was demonstrative, in some sense providing certain kno wledge. He makes a great deal of the principle of the Freedom of Philosophising, the greatest ornament and duty of the human mind. Nothing could be further from the scepticism of the previous century. To escape the grandiloquent but medical ly useless systems of the modern chemists, Cartesians and others, Hoffmann turne d to God. God as the Creator of everything was the grand reason why medicine was entirely congruent with natural philosophy. Hoffmann was also escaping from the atheists of his time and place. There was a contemporary saying that the man wh o went to Halle came back either a Pietist or an atheist, and quite clearly in H offmanns Halle there were men who openly admitted their atheism. This is arroganc e of mind and blindness of heart, said Hoffmann, who believed that every person had in their heart a natural vestige of the idea of God, which ought to be devel oped, but which could be suppressed. Hoffmann was also escaping from men who tho ught that natural philosophy, which he here calls physica rationalis or experime ntalis, was mere curiosity (a charge levelled at others by scholastic theologian s since the 21 Hoffmann, Preface, p. xxxii.

Enlightenment, systems and science 235 Middle Ages). Indeed, says Hoffmann, it was precisely because nobody practised n atural philosophy in the universities that misunderstandings often emerged betwe en theologians and teachers of rational medicine. It looks rather as though Hoff mann himself had been involved in disputes with theologians and he consequently thought that theologians would be better if they modelled themselves on doctors. 22 Theology was in this case simply the medicine of the soul and so had many paral lels with the medicine of the body. Both could be theoretical and practical, for the theoretical theologian was one who defended his faith against others and hi s practice was pastoral care of the individual. In doing so, Hoffmann argued, he should take into account the variable nature of the individual and his circumst ances, just as the doctor varied his practice according to the particular needs of his patient. Doctors since the Middle Ages had recognised the parallel betwee n a general purging, the invariable rst step in treatment of speci c diseases, and confession, which purges the soul. Hoffmann knew of the long and sacred history of confession, but as a Protestant he also believed that it had become one of th e worst abuses of the church: . . . but O Immortal God! What deplorable abuse aro se from it!23 Again like the schoolmen, Hoffmann saw that the purpose of both med icine and theology was salus, both health and salvation. He thought his own method o f practice of medicine could be applied to theology, giving rules for healing th e soul.24 Both disciplines had unshakeable foundations, said Hoffmann: the basis of medicine was the wonderful order and concatenation of the parts of the body and of the world in a word, mechanism. And the rock on which theology was built was the revealed word of God. Again, it is God who, as the Author of revealed an d natural knowledge, ensured that the system is unshakeable: Hoffmann says that the system produces only necessary effects (which the doctor can accordingly han dle). He represents theology as being like medicine in being a matter of reason and experience, where the theologian learns from symptoms about the faults in a patients soul and applies spiritual remedies in accordance with the needs of the individual. While the physician is the servant and not master of nature, says Ho ffmann (exploring another well-known theme), the theologian is the servant of Go d; and both kinds of practitioner may lose the patients body or soul through lack of reason or skill. 22 23 24 See his in the entum . sanandi Dissertatio Theologico-Medica de Of cio Boni Theologi ex Idea Boni Medici rst volume of the collected works. Operum Omnium Physico-Medicorum Supplem . . Pars Prima, Geneva (The Brothers de Tournes), 1749, p. 58. Methodum animam, Supplementum . . . Pars Prima, p. 57.

236 The crisis Clearly then, a rational awareness of God was the basis of Hoffmanns world-view. In his work on the best way of philosophising he makes the connections very plain. Philosophy is Gods greatest gift to man and has the purpose of making man more p erfect and rational. Hoffmanns optimism about human improvement is not an abstrac t principle, but is partly based on recent achievements. He held that the ancien ts did not know how natural things worked and could not therefore prognosticate about them. He pointed in contrast to the heights reached at this time by astron omy, physico-mechanical anatomy (the actions and uses of the parts) and chemistry, all parts of the scientia of natural things. He agreed with his correspondent L eibniz that one piece of physica experimentalis was more worth reading than a hu ndred of the usual kinds of metaphysics, ethics or logic.25 The general intellec tual orientation of Hoffmanns natural theology was towards the English writers: W illiam Derham, Matthew Hall, John Ray, Edward Stilling eet (bishop of Worcester) a nd Robert Boyle. More specifically he draws on authors known to him personally, such as Philipp Jakob Spener, who Hoffmann says was one of the rst theologians to discuss physical things. Spener, a Pietist, had helped to set up the university of Halle, founded by Frederick III of Brandenberg-Prussia and was undoubtedly i n uential in the intellectual tone of the place. Hoffmanns particular friend was Ch ristian Wolff, who arrived in Halle in 1706 and whose natural theology appealed to Hoffmann, but who aroused the opposition of the Pietists in 1721. For Pietist s did not necessarily believe that a rational demonstration of God from his work s was possible or desirable. Brought up on the mystical works of Jacob Boehme an d Johann Arndt, Pietists believed in the presence of God within themselves and s ome of them behaved with a great deal more religious enthusiasm than others thou ght seemly; Hoffmann thought that enthusiasmus was the result of a physical diso rder of the brain. His own theology was as distant as possible from enthusiasm. He writes in numbered paragraphs, geometry-style, with scholia and notes. He pro ves the existence of God a priori and a posteriori, from rst principles and from effects. It is the argument from design, where the design is a set of invariant and necessary rules of motion, mechanismus. God is simply the perfect mechanic.2 6 25 26 Exercitatio de Optima Philosophandi Ratione in his Operum Omnium Physico-Medicor um Supplementum . . . Pars Prima, Geneva (The Brothers de Tournes), 1749, p. 4; the letters to and from Leibniz begin at p. 49. Deus rectissime summus et perfect issimus mechanicus. p. 14.

Enlightenment, systems and science s ta h l 237 Hoffmanns natural theology, a serene and con dent product of his old age, hid what was probably the biggest intellectual battle of his life. The picture that he tr ied to build up of a new certain system based on the undeniability of the Creato r and the physical truths of mechanical nature, and which he hoped would be acce pted as supporting medicine as closely and as widely as traditional natural phil osophy was challenged on his very doorstep. Georg Ernst Stahl (16601734) was a fe llow teacher of medicine in Halle and a fellow Pietist, but of a very different stamp. He dismissed mechanism entirely. For him the centre of the body, and its actions in life, health and disease, was the soul. It was the direct action of t he soul that turned food into blood and supplied heat and motion to the body. Th e soul generally acted for the good of the body and, for example, produced the s ymptoms of fever in ejecting noxious matter from the body. But it did not necess arily use conscious reason, and certainly not mechanism in doing these things. I ndeed, it could act entirely wilfully, even choosing to leave the body. Stahls te rm was not mechanism but organism, the holistic action and reaction of the soul-andbody. For him the ordered coherence of the body was due to the souls tonic motion t hat behaved wisely, for example in directing the ow of blood to a part where it w as needed.27 The very enthusiasm of the Pietists led to physical disorders that Stahl clinically judged to come from the soul. In Stahls system there was no dist inction in kind between perception, reason and emotion. Since Descartes, mechani sts had tended to see the soul in terms of its two great gifts to man, immortali ty and reason. At its extreme, this made animals, mortal and irrational, mere ma chines. Mechanism also ignored actions in the human body that involved perceptio n, seemed to be guided for the good of the body, or were not conscious: unconscio us perception was a nonsense to a mechanist. But for Stahl sensory perceptions tu rned into physical reactions and into feelings, intuition, knowledge and thought .28 Stahls doctrines had considerable appeal to radical Pietists, those who tangi bly felt God within themselves as both a driving force and a guide. To us they r epresent yet another philosophy that could ourish in the absence 27 28 See Joanna Geyer-Kordesch, Georg Ernst Stahls radical Pietist medicine and its in ue nce on the German Enlightenment, in Cunningham and French, eds., Medical Enlighte nment, pp. 6787, at p. 75. Ibid., p. 77.

238 The crisis of traditional natural philosophy; to his contemporaries Stahl seemed retrogress ive, going back to the very Aristotelianism of traditional philosophy. Certainly Stahls body-and-soul was teleological in acting for a purpose, one that it seeme d could not be read into the laws of matter and mechanics. Hoffmann was deeply a ntagonistic, for it seemed to him that Stahls doctrines were extremely enthusiasti c and a threat to the calm tranquility of body and soul that was the goal of medi cine and theology. Most of his preface to the entire collection of his printed w orks is given over to a rejection of Stahls doctrine, although Stahl is not named ; Hoffmann devoted a separate exercise to explaining the difference between his own system of medicine and Stahls.29 animism We have seen that in the absence of Galens theoretical etiology and pathology some physicians gave their attention to the practice of medicine and the nature of disease. This suited what the Enligh tenment saw as improvement, and perhaps nosology gave to medicine a new intellectu alism to replace the old. With the collapse of the Galenic system some doctors a lso began to think of the soul and disease. It was now a single soul (unlike the two souls of Willis, for example, in the previous century) but it was not simpl y reason, in the Cartesian manner. Nor was it a tabula rasa at birth.30 Just as Stahls soul acted unconsciously in ejecting noxious matter from the body (and thu s producing disease), so for example the nosologist de Gorter came to think that the soul acted without the knowledge of reason. In particular, glandular secret ion was inexplicable in mechanical or chemical terms and relied on distinct laws of life.31 This was in the 1730s, when a number of other physicians felt obliged to withdraw from the orthodoxy of mechanism. Like Stahl, the nosologist Sauvages thought that the soul acted independently of reason in expelling noxious matter from the body, 29 30 31 Stahl has received some attention from historians, and it is not the intention h ere to repeat what is readily available. A recent essay on Stahl is Francesco Pa olo de Ceglia, Introduzione alla Fisiologia di Georg Ernst Stahl, Lecce (Pensa M ultimedia), 1999. On Hoffmann see also Roger French, Sickness and the soul: Stahl , Hoffmann and Sauvages on pathology, in Cunningham and French, eds., Medical Enl ightenment, pp. 88110. For George Cheynes discussion of the matter see Akihito Suz uki, Anti-Lockean Enlightenment? Mind and body in early eighteenth-century Englis h medicine, in Roy Porter, ed., Medicine in the Enlightenment, Amsterdam (Rodopi) , 1995 (The Wellcome Institute Series in the History of Medicine), pp. 33659, at p. 344. Hobbes and Locke were regarded as materialists and even atheists by many . Johannes de Gorter, Oratio de Animi et Corporis Consensione Mirabili, (1730), Frankfurt and Leipzig (Johannes Fridericus Jahn), 1749.

Enlightenment, systems and science 239 the process constituting disease. The problem of the motion of the heart was aga in central, as it had been for Froidmont and other opponents of Descartes in the previous century. The heart beat was the only motion in the body that was not s ubject, to some extent, to the will, or in other words, it was not subject to th e rational soul. Even the mechanist Borelli had to assume that some unconscious perception of the soul was involved,32 and Sauvages constructed a thorough-going animist physiology.33 When Hoffmann declared that life was nothing more than a continuation of all the mechanical processes of the body, primarily the circulat ion of the blood, he put his nger on a cardinal point of theory. Its corollary wa s that the soul was, in this life, simply conscious rationality. Almost certainl y this was a complexion given to mechanism by Descartes through his strict disti nction between the extended body and the non-extended thinking soul. Just as man y of Descartes contemporaries thought it was impious or too radical to deny the a ction of the soul in, for example, making the heart beat, so in the next century some medical men began to wonder whether mechanism could in fact explain all th e appearances of life. The central question that arose among such men was: given that the body was mechanical, what moved the machine? Many mechanists had trace d out pathways of motion in the body, and it was the need to trace all motion fr om a single source that made Descartes both adopt Harveys doctrine of the circula tion and change Harveys notion of the heart beat.34 But some systems of mechanism derived the pulse of the heart from the brain by way of a nerve-juice, which in turn was originally moved by the heart. The mechanical absurdity of this perpet ual motion was clear to many. George Cheyne said that the arrangement was a plain Circulation of Mechanical Powers; ie a Perpetuum Mobile and therefore impossible .35 We shall meet further answers to the question What moves the machine? later on , and we must here look at gures who were still formulating it. One of the earlie st was John Tabor (born 1667), whose book was approved by the censors and presid ent of the London College of Physicians in 1711. What was in his mind was the st ill troubling fact of con icting theories 32 33 34 35 Giovanni Borelli, De Motu Animalium. I have used the edition of Leiden (Petrus v ander Aa), 1685: part 2, p. 109. For the network of animists invoked by Sauvages , see Roger French, Sauvages, Whytt and the motion of the heart: aspects of eight eenth-century animism, Clio Medica, 7 (1972) 3554. That is, Descartes denied activ e contraction of the heart because it meant that the parts of the heart were att racting each other, which was unthinkable in Descartes mechanism. See Roger Frenc h, William Harveys Natural Philosophy, Cambridge (Cambridge University Press), 19 94, esp. ch. 8. George Cheyne, Philosophical Principles of Natural Religion: con taining the Elements of Natural Philosophy, London (G. Strahan), 1705.

240 The crisis within medicine: the Hippocratic, the chemical and the mechanical.36 Hippocrates , as always, is an approved special case. Tabor, like the mechanists, argued tha t the directing parts of the body were the solids; and his notion of the intesti nal motion of the liquids may be an echo of the fermentation of the chemists (of w hom he broadly disapproved). But the solids are moved not by an inherent or Godgiven force, the vis insita of the mechanists and Haller, but by an animated age nt. Tabor is not systematic in this doctrine (he was concerned after all with di seases and symptoms) but it is clear that the soul and the external and divine p rinciple, which began and above all guided motion, was Tabors response to the per ceived inadequacies of chemistry and the mechanical structures of the body, to w hich it was separate and superior.37 What moves the muscles? What guides the par ts of the growing embryo to their right places? His mention of gravitation, subt le matter and Gods control suggests that he had found some answers in Newton.38 B y the 1730s mechanism of some kind had pretty well become an orthodoxy of a kind and the time had passed when medical men were trying to avoid the problems of t he fragmentation of traditional natural philosophy. The animists, those eager to g ive a place to the soul in their medical thinking, sought to modify aspects of m echanism rather than to overthrow it (with the exception of Stahl). Indeed, both animists and mechanists often tried to nd common ground in a new, con dent and enl ightened system of medicine. ro s e t t i We can take as an example Josephus Tho mas Rosetti, whose work was pronounced safe for Catholics by the Paduan Riformat ori in 1733.39 Its title announces that it is a new system no room for scepticis m here which is at once mechanical and Hippocratic. We have seen in the endless interpretations of Hippocrates, and especially of the Aphorisms, that it was use ful to enlist the Father of Medicine as somehow covertly using the rudiments of a new form of medicine. It showed that the new system had the dignity of age, th e authority of a great name and it revealed a truer Hippocrates. But this was be coming a strategy that worked perhaps only for Hippocrates, and we are looking a t a period when mechanism as a new orthodoxy was 36 37 39 John Tabor, Exercitationes Medicae, quae tam Morborum quam Symptomatum in pleris que Morbis Rationem Illustrant, London (Guilhelmus Johannes Innys), 1724, p. xv. 38 Ibid., pp. 14, 36, 50. Ibid., pp. 58. J. T. Rosetti, Systema Novum Mechanico Hippocraticum de Morbis Fluidorum, et Solidorum, ac de singulis ipsorum Curation ibus. Opus Theorico-Practicum, Venice (A. Bortoli), 1734.

Enlightenment, systems and science 241 eclipsing the Galenic system of medicine. Rosettis language re ects the new Enlight enment con dence of the period, which embraced the principle that the ancients had no automatic rights to veneration. He points with pride to modern achievements, from Columbus discovery of a new world unknown to the ancients, to the modern an atomists, chemists and mechanists. Good God! he exclaims, think of anatomy since Harvey, chemistry after Paracelsus and physical theory after Descartes!40 Not s urprisingly, given that his system is self-consciously new, he has some disagree ments, especially with the chemists, but his programme is one of reconciliation, not aggression; a defence of the moderns. Like Hoffmann, he champions the princ iple of Freedom of Philosophising, which is compromised, he says, by too great a veneration of the ancients. In pointing to the great differences between the an cient sects of philosophers (and particularly the medical sects described by Gal en) Rosetti is reversing the Renaissance desire to recapture ancient life and an nouncing the superiority of the modern, more uniform, orthodoxy. Yet Rosettis den ial of the ancients is far from complete. With what looks to us like some consid erable irony, Rosetti has ancient authority for both denying and accepting ancie nt authority. With Seneca he notes how the words of ones (ancient) teachers stay in the mind. The very superiority of modern doctrine justi es giving them the name of Athena, the goddess of wisdom.41 Plato is my friend, Socrates is my friend, b ut truth is a greater friend is an Enlightenment aphorism only because of the aut hority of Plato and Socrates. It is with Plutarch that Rosetti nds that philosoph y never stops and he learns from Seneca of much ancient philosophy that was late r ignored. He concludes that some of the ancients were more sagacious and had a desire to know and perfect things, a thirst for truth that has come down to us a fter a long interval. These veteres cordatiores were a special category of ancie nts, to whom belief could be given.42 In short, Rosetti is making a special plea for Hippocrates. He has a special reason for doing so, but he has to prepare th e ground for it by explaining in Enlightenment terms why Hippocrates is the exce ption. When he denies the four elements, he destroys the whole of Galenic theory , from elementary qualities, complexions and humours to the faculties and spirit s.43 Most of his readers would have agreed. They would also have agreed that doc trines in medical theory had to be supported by experiments and observations, 40 41 42 43 Ibid., p. 3. Et O quam decora est recens haec doctrinarum Athenas, prisca longe n obilior. Ibid., p. 5. Plato is the only ancient besides Hippocrates to be said by Rosetti to be in the group. Ibid., p. 3. Ibid., pp. 5, 6.

242 The crisis for (he says) it is a vanity to philosophise without experience.44 He means part ly the experiments in anatomy, chemistry and mechanics that he says have proved the principles he has selected from these areas to build up his system, which he claims will avoid dissent.45 And partly he means medical experience, as in the r st aphorism, where life is short but the art is long. We have seen that the rst aph orism was always at the cardinal point where theory and practice met. It was the point at which the learned doctor could justify doing such an empirical thing a s collecting observations, the point where a doctor could argue that medicine wa s simply an art and not a science, and the point where a commentator could argue that the length of the art meant that Hippocrates had some rational system in m ind. Rosetti opens his preface by rmly locating his own reasons and experience in t he context of the danger of the art, which suggests that he had the aphorism in mi nd (it goes on to state the danger of experiment).46 It is in the context of thi s rst aphorism too that Rosetti justi es his new departure. For all the superiority of a broadly mechanistic medicine, on its own mechanics does not explain the ap pearances of life and its rules make for bad practice. The Mechanical Light has no t yet illuminated medicine so that the judgement of the art is less dif cult or th e dangerous experiment is less dangerous.47 In other words, Rosetti is saying th at at least where medical practice is concerned, the programme of mechanising me dicine is not complete. In these circumstances, we ask the Oracle of Cos.48 It is not just that we rst follow the vestiges of Hippocrates before selecting our own reasons from proven experiments, nor merely avoid dissent under the safest opini on of the Divine Old Man,49 but that we go to a location in Hippocrates that now has an enormous signi cance for Rosetti. This is where Hippocrates says that the body consists of Containing Parts, the Contained, and the impetum faciens. There were several reasons why this was important for Rosetti and others. The rst was that it was a new way of looking at the body that avoided the categories of the discredited system of Galen, for example the distinction between similar and organi c parts (they are all organic, says Rosetti).50 The second was that the Containin g Parts could readily be seen by the mechanists as the solids of the body the bre s, membranes, nerves and bones held together by mechanical forces (Rosetti has a nother Hippocratic location for this). Correspondingly, the Contained Parts were the uids 44 46 45 Ibid., p. 7. Ibid., preface. Experimentis itaque, et rationibus rmiter in haerendo (saepius namque Artis pericula inspeximus) opus hoc nostrum construere sategimus, his, inquam, tutus Morborum ditiones lustrare tandem deliberavimus. Ib id., preface p. 1. 48 Ibid., p. 8. 49 Ibid., pp. 6, 7. 50 Ibid., p. 8. Ibid., p. 6. 47

Enlightenment, systems and science 243 whose motions were controlled by the solids in an equally mechanical way. But by far the most attractive feature of the doctrine for Rosetti was the impetum fac iens, that which gave motion to the whole. It was this that made Rosettis Hippocr atico-Mechanical medicine different. The impetum faciens was non-mechanical and made him dissatis ed with mechanism as a total account of the living body. He call ed it the enormon and argued that activity was its essence. He saw that in dismiss ing spirits from the body the mechanists had lost a source of motion. Those (suc h as Santorini) who denied the existence of a nervous spirit replaced it simply by geometry, and Rosettis complaint is against those who were satis ed with a mecha nico-geometrical machine. But, he claimed, neither physics nor medicine can deny the enormic energia of the living machine, for without it there would be no ani mal or vital functions. Rosettis enormon was not the soul, but rather the souls mi nister.51 Part of its role was that of the traditional spirits, the moving power of the body in the traditional but now discredited seven naturals, the components of the body from the elementary qualities upwards. Rosetti sometimes calls the enormon spirit, having identi ed the quite different material spirits of the chemist s and having dismissed the traditional spirits. It is the energeticus spiritus, or simply an energeticum that performs the vital functions at the bidding of the mind (or soul).52 Sometimes he slips into more usual medical usage and uses spir it to mean that which is guided by the enormon. He is not clear whether the enorm on is material or not. He says it cannot be located, at least with the microscop e; it has the smallest possible extension and the greatest possible activity; it is also present as spiritual corpuscles which have as properties energia and an e lastic force of expansion and contraction, all of which are essentially vital. T he enormon is also present in animal bodies, Rosetti says, where it possesses si mple powers of judgement that are able to decide, in the sensus communis, whethe r the impressions of perceived objects are good or evil, and to act accordingly. 53 In man this power is present but is mere popular feeling, a democracy subject t o the soul.54 But there can be rebellion in the democracy and the enormon can su bvert natural regimen or lead esh against the soul. Stahl is not mentioned, but R osetti appears to use some of his doctrines, particularly when he claims that di sease is not caused (as most doctors think) by insensible 51 52 53 54 Ibid., preface. See also p. 11 where the soul, anima, is quite distinct. Itaque d e facto datur in homine hoc activissimum vitalis impetum seminium, et incrementu m, quod divinus Senex Enormon, seu impetum facientem nuncupavit. Ibid., p. 11. In animals the enormon is clearly material and mortal. Animals have arbitrium and animale Judicium. Rosetti, Sytema Novum, p. 11.

244 The crisis matter entering the body and changing it in accordance with the matters qualities . No, diseases are caused by the enormon in ejecting noxious matter. w h at m ov e s t h e m ac h i n e ? Rosettis emphasis on the power of the enormon can serve to introduce a problem not recognised by the early mechanists. Descartes and oth ers had traced out pathways of motion in the body but had given little thought t o its quantity. Geometers such as Santorini similarly explained, by the use of d iagrams, only what directions could be taken within a mobile bre. Considerations of quantity were entered into by those who followed what looked like a Harveian programme of work. A spurting of blood from a punctured ventricle of the heart s howed that blood was literally being thrown out of the heart, and the Latin term s used were often variants of the verb to throw. The natural apparatus to use in u nderstanding this was ballistics, a subject of great importance in the Renaissan ce. As we saw with Baglivi, when an artery distant from the heart was opened, th e blood also emerged forcibly, as though it had been thrown, and Baglivi used th e term arch to describe, and measure, the trajectory of the blood. It appeared, th en, as though blood was being thrown into the arteries and reached the capillari es by projectile motion. But, particularly in the context of Newtonian hydraulic s, a number of people began to see that a projectile motion would rapidly be los t by friction through the tortuosity and subdivisions of the arteries. Attempts to determine whether the force of the heart was enough to circulate the whole ma ss of blood constitute a recognisable research topic of the eighteenth century. Muscular motion also became a problem.55 The question of the loss of projectile motion through arteries became a special case of a general argument about loss o f motion in machines. Those with a grasp of mathematics could calculate what pro portion of motion coming into a machine was lost by friction. Machines in the ei ghteenth century were, of course, devices for turning one kind of motion into an other: mills, pulleys, levers, screws and so on did not generate motion. It was also clear to many more men than Cheyne that perpetual motion was impossible. Ye t the body moved constantly. What moved it? If motion was constantly being lost by friction, what replaced it? There was a real threat to the orthodoxy of mecha nism when a number of 55 So did animal heat a problem caused by the lack of Aristotelian innate heat.

Enlightenment, systems and science 245 medical men began to think that it might, after all, be the soul, something so e ssentially alive that it generated motion. There were other problems with mechan ism too. How could a machine reproduce itself? How could animal machines perceiv e? In attempting to answer the rst of these questions some mechanists suggested t hat all the parts of future bodies were contained in the eggs of the present. d o c to r s a n d pat i e n ts To summarise to this point there were, over the rst three or four decades of the eighteenth century, a variety of new rational syst ems of natural philosophy available to the medical man. But simply because of th eir number they could not be used in the same way as traditional natural philoso phy by the Learned and Rational Doctor who wanted a Good Story to tell. Galenic texts competed for market niches with the most neoteric treatises. Animists argu ed with Newtonian mechanists, and almost all learned doctors agreed in attacking the chemists, whom they saw as building up a new world-view based on a new set of elements. The chemists seemed arrogant and doctrinaire, producing the worst k ind of system. Competition among doctors made Newtonianism a useful adjunct to the doctors learning in the traditional way. The self-proclaimed Newtonian doctors w ere so successful that they attracted the criticism of Bernard Mandeville in 171 1: those Braggadocios, who . . . only make use of the Name of Mathematicks to impo se upon the World for lucre.56 Thus, while a doctor could attempt to give some in tellectual respectability to his practice and even regain his authority, he coul d no longer rely on an educated patient or potential student sharing his world-v iew. Indeed, it has been argued that the patient now took a more active role in the doctorpatient relationship and helped to decide what he was suffering from.57 As a customer and consumer his voice had a part to play in the generation of me dical knowledge. He could choose between different systems or diseases in which the doctor offered to drum up business, or force a trade as Smollett put it.58 The story is told of an apothecary who had just 56 57 58 Quoted by Anita Guerrini, Newtonianism, medicine and religion, in Grell and Cunnin gham, eds., Religio Medici, pp. 293312, at p. 296. See N. D. Jewson, Medical knowl edge and the patronage system in eighteenth-century England, Sociology, 8 (1974) 36985. Quoted from Dewhurst, Thomas Williss Oxford Lectures, Oxford (Sandford Publ ications), 1980, p. vii.

246 The crisis read a learned book of 1764 on nervous diseases and realised that he had a new a dvantage in the medical marketplace: Before the publication of this book, people of fashion had not the least idea th at they had nerves; but a fashionable apothecary of my acquaintance, having cast his eye over the book, and having often been puzzled by the enquiries of his pa tients concerning the nature and causes of their complaints, derived from thence a hint, by which he cut the gordian knot Madam, you are nervous; the solution was quite satisfactory, the term became fashionable, and spleen, vapours and hyp, w ere forgotten.59 In customer-led medicine the doctor lost some of the traditional power to secure t he obedience of his patient. Grand patients such as kings often disregarded their physicians advice, and French royalty frequently brought in quacks (like the Englis hman Talbot with his quinine wine in 1679): the court changed its doctors quickl y and at a whim.60 Popes, too, often ignored their doctors advice61 and it may ha ve become fashionable for the aristocracy to do likewise. t h e n ew n at u re I n some universities, mostly Protestant (our examples are Halle and Cambridge), t he crisis in philosophy was met with the construction of a new discipline, the L aw of Nature and Nations. The basic doctrine was that things, and people, acted according to their natures. These natures were God-given and could be understood by the use of human reason. One of the origins of the discipline had been devel oped in the seventeenth century by scholars such as Hugo Grotius, who sought way s of handling the different national legal systems (demanded, for example, by co mmerce). An antecedent might be seen in the Roman ius gentium, the mechanism tha t kept different systems together in the empire. Roman Law too had a doctrine of natural law that held that, for example, since it was in the 59 60 61 Quoted from James Adair (1786, speaking of the 1760s) in Richard A. Hunter and I da MacAlpine, ed., Three Hundred Years of Psychiatry, 15351860: A History Present ed in English Texts, London (Oxford University Press), 1963, p. 501. See Laurenc e Brockliss, The literary image of the Mdicins du roi in the literature of the gra nd e si cle, in Vivian Nutton, ed., Medicine at the Courts of Europe, 15001837, Lo ndon (Routledge), 1990, e pp. 11754. See Richard Palmer, Medicine at the papal cou rt in the sixteenth century, in Nutton, ed., Courts, pp. 4978, at p. 63. But, of c ourse, to be a papal physician was to have great status; after the death of a po pe, his physician would open the body in a ritual which con rmed their mastery of t heir profession, i.e. they could demonstrate the cause of death, for instance, fr om a bladder stone. Palmer, Papal court, p. 67.

Enlightenment, systems and science 247 nature of birds to y, your pigeons remained yours only while they lived in your l oft. The ius gentium was in a sense eirenical, and the Law of Nations studied th e rights and duties of man, as a rational and created being, that arose from his God-given nature. This was quite different from local law and potentially could be applied to all men. The unity of the new discipline came from the belief in God as the universal Creator. Just as Boyle, for all the scepticism of the time, could see coherence in nature because it was creation, so in the Enlightenment, with a new con dent reason, they looked at man as created everywhere the same. In some sense the Law of Nature and Nations replaced the philosophy of Aristotle i n the universities. Its reasonings on the rights and duties of man had the same curricular role as moral philosophy, with the advantage that it was more pious t han Aristotles. Like Aristotles physical works, the Law of Nature explained how th e world worked. And the overall purpose of the educators was the same: to have a system that was, above all, agreed upon. The religious basis of the new discipl ine was apparent too in another Enlightenment use of reason, natural theology. T his sought to demonstrate the existence and attributes of God in a rational way; and this too was eirenical in cutting across the confessional differences that had caused so much trouble in Christendom in the previous century. In practice, the natural-theological reading of the book of nature was most prevalent in and wa s valuable for English and Dutch society.62 Catholics treated natural theology a nd natural law in a different way, beginning with God and reaching to the nature s of men and things. To a certain extent the Law of Nature could, for the medica l man, act as the old natural philosophy had done in lending authority to his me dicine. It was still dif cult to agree precisely on which principles God had decid ed to create the world (where once everyone had agreed they were Aristotelian). But the Law of Nature allowed one to say that the forces and structure within th e body were direct creations of God. This is exempli ed in Halle, the university o f Hoffmann and Stahl, by the little textbook of Martin Heinrich Otto.63 His Elem ents of the Law of Nature and Nations is the second part of a larger work on div ine law, which reminds us that the whole doctrine had a cogency based on God as Creator. It is this too that binds natural philosophy to medicine. Because it wa s Gods law that explained how the 62 63 See Harold J. Cook, The new philosophies in the Low Countries, in Porter and Teich , eds., Scienti c Revolution, pp. 11549, at p. 140. Martin Heinrich Otto, Elementa Iuris Naturae et Gentium una cum Declineatione Iuris Positivi Universalis, Halle , 1738.

248 The crisis physical world worked, as much as it was Gods law that gave man his nature, there was a necessity about it. Causes preceded effects and effects always followed c auses. Physical or natural changes in the human body, says Otto, are those over which man has no control, those which necessarily follow from the mechanism alon e of the body.64 It is not just that the philosophers have taken over the termin ology of the doctors (here what Hoffmann called mechanismus) but that they share d the belief that in a world where Newton had, without framing hypotheses, shown how God made the world, events necessarily occurred according to the physical n atures of things. Otto declares that life consists of actions and motions that a re produced mechanically by the structure of the parts, making use of a force th at was created with all matter.65 This, says Otto, is an inherent force, a vis i nsita of the material parts. He decides that he is going to follow those who cal l this mechanical structure together with its innate force nature, so that by natur al law he here means almost exactly what the mechanist doctors thought in their the oretical considerations of how the body worked. We have seen that the mechanists needed an innate force to explain the motions of the body; Hoffmann agreed with Leibniz that a totally inert body could never receive motion, or even exist. In arguing against the animists and their higherthan-mechanical source of bodily m otion, the great Albrecht von Haller also identi ed a God-given vis insita that ne eded no further explanation.66 Almost another guarantee that the actions of the body were mechanical in this sense was right reason, the reason that resided natur ally in man as a gift of God: Otto implies that insofar as it is ultimately divi ne, reason will not deceive us.67 Another way to avoid being deceived by differe nt religious confessions was to look to mathematics. We have seen that after the collapse of traditional natural philosophy, demonstration was reckoned possible only in mathematics. It seemed to Christian Wolff, who was born in 1679 and who as a Protestant lived among Catholics, that religious truths could not indeed b e demonstrated except by mathematics, which was universally accepted. Like Stahl , Hoffmann and Otto, he became a professor at Halle and taught mathematics, natu ral philosophy, natural theology and natural law.68 64 66 65 Ibid., pp. 923. Ibid., pp. 1013. Albrecht von Haller, Ad Roberti Whyttii nuperum Scriptum Apologia, n.p., 1764, p. 27. See also his Elementa Physiologiae Corporis Humani, 8 vols., Lausanne (M. M. Bousquet and Associates), 175766, vol. 4, p. 183. Otto, Elementa, p. 8. See Christian Wolff, Jus Gentium Methodo Scien ti ca Pertracta, 2 vols., Oxford (Clarendon Press), 1934. 67 68

Enlightenment, systems and science 249 In Cambridge they read Samuel Pufendorf,69 who was the rst to teach the Law of Na ture and Nations at Heidelberg in about 1662.70 It is worthwhile too to glance a t what was being taught in Glasgow and our example is Francis Hutchesons Synopsis of Metaphysics.71 Like the Law of Nature, this is an arts-course text which inf ormed the prospective medical student about the nature of the world and determin ed what kind of philosophy was available if he wished to make his medicine philo sophical. Like the other new natural subjects, this was a replacement for the old philosophy. Hutcheson opens his treatment by explaining how the ancient division of philosophy into physical, moral and intellectual was now inappropriate and t hat the modern metaphysics includes ontology and pneumatology. The former embraces t he study of being, of existence, of causes and effects and the Law of Nature, wh ich describes the invariable manner in which matter is moved (the Newtonians are mentioned). Pneumatology is likewise an explicit replacement of ancient doctrin e, and deals with the human soul, other spirits and God.72 The soul, as some of the animists also said, is simple (without parts), active and not extended with the body (which is, in contrast, inert and divisible). It is the soul of religio n as well as of the new philosophy: it is divine and separable. It is in some se nse the soul that moves the machine (for all material bodies are passive), altho ugh we cannot feel or tell how it excites the nerves to the muscles; perhaps it does so by Gods original design or present intervention. Thus the new philosophy is to be more pious than that of the pagan ancient philosophers. Indeed, the thi rd part of metaphysics is about God and opens with natural theology. It is the a rgument from design and Hutchesons authorities are a remarkably consistent group of authors, found also, for example, in Hoffmann: Stilling eet, Ray and Derham; Hu tcheson also calls on Cudworth and Cheyne.73 The Cartesian proof of the existenc e of God and of clear and simple ideas is indignantly rejected.74 69 70 71 72 Like other new disciplines and doctrines, including those within medicine, the L aw of Nature and Nations created a history for itself, and its exponents wrote t exts of the Institutes kind. See, for example, Samuel Pufendorf, De Of cio Hominis e t Civis juxta Legem Naturalem libri duo, London (G. Thurlbourn & J. Woodyer), 17 58, ed. Thomas Johnson, Fellow of Magdalene College, which was intended for the Cambridge market. It is prefaced by a history of natural law by Johannes Francis cus Buddeus, the theologian of Jena, who establishes its ancient Fathers. Pufend orf is here concerned with natural law rather than the law of nature. For the latter see, for example, his Of the Law of Nature and Nations, trans. B. Kennet, Londo n (R. Sare), 1717. See Basil Willey, The Eighteenth Century Background. Studies on the Idea of Nature in the Thought of the Period, Harmondsworth (Penguin/Chatt o & Windus), 1962, p. 21. Francis Hutcheson, Synopsis Metaphysicae, Ontologian e t Pneumatologian complectens, 4th edn, Glasgow (printed by Robert and Andrew Fou lis for the university), 1756. 73 Ibid., p. 201. 74 Ibid., p. 220. Ibid., p. 103 .

250 The crisis Another new nature discipline was natural history. The natural historians of the s ixteenth and early seventeenth centuries were for the most part men of Reformist tendencies. It was agreed that the book of nature could be read alongside the s criptures to discover more about God. The anatomists who felt themselves to be s tanding in a theatre of creation as well as an anatomy theatre expressed the sam e viewpoint as the natural historians who sought the invisible things of God in the visible. The view prevailed into the scienti c revolution and the Enlightenment, and it became a fashion to establish cabinets of specimens. The subject was aki n to medicine in a number of ways: it suffered no more elaborate theory than Gods rationality; its practice was by sensory observation of particulars, producing m atters of fact; the results could be set down systematically to produce a history, which had echoes of what was admirable in Aristotles treatment of animals and str onger connotations of Bacons sylva and the use made of his method by doctors such as Baglivi; and the collection and cultivation of plants was directly related t o medicine. Thus natural history not only generated the cabinets of Enlightened gentlemen but also physic gardens, for example those in the universities set up to direct the values of the young of the United Provinces.75 Many collectors of natural-history items were medically quali ed, and doctors sometimes set up their own museums.76 Although natural history and the religious or at least edifying r easons for practising and teaching it were not uniquely Protestant, the principl es behind it could be strikingly different in Catholic countries. While the stud ents at the universities of the United Provinces understood the nature group of su bjects in something like the way described above, generally called physico-theolo gy, it was different in Paris. Though some formal Catholic expositions of theolog y do not mention nature at all,77 we can take as an example one of those that do es address natural and revealed religion, that of L. J. Hooke.78 It deals with the principles of the subject and, although it was in use past the middle of the ei ghteenth century, it is set out in scholastic form for the bene t of his Parisian students. It is essentially a re-emphasis of points of doctrine of the churchs le arned tradition. It tackles the question of natural theology in a manner that wo uld have looked to Protestants to 75 76 77 78 Cook, The new philosophies, p. 119. See, for example, Paula Findlen, Possessing Na ture. Museums, Collecting and Scienti c Culture in Early Modern Italy, Berkeley (U niversity of California Press), 1994, esp. ch. 6. See, for example, Rev. Patr. T homas, ex Charmes, Theologia Universa, Venice, 1757. The argument is that theolo gy is ultimately a question of revelation, and while absolutely necessary for th e church as a whole, was not necessary for the faithful individual. L. J. Hooke, Religionis Naturalis et Revelatae Principia, vol. 1, Venice (Johannes Baptista Pasquali), 1763.

Enlightenment, systems and science 251 be the wrong way round. It begins with God and uses reason to show how the natur e of man should interact with God. It is from a knowledge of God and his relatio nship to man that this natural religion turns to the attributes of man, and from there to the of ces owing by natural necessity from man to God. Hooke calls the rst o f these, knowledge of the nature of God, natural theology. The second, the nature of man, is moral philosophy, and the third, mans duties to God, is natural law. None of these terms corresponds to those used in the Dutch or English natural theolog y or physico-theology, for example that of William Derham.79 Perhaps this is an attempt to give Catholic values to a new Protestant discipline. This view is enc ouraged by the address from a third party to the readers, who singles out (from Hookes text) Bayle, Hobbes and Spinoza as deserving of refutation. These were the traditional atheists of the new philosophy from a religious viewpoint (Boerhaave had to give up ambitions of a church career when he thought someone had accused him of being a follower of Spinoza), and indeed Hookes substantive arguments begi n with refutations of atheism. Hookes reasons for the existence of God (the rst po int to be established in a scholastic disputation) include, in third place, the physical. This is the Argument from Design, and few Protestants would have disag reed with it. But they would have perhaps been surprised that it features so lar ge in Hookes account mainly because its opposite (that there was no design, or pu rpose, in nature) was said to be the common feature of all forms of atheism. Hoo ke says that the opposite of atheism is theism by which he means, of course, prope r church doctrine which elevates the nature of man and holds society together.80 Like Protestant educators, he saw the need for uniformity of belief. pe e r g r o u p rev i ew It has been argued through this book that the university-trained doctor used his rationality and learning in the interests of professional succes s.81 He was promoting an image of himself and his kind that gave him authority a nd helped to guide the expectations of patients and others. In the Middle Ages hi s kind were perhaps only the other doctors of his school or immediate knowledge, while by the Renaissance there came an awareness that 79 80 81 Derham (16571735) gave the Boyle Lectures in 171112, the basis of his Physico-Theo logy of 1713. It went through twelve editions in half a century and it was read by Hoffmann, perhaps in German. Hooke, Principia, p. 4. When criticism was made of Enlightenment doctors it was about behaviour and lifestyle, not clinical fail ure. See Mary Lindemann, The Enlightenment encountered: the German physicus and h is world, 17501820, in Porter, ed., Medicine in the Enlightenment, pp. 1817, at p. 185.

252 The crisis all Learned and Rational Doctors should behave in the same way for mutual bene t. On top of this there were individual efforts for self-promotion. A good teacher might achieve fame by the subtlety of his theory in disputations, particularly i f they were written down and circulated, such as the works of Pietro dAbano and P lusquam Commentator. But circulation was slow. It took a very long time to copy out the millions of words in Gentile da Folignos commentary on the Canon. Work by his contemporaries likewise circulated to Gentile slowly, and, as we saw, he co uld not be certain that he knew the detail of what they were teaching. Yet the w orks of these three authors remained famous enough to be printed early in the si xteenth century. Printing, of course, made a difference. In the history of print ing the rst works to appear were those considered important and which had a marke t, largely ancient works. But not long into the sixteenth century authors could see their own works published in their lifetimes.82 This meant that an author co uld go into print, perhaps at his own expense, to justify or defend himself. Sma ll tracts could be produced cheaply and quickly and distributed in a directed wa y: pamphlet wars became possible. By means of dedications and addresses the auth or could seek to ingratiate himself with a powerful gure as a patron, perhaps wit h a view to seeking a retained position in a great household. As we saw, Vesaliu s addressed the emperor and became imperial physician, and Fuchs in a similar wa y became a ducal doctor. The title-page was a Renaissance invention, enabling th e work to be quickly identi ed in a growing number of books. The editor was also a Renaissance gure, justifying the published text or the particular collection of texts in an anthology. Pamphlet wars could be turned to advantage by publishers who collected together those on a particular topic and published them as a colle ction. We have seen how controversies in the seventeenth century could be presente d in this way. We saw, too, how Descartes sent out review copies of the Discours e on Method to test the eld for the reaction to his doctrines. Publishing a book became a recognised step in a career. For example, Richard Mead and George Cheyn e became famous and employable Newtonians who found employment as a result of wr iting on Newtonian topics.83 82 83 See Jon Arrizabalaga, The death of a medieval text: the Articella and the early p ress, in Roger French, Jon Arrizabalaga, Andrew Cunningham and Luis Garca-Balleste r, eds., Medicine from the Black Death to the French Disease, Aldershot (Ashgate ), 1998, pp. 184220, at p. 187. See Anita Guerrini, Isaac Newton, George Cheyne an d the Principia Medicinae , in Roger French and Andrew Wear, eds., The Medical Revo lution of the Seventeenth Century, Cambridge (Cambridge University Press), pp. 2 2245, 230.

Enlightenment, systems and science 253 But sometimes it seemed that there were too many books. We noticed above that Ba glivi held that a doctor should not read a book unless it was relevant to his pr ogramme and true. But, there was no mechanism of critically evaluating books whi ch had been produced with a great range of motives from ideological agenda to pe rsonal attack. Booksellers produced long lists of medical books which not even t he most assiduous doctor could afford the time to read or the money to buy. From the end of the seventeenth century attempts were made to simplify the problems. There appeared histories of medicine (and of anatomy) that were in part a guide to the literature. Critical bibliographies were compiled, such as the vast coll ections of Albrecht von Haller. Anatomy in particular attracted the attention of biographers and bibliographers.84 There also appeared a new form of publication , brief papers in a serial journal, edited by a professional group.85 Our exampl e here is the anonymous Society set up in the 1730s by serious-minded medical men in Edinburgh, where there was now a medical school to rival that of Leiden and b ased on the medicine of Boerhaave. They were concerned with the large number of medical books, doubly impossible for a learned doctor to cope with because each book referred back to many others. Moreover, not all potential medical authors w anted to write a whole book and what they did write did not therefore appear in booksellers lists. The Society accordingly proposed to publish a series of volume s containing short pieces: more authors and fewer books.86 The important feature of the Societys plans was that each piece of writing submitted for publication w as subject to scrutiny by the members of the Society in an editorial capacity. T his is why they are anonymous. They called themselves Collectors (that is, of the written material) and they felt that their peer-group review of submissions woul d be prejudiced by external in uence if their names were known. They had, of cours e, their own agenda, a kind of medicine of which they approved. This made the in timidatingly long publishers lists of medical books an unsatisfactory guide to th e medical literature: not only were they so vast but not all the books listed we re based on the repeated Observation of Facts on which alone axioms can be based 84 85 86 See, for example, James Douglas, Bibliographiae Anatomicae Specimen sive Catalog us Omnium pene Auctorum qui ab Hippocrate ad Harveum . . . , 2nd edn, Leiden (n. p.), 1734; and Andreas O. Goelicke, Introductio in Historiam Litterarium Anatome s, Frankfurt (J. G. Conradus), 1738. The Journal des Scavants, the organ of the Academie Royale des Sciences, carried reviews of scienti c books from 1665. Medica l Essays and Observations, Revised and Published by a Society in Edinburgh, vol. 1, 2nd edn, Edinburgh, 1737, was printed by T. and W. Ruddimans for W. Monro an d W. Drummond and sold by named booksellers in Edinburgh, London, Dublin, Glasgo w and Amsterdam.

254 The crisis for medical practice. In short, their medicine was to be a branch of the natural philosophy pioneered by Boyle and others, just as we saw in the case of Hoffman n. This is why the Collectors in the rst volume address Sir Hans Sloane as the pr esident of the Royal Society, a glorious Example given to the World and a model fo r their own Society. Like others who wished to promote a certain kind of medicin e, the Collectors give a brief history of medicine, explaining its honourable or igins and the reasons for its recent (but correctable) confusion. The Collectors are very clear on what we have called the fragmentation of philosophy. As we descend nearer to our own Time, some of these dif culties are indeed gradual ly removed, tho it is to be regreted, that [in] the Succession of different Philo sophies prevailing in the theory, has continued other dif culties in the Practice of Medicine. These Medical Essays and Observations were intended to be like the Royal Societys Philosophical Transactions but narrower in range and specialising in matters re lating to the British Isles, where the climate and mode of life differed from th ose parts of Europe where most medical texts and early records emanated. The met hod of peer-group review was held by the Collectors to be superior to previous b ut similar publications, the Berlin Acta Medica, which the Collectors thought wa s simply a publishers enterprise, and the Acta Wratislaviensia, which they though t too local and German. The Paris Philosophical Society, the Imperial Academy in St Petersberg, and the Academia Naturae Curiosorum in Germany get better notice s for their practice of peer-group review. The Edinburgh Society also intended t o promote its own kind of medicine through book reviews and medical news of the formation of new societies and the making of new discoveries. The Medical Essays and Observations are indeed like the Royal Societys journal in recording observa tions rather than elaborating theory. Contributors whose names were printed abov e pathological observations or surprising cures no doubt added to their reputati ons, but as observational and experimental doctors, not as Newtonian philosopher s. When John Stevenson wrote on the nature of animal heat he introduced his piec e with an apology, justifying it only in terms of practice.87 Indeed, the Collec tors had a rigid code of conduct to be observed by their contributors. Descripti ons of simple drugs had to omit a priori arguments, which are liable to lead in E rror; all experiments are to be fully described, and no ingredient to be kept sec ret; In all Questions and Disputes relating to the Animal 87 Medical Essays, vol. 5, part II, 1744, p. 806.

Enlightenment, systems and science 255 Oeconomy, Theory and Practice of Medicine, we desire all personal Re ections, and offensive Terms may be shunned; case histories are to be related without any theo retical reasoning; unsuccessful cases are to be reported (if desired, anonymousl y) when they contain a lesson. The language of the essays was to be plain Englis h. Although the Collectors admitted that they would themselves make more mistake s in English than in Latin, the overall aim was intelligibility, which is the pri ncipal Thing in a Work of this Kind, where Elegance of Stile cannot be expected, and Wit would be hurtful. Plain language, detailed descriptions, and absence of personal bickering and of theoretical systems is a protocol of what is now group medicine with clear echoes of experimental philosophy, Bacon, Hippocratic aphor isms and case-histories. Learned doctors who published in the Medical Essays wer e thus subscribing to a particular kind of medicine, and where the in uence of the Society was strong, as in the Edinburgh medical school, publication could lead to advancement.88 haller and the soul Whereas Boerhaave was the most famous medi cal teacher of the Enlightenment, the Swiss baron Albrecht von Haller was the gr eatest medical scholar. He surveyed essentially all of the medical literature th en available, and published compendious bio-bibliographies of those who had writ ten in various medical specialties.89 He was a member of at least ten European m edical and philosophical societies and president of two of them. He critically e valuated the work of others in the light of his own mechanistic orthodoxy. His h uge Elementa Physiologiae draws out this orthodoxy from a wide range of diverse material and remains an excellent guide to the issues and personalities of Enlig htenment medical controversies.90 Haller also experimented assiduously. We can r ecall that the medical experiment had had an important place in European medicin e since the anatomists of the Renaissance had revived those of Galen. They were a natomical experiments in the wide sense of including function, and 88 89 90 For example, the reputation of Robert Whytt was founded on his publication on li me-water as a cure for the stone in the Medical Essays of 1743. For further biog raphical and bibliographical details of the animists, see Roger French, Robert W hytt, the Soul, and Medicine, London (Wellcome), 1969. See, for example, his Bib liotheca Anatomica. I have used the edition of Zurich (n.p.), 17747. Medical bota ny was dealt with in his Bibliotheca Botanica (see the edition of Z rich (n.p.), 17712). The whole u bibliographical exercise was intended to be a Bibliotheca Med ica. Albrecht von Haller, Elementa Physiologiae Corporis Humani, Lausanne (M. M. Bousquet and Associates), 1757: the rst volume begins with the circulation of th e blood, bres and vessels, the prime interests of early eighteenth-century physio logy.

256 The crisis anatomy and experiments survived the crisis in philosophy and provided a means o f arguing in disputes such as the circulation of the blood and the nature of res piration.91 In the eighteenth century experimenters such as Stephen Hales worked on remaining problems of blood ow within a background of Newtonian mechanism. Par t of Hallers concern was with the topic of sensibility and irritability, the abilit y of the animal machine to react to external stimuli.92 The animists argued that both aspects of this ability perception and motion could result only from the s oul, for no machine could perceive or initiate its own motion. In Edinburgh Robe rt Whytt, for example, showed that a frog with its head removed would still remo ve its foot from an unpleasant stimulus such as a prick of a needle. Clearly, th is was not a rational action, for even assuming that the frog had a rational sou l, it would have been in the brain. Yet it was in some sense a purposeful action that had the effect of protecting a part of the animal. Whytt assumed that purp ose, sentience and motion were not at all mechanical and owed their existence to the soul, which was coextensive with the body and bound by laws of union with the parts, so that it could initiate motion only in the muscles and perceive only i n the nerves. This perception was necessarily unconscious, a concept unintelligi ble to Haller and other mechanists for whom Cartesian dualism was part of their mental furniture. Whytt showed further that the movement of the frogs leg at the prick of a needle was lost when the spinal cord was destroyed: to him, this show ed that the soul in the cord had the power of organising local muscular motions in response to a stimulus in a purposeful way. Haller disagreed with all explana tions that involved the soul as more, or less, than a rational and immortal enti ty. He equated Whytt with the more famous Stahl, who attributed all motion to th e freely acting and sometimes capricious soul. Haller defended his position with a series of experiments in which he tested the various parts of the body for th eir capacity to show reaction to stimuli. He had engaged in a controversy with W hytt, who argued that the ability of a muscle to contract could never be attribu ted to any arrangement of mere matter, and to hold that it could was an 91 92 The problems of respiration and the work of Boyle, Richard Lower, John Mayow and others is a very traditional part of scienti c revolution history and it is not the purpose of this book to repeat the familar. An excellent introduction to these post-Harveians is Robert Frank, Harvey and the Oxford Physiologists. A Study of Scienti c Ideas, Berkeley (University of California Press), 1980; see also Franks Th e image of Harvey in Commonwealth and Restoration England, in Jerome J. Bylebyl, ed., William Harvey and his Age. The Professional and Social Context of the Disc overy of the Circulation, Baltimore (The Johns Hopkins University Press), 1979, pp. 10343. Albrecht von Haller, A Dissertation on the Sensible and Irritable Part s of Animals, London (J. Nourse), 1755, reprinted with an introduction by Owsei Temkin, Baltimore (The Johns Hopkins University Press), 1936.

Enlightenment, systems and science 257 impious materialism and mechanism. Haller replied that the innate force of the con tracting muscle was a direct gift of God, just as Otto had said in discussing th e law of nature. This is no place to follow the later history of the animist/mec hanist dispute except to say that the extreme animist position did not survive t he period in which religion came to play a lesser role in philosophy and medicin e. It was also generally recognised that there were, after all, limits to what m achinery could achieve and that there was something special about the matter of the living body. The result was a vitalism that argued, for example, that only l iving bodies could produce organic compounds. medical science? It has been argue d in this book that the doctors clinical success in the past has largely been inv isible and that his success has to be measured on another scale. Success was dis tinguished patients, fame as a teacher and a fat income. Contemporaries often ju dged their peers in a similar way, as Melchior Adam had measured distinguished G erman doctors by their cultural erudition and the company they kept. Experimente rs could be successful in the generation of medical knowledge, as the anatomists showed, but although practical, their success was not clinical. But towards the end of this story clinical success edges forward. The bills of mortality gave s ome sort of quantitative knowledge of how populations fared. When Hans Sloane an d Charles Maitland inoculated six condemned prisoners in 1721 they were performi ng a very direct experiment.93 It was intended to lead towards a very practical clinical success, the eradication of smallpox. When James Jurin compiled statist ics of the success of inoculation he was essentially measuring the clinical succ ess of a new technique,94 the kind of success that we have so often noted genera lly left little evidence. He worked from individual case-histories and so establ ished a link between the most ancient of medical experience and description (the Hippocratic) and a statistical procedure made possible by the new opportunities for rapid communication between medical men. When James Lind undertook clinical trials of remedies for ship-borne scurvy, he was perhaps making 93 94 See Adrian Wilson, The politics of medical improvement in early Hanoverian London, in Cunningham and French, eds., Medical Enlightenment, pp. 439, at p. 27. See An drea A. Rusnock, The weight of evidence and the burden of authority: case histori es, medical statistics and smallpox inoculation, in Porter, ed., Medicine in the Enlightenment, pp. 289315. On quanti cation and statistics see also Roy Porter, The eighteenth century, in Lawrence I. Conrad, Michael Neve, Vivian Nutton, Roy Porte r and Andrew Wear, The Western Medical Tradition, 800 b c to a d 1800, Cambridge (Cambridge University Press), 1995, pp. 371475, at p. 376.

258 The crisis experiments in a modern sense.95 Again, the aim was a very practical one, of pre venting the loss to scurvy of more men in ships of the line than were lost in ba ttle, at a time when the British sea-borne empire was growing rapidly. The aims were to banish named diseases smallpox and scurvy and the experiments were not l ed by theory but suggested by observation. Like a ship at sea, the hospital prov ided something of an experimental situation. Whereas for the Arabs hospitals exi sted for medical purposes (Haly Abbas recommended doctors go there for experienc e), we have seen that in the Western tradition of medicine hospitals were places for the exercise of charity. Certainly monastic in rmaries did their best to trea t ill people and even began to call in professional doctors. But, for much of th e Renaissance, hospitals were refuges for the disadvantaged. Charity supported t he incurables in the sixteenth century.96 But now also hospitals were being used f or teaching, for example by Zerbi and da Monte.97 By the time of Baglivi and Boe rhaave hospitals were very much places of teaching and treating, although the vo luntary hospitals in Britain were still institutions of charity and improvement in the eighteenth-century manner, with medical or surgical attendants.98 Some of them (the example of Aberdeen is given above) preferred acute cases for a rapid turnover of patient numbers and ef cient use of nancial resources. The patients we re generally the poor, without other resources. While the doctor often deferred to his genteel patients outside the hospital, inside he not only gained status b y his charitable practice but exerted a degree of authority over his patients th at allowed experimentation.99 Dealing with large numbers in clinical trials, hos pitals or ships is very different from the old doctors preferred form of retained practice, another theme of this book. But the medical man who admitted a patien t to an acute hospital was responsible to the board of governors for the expendi ture of designated monies and sometimes had to write down his diagnosis. In prac tice, he avoided naming the disease with which the medical literature was full a nd described instead the symptoms. Often enough he was unable to tell the differ ence between chronic and 95 96 97 98 99 James Lind, Treatise on Scurvy, ed. C. P. Stewart and Douglas Guthrie, Edinburgh (The University Press), 1953. But there is a sense in which Linds experiments ar e, like Galens, a rhetorical refutation of the opinions of others and a defence o f his own; the context was prevention rather than cure. See Jon Arrizabalaga, Jo hn Henderson and Roger French, The Great Pox. The French Disease in Renaissance Europe, New Haven (Yale Univerity Press), 1997. See David E. J. Linden, Gabriel Z erbis De Cautelis Medicorum and the tradition of medical prudence, Bulletin of the History of Medicine, 73 (1999) 1937. Mary E. Fissell, Patients, Power, and the P oor in Eighteenth-Century Bristol, Cambridge (Cambridge University Press), 1991, pp. 734. Historians of later medicine point to French hospital medicine as a maj or step in the development of medicine. This cannot be part of our story here.

Enlightenment, systems and science 259 acute symptoms.100 His diagnostic prowess would be judged by the ensuing clinica l history of the patient. Was Haller practising science? Is he an appropriate gur e with whom to end a book devoted to prescienti c medicine? It would take another book (and another author) to make the case for the rst appearance of medical scie nce, but there are certain external features of what he was doing that may be si gni cant. He proceeded by experiments, which were intended to be repeatable and th erefore to have potentially many witnesses (we have noted the jury principle in th e case of anatomical experiments). He had a thorough knowledge of the medical li terature, treated it critically, prepared bibliographical guides to it and treat ed it historically. He read and published in journals that operated a system of peer-group review. He belonged to societies devoted to the improvement of medici ne and natural philosophy. He expected that new medical understanding would be o f practical, clinical use, that is, additional control of nature. He wrote in a plain style, without the elegance, wit or personal remarks that the professional bodies objected to, the style, in fact that was part of Bacons and Baglivis proto col for the assembling of historiae. It was indeed historical language, the descri ptive style of the Hippocratic case-histories (and of the aphorisms). It is argu able even that there is a predecessor in Aristotles remarks on the language prope r for putting together historiae of animals and nature, for he rejects other sty les of reporting and prefers that of the Greek historians, who reported without embellishment from as close as they could get to the primary sources. Possibly sc ienti c writing has some such pedigree. 100 See Roger French, Surgery and scrophula, in C. Lawrence, ed., Medical Theory, Surg ical Practice: Studies in the History of Surgery, London (Routledge), 1992.

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268 Select bibliography Singer, Charles, trans., Galen on Anatomical Procedures, London (Oxford Universi ty Press), 1956. Siraisi, Nancy, Taddeo Alderotti and his Pupils. Two Generation s of Italian Medical Learning, Princeton (Princeton University Press), 1981. Avi cenna in Renaissance Italy. The Canon and Medical Teaching in Italian Universiti es after 1500, Princeton (Princeton University Press), 1987. Medieval and Early Renaissance Medicine. An Introduction to Knowledge and Practice, Chicago (Univer sity of Chicago Press), 1990. The Clock and the Mirror. Girolamo Cardano and Ren aissance Medicine, Princeton (Princeton University Press), 1997. Medicine and th e Italian Universities, 12501600, Leiden (Brill), 2001. Skinner, Patricia, Health and Medicine in Early Medieval Southern Italy, Leiden (Brill), 1997. Skinner, Q uentin, and Eckhard Kessler, eds., The Cambridge History of Renaissance Philosop hy, Cambridge (Cambridge University Press), 1988. Smalley, B., The Study of the Bible in the Middle Ages, 3rd edn, Oxford (Clarendon Press), 1984. Smith, Wesley , D., The Hippocratic Tradition, Ithaca and London (Cornell University Press), 1 979. Southern, R. W., Scholastic Humanism and the Uni cation of Europe, Vol. 1: Fo undations, Oxford (Blackwell), 1995. Spade, Paul Vincent, Lies, Language and Log ic in the Late Middle Ages, London (Variorum Reprints), 1988. Spencer, W. G., ed ., Celsus De Medicina, London (Heinemann) and Cambridge, Mass. (Harvard Universi ty Press), 1971. Spitz, Lewis W., The Religious Renaissance of the German Humani sts, Cambridge, Mass. (Harvard University Press), 1963. Strauss, Gerald, ed., Pr e-Reformation Germany, New York (Macmillan), 1972. Swan, John, The Entire Works of Dr Thomas Sydenham, newly made English from the Originals, London (Edward Cav e), 1742. Tabor, John, Exercitationes Medicae, quae tam Morborum quam Symptomatu m in plerisque Morbis Rationem Illustrant, London (Guilhelmus Johannes Innys), 1 724. Taddeo Alderotti, Thaddei Florentini Expositiones in arduum aphorismorum Ip ocratis volumen. In divinum pronosticorum Ipocratis librum. In preclarum regimin is acutorum Ipocratis opus. In subtilissimum Ioannitii Isagogarum libellum, Veni ce (A. Giunta), 1527. Temkin, Owsei, Galenism. Rise and Fall of a Medical Philos ophy, Ithaca and London (Cornell University Press), 1973. Hippocrates in a World of Pagans and Christians, Baltimore and London (The Johns Hopkins University Pr ess), 1991. Ullmann, Manfred, Islamic Medicine, Edinburgh (Edinburgh University Press), 1978. Van Engen, John, ed., Learning Institutionalized.Teaching in the M edieval University, Notre Dame, Ind. (University of Notre Dame Press), 2000.

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Index a priori arguments, 254 Aaron, 85 Abano, Pietro d, 62, 90, 95, 97, 1057, 252 and a strology, 133 complaint of, 119 Conciliator, 105 and the New Galen, 108 nickname , 105 rationalism, 10910 abdominal wall, 136 Aberdeen In rmary, 232, 258 Aberdeen U niversity, 198 Abingdon market, 199 abortion, 16, 125 abstracts, 55 Academia Nat urae Curiosorum, 254 Accademia del Cimento, 218 accessus ad auctores, 62 accessu s ad corpus, 63 acids, 206, 213, 215, 220 Acta Wratislaviensa, 254 actions, 70, 175, 214, 223, 256 acupuncture, 220 Adam, Melchior, 202, 257 Adam of Buck eld, 7980 , 104 administration, 203 advertising, 66, 122; see also self-promotion advice, medical, 121, 1323, 246 Aegina, 14 Aesculapius see Asclepius afterlife, 208 Agnell us of Ravenna, 612, 104 agreement, 69 agriculture, 11 air, 159 Albi, 78 Alcmaeon, 30 alembic, 206 Alexander of Damascus, 40 Alexander the Great, 28 Alexandria, 2 78, 31, 34, 59, 61, 153 library, 10, 32 vivisection, 30, 55 Alexandrians, 19, 33, 59, 62 Alfanus, archbi shop of Salerno, 65 Alfons III, 91 Alfred of Shareshill, 68, 76, 79, 103, 144 al legory, 111, 164 Altdorf, university of, 223 altruism, 14 ambiguity, 13 Americas , 190; see also New World amulets, 164 anatomists, 3, 63, 113, 136, 142 anatomy, 64, 125, 149, 170, 176, 197, 205, 223, 2278, 236 experiments, 63, 242, 255 Galen , 34, 39, 41, 48, 114, 142 Herophilus, 31 Hippocrates, 26, 38 histories of, 253 Newtonian, 214 origins of, 11314 and philosophy, 113 rational, 27, 33, 39, 41, 63 , 114 Reformation, 148 solidism, 215 survival of, 190, 222 Vesalius, 1423 ancient knowledge, 2, 241 see also ancient medicine; Greek philosophy ancient medicine, 23, 15, 18, 162, 167, 227, 241 perception of, 9, 2078 reconstruction of, 107, 112 see also Greek philosophy angels, 78 animal experiments, 3, 61, 176, 221, 223 a nimals, 21, 23, 25, 2930, 47, 67, 142, 166, 1756, 217, 237, 243, 245, 254 Aristotl e and, 207, 30 motion, 31 pregnancy, 124 270

Index stimuli, 256 see also animal experiments; cats; dogs; elephants; pigs animism, a nimists, 23840, 245, 249, 2567 antidotes, 100 antimony, 206 apes, 39, 40 aphorisms , 11, 13, 17, 34, 4950, 10910, 187, 207, 210, 255 Arnau of Vilanova, 111 arrangeme nt, 229 Aphorisms (Hippocrates), 10, 12, 18, 20, 489, 51, 59, 734, 85, 109, 115, 1 90, 240 commentaries on, 49, 62 rst aphorism, 10, 4950, 74, 195, 222, 242 fourteen th, 50 Latin translations, 64 apothecaries, 93, 160, 188, 1967, 200, 245 Apotheca ries Company, 1956 Aquinas, Thomas, 79, 97, 131, 147, 180 Arabic language and medi cine, 12, 22, 60, 65, 67, 72, 76, 82, 84, 87, 100, 1078, 167 astrology, 75, 132 c auses, 108 contagion, 158 and the New Galen, 102 sources, 83, 85, 135 theorists, 112 Arabs, 60, 635, 85, 135, 212, 228, 258 Aragon, Crown of, 912 Archimedes, 215 argument, 18, 49, 53, 71 arguments, 2, 4, 13, 19, 24, 48, 103, 106; see also des ign, argument from aristocracy, 246 Aristotelianism, 3940, 434, 50, 86, 97, 106, 1 313, 157, 159, 165, 180, 219, 223, 238 Averroistic, 137 English, 214 Harvey and, 176 Jesuits, 169 Lutherans, 169 and mathematics, 163 Aristotle, 3, 1821, 278, 301, 33, 37, 40, 51, 54, 60, 79, 99, 106, 11314, 1245, 133, 147, 164, 1667, 170, 173, 17 56, 1834, 186, 195, 199, 201, 216, 219, 223, 247 and Alexander, 29 and anatomy, 26 and animals, 207, 2930, 250 Categories, 70 Church and, 78 criticism of, 170 De An ima, 81 271 De Sensu et Sensato, 801 Decorum,, 22, 26 doctrine of elements, 22 History of Ani mals, 24, 71 Interpretation, 70 libri naturales see physical works logic, 25, 697 0 and medicine, 24, 27 Metaphysics, 99, 194 Meteorology, 148 Metheora, 68 and na ture, 23, 74 On the Difference Between the Soul and the Spirit, 80 Parts of Anim als, 25 physical works, 26, 68, 71, 7480, 97, 99, 1034, 125 Physics, 23, 66 Poster ior Analytics, 26, 71, 102 predecessors, 212 Prior Analytics, 71 procedure, 23, 3 0 Prognosis, 22 Sophistical Refutations, 71 text, 23 Topica, 71, 96 translations of, 76 see also Aristotelianism; logic arithmetic, 78, 214 Arnau of Vilanova, 9 3, 101, 11011, 115, 1201, 138, 142, 227 arrangement, 31, 209, 229 Ars Commentata, 74, 97, 100 Ars Medicine, 734, 100 Ars Parva, 168 art, length of, 50 arteries, 43 , 46, 216, 220, 244 Articella, 72, 74, 82, 89, 100, 133, 147 commentaries on, 10 45 arts, 545, 66, 86, 106, 170, 187, 195, 242 course, 77, 79, 84, 90, 93, 95, 98, 103, 106, 117, 1478, 170, 183 productive, 24, 68, 106, 193, 195 see also liberal arts Asclepiades, 37 Asclepius, 1067 temples, 35 astrology, 67, 75, 1304, 138, 159 , 203 decline of, 134 mathematical, 138 translations, 76 astronomy, 78, 86, 222, 236 Astruc, 230 atheists, 170, 234, 251 Athens, 14

272 atomism, atomists, 21, 28, 37, 136, 174, 213, 218 see also atoms atoms, 164, 166 , 170, 219, 229 attraction, 1745, 182, 213, 215 Aubrey, John, 197 authority, 1, 6 , 10, 72, 75, 77, 84, 87, 102, 107, 112, 114, 193, 231, 247, 258 axioms, 110 and ethics, 146 Hellenists, 140 Newtonianism, 213 weakening of, 131, 151 authors, 6 24, 73 autopsies, 123 Averroes, 137 Colliget, 100, 107, 137 Avicenna, 114, 1223, 1 27, 136, 179, 200 Canon, 75, 823, 100, 104, 107, 110, 123, 128, 152, 167, 179 axi oms, 4, 81, 86, 98, 109, 189, 195, 21011 Bacon, Francis (15611626), 1723, 178, 183, 1912, 209, 21112, 22930, 250, 255, 259 Advancement of Learning, 173 De Dignitate e t Augmentis Scientiarum, 173 Novum Organon, 173 Bacon, Roger, 79, 82, 103, 107, 215 Baconian histories, 207, 209, 211 Baconian method, 208, 225 bacteriology, 3 Ba glivi, Giorgio, 20612, 21921, 225, 230, 244, 250, 253, 259 ballistics, 244 bandagi ng, 9 barometer, 209 Bartholin, Thomas, 179, 219 Bartolomeo da Varignana, 122 Ba uhin, Caspar, 148 Bayle, 251 belief, uniformity of, 251 Bellarmine, Robert, 150, 1801 Bellini, Lorenzo, 195, 21718 Berengario da Carpi, 125, 1356, 139, 145, 222 Be rlin Acta Medica, 254 Bernard of Gordon, 110, 115, 121 Bible, 66, 75, 110, 149 b ibliographies, 253, 255, 259 Biggs, Noah, 206 bills of mortality, 257 bio-biblio graphies, 255 biographies, 2023 bishops chancellor, 69, 116 Black Death (plague), 88, 93, 127, 12931, 133, 150, 152, 158, 162, 191, 196 Index blood, 46, 177, 1812, 220, 227, 237, 244 projectile motion, 216, 244 see also circu lation of the blood blood-letting, 35, 457, 120, 175, 208, 227 blood vessels, 31, 36, 42, 45, 114 body, human, 4, 20, 2930, 623, 66, 71, 175, 179, 181, 216, 227, 2 378, 256 Aristotle, 26, 28 Galen, 39, 51, 114 Hippocrates, 242 knowledge of, 378, 41 logic and, 96 machines and, 216 motion, 244, 248 Plato, 20 rationality of, 71 Reformation and, 1489 and soul, 28, 168, 249 see also solids of the body Boerhaa ve, Herman (16691738), 4, 224, 230, 232, 251, 253, 255 and Hippocrates, 2289 Insti tutes of, 228 Boethus, Flavius, 40, 423, 47, 49 Bologna, 767, 88, 95, 11819, 1278, 1 39, 145, 153, 167, 21718 disputations, 102, 104 dissection, 113 medical colleges, 200 medical degrees, 93 studium, 94 books, 32, 37, 65, 75, 112, 117, 148, 199, 211, 24953 foreign, 223 see also printed books booksellers, 253 Borelli, Giovanni Alfonso (160879), 196, 21718, 239 botany, medical, 2234, 2289 Boyle, Robert, 189, 1 92, 1956, 204, 208, 215, 219, 229, 233, 247, 254 brain, 301, 33, 39, 42, 48, 136, 179, 220, 239 breath, 30 Browne, Sir Thomas, 193 Burley, Walter, 95 Byzantines, 64, 1345 theorists, 112 Cabriada, Juan de, 224 Calcidius, 20 Calvin, John, 181 Ca lvinists, 169, 224 Cambridge University, 89, 934, 169, 176, 182, 246, 249 medical degree, 198

Index candidates, 11517, 168 Canon see Avicenna canon law, 110, 186 canonisation, 122 ca nons, 11011; see also aphorisms Cardano, Girolamo (150176), 131, 160, 166, 194, 2151 6 careers, 69, 71, 99, 203 Carolingian age, 65 Cartesian dualism, 256 case-histo ries, 19, 112, 191, 255, 257, 259 Catalonia, 91 Cathars, 78 cathedral schools, 6 9, 77 Catholic countries, 4, 185, 250 Catholics, 78, 150, 171, 17980, 223, 240, 2 47, 251; see also Catholic countries; church; Jesuits cats, 220 causality, medic al, 175 causes, 245, 78, 108, 160, 162, 189, 197, 20910, 214, 231, 248 and observa tions, 207 see also nal causes; natural causes; secondary causes causes of death, recording, 152 cedula, 117 celestial forces, 159, 1634 Celsus, 5, 29, 31, 38, 545 , 59, 63, 140 central nervous system, 30 certainty, 71, 75 change, 18, 23, 85, 1 31, 136, 151, 192 fear of, 167 intellectual, 172 natural philosophy, 168, 192 ch arity, 147, 258 Charles II, 199 Charles V of France, 120 Charleton, Walter, 219 Chartres, 74 chemistry, 190, 1989, 2056, 215, 2289, 236, 240, 242 chemists, 171, 19 7, 2056, 212, 2267, 245 Cheyne, George, 201, 213, 239, 244, 249, 252 childbirth, 1 23 children, 16, 1234, 125 Christ, 68, 170, 208 Christianity, 20, 54, 667, 99, 107 , 111, 137, 208, 233 and Aristotle, 80, 97 and change, 1312 eastern, 60 and new m edicine, 224 Christians, 29, 54, 60, 64, 66, 171, 211, 225, 229 273 chronology, 2 church, 20, 679, 789, 90, 131, 147, 168, 171, 205, 233 doctrine, 170 , 251 learned tradition, 180, 250 licences, 90, 94, 116 and medical graduation, 118 see also Catholics; Protestants circulation of the blood, 172, 175, 189, 217 , 239, 256 controversy, 179, 181 and mechanism, 182 problem of, 216 support for, 179 cities, 122; see also towns civic humanism, 131, 139 civil administrations, 130 classi cation, 191, 229 classrooms, 31, 623, 867 Clementini, Clementi, 1467 cler gy, 84, 90, 125, 131 clientpatron relationship, 36, 44 clients, 36 clinical succe ss, 1, 121, 2312, 257 clinical trials, 3, 2578 Cnidus, 60 cognition, 180 Coimbra, 150, 169 cold, 168 colic, 209 collaboration, 69, 172, 221 Collectors, 2534 Colleg e of Physicians see London College of Physicians colleges, 116, 118, 145; see al so medical schools; schools; studia; universities Collenuccio, Pandolfo, 13940 Co lombo, Realdo, 1767, 181, 222 commentaries, 5, 623, 100, 1045, 107, 128, 135, 139, 143 Aristotelian, 68, 7980 in education, 98, 103 in examinations, 115 Galenic, 612 , 108, 175 heroic, 105, 119 Hippocratic, 20, 32, 489, 51, 74, 125 Commodus, emper or, 3, 36, 47 community of origin doctrine, 174 compass, 160, 165, 171, 174 compet ition, 10, 13, 17, 356, 45, 118, 198, 245 masters, 104 complexion, 51, 67, 97, 10 1, 109, 114, 152, 158, 162, 168, 194, 2267, 241 Conciliator, 112 concoction, 44

274 Index Democedes of Croton, 14 Democritus, 21, 106, 21819 demonstration, 34, 3941, 53, 71 , 187, 1945, 210, 213, 217, 219, 248 denial, 194 deontology, 86, 110, 194 Derham, William, 236, 24953 Descartes, Ren (15961650), 1723, 179, 182, e 201, 204, 216, 239 , 241, 244 Discourse on Method, 182, 252 and Harvey, 182 and medicine, 183 and U trecht theologians, 184 see also mechanical philosophy Desiderius of Montecassin o, 65 design, argument from, 236, 249, 251 Despars, Jacques, 128, 134 determinis m, 138, 159 diagnosis, 16, 121, 258 dialectics, 10, 25, 47, 51, 83, 956, 102, 1056 , 10910 diaphragm, 39 diastole, 176 diet, 18, 38, 100, 121 differences, 105 differe nces of opinion, 14, 119 Digest of Justinian, 75 disagreements, 69, 1456 discipli nary boundaries, 81, 99, 133 diseases, 55, 678, 80, 100, 113, 1212, 130, 167, 230, 244 acute, 53, 132, 259 chronic, 132, 258 civic notion of, 151 classi cation, 230 as entities, 207, 209, 230 histories of, 191, 209 identity of, 191 infectious, 3 names of, 152, 2312 neo-Platonists and, 162, 164 nerves, 41 new, 1623 occult, 166 ontology, 2301 as persons, 164 seeds of, 164, 166 see also epidemics dislocations, 9 disputations, 102, 105, 117, 128, 152, 1823 see also disputed questions dispute d questions, 98, 1035, 143, 181, 226 disputes, 235, 256; see also controversies; disputed questions confession, 235 Conring, Herman, 179 conservatism, 5 consilium, 117, 1212 consort ia, 70, 77 Constantine the African (d. 1087), 65, 67, 72, 75, 85 Constantinople, 59, 134 consumption, 231 contagion, 1589, 1616 continuity, 5, 128 contracts, 1, 1 20, 122 control, 70, 912 controlling centres, 30, 33, 48 controversies, 1812, 252, 2556 convulsions, 31 Corinth, 34 corporations, 69, 94, 119, 130, 168; see also i ncorporation corpus vetustius, 82 corpuscles, 174 correspondences, 164 corruptio n, 96 Cos, 60, 228 Counter-Reformation, 180, 200, 223 court culture, 122, 131, 1 33, 141, 199 Creation, 20, 54, 78, 99, 211 Creator, 42, 54, 78, 149, 176, 208, 2 47 ex-nihilo, 171 rational, 51, 110 criminals, 27, 29 cruelty, 29, 38 Cudworth, Ralph, 249 Culpeper, Nicholas, 167 cure, method of, 1912 curriculum, 602, 72, 91, 101 reformed, 148 customary law, 186 Daniel of Morley, 67, 76 De Humani Corporis Fabrica, 1423, 148 De Medicina, 54 De Plantis, 144 death, 12, 16, 20, 28, 123 de bates, 46; see also disputations dedications, 49, 144, 252 deduction, 256, 210 de n itions, 106, 137 degrees, medical, 77, 924, 116, 145 sale of, 198 Deidier, Antoin e, 206, 2267, 230 Institutes of, 226 Demiurge, 20, 23, 36, 39, 41, 42, 514, 114, 1 75

Index dissection, 21, 24, 27, 29, 32, 34, 38, 47, 102, 112, 123, 1423, 176, 180 anatomi cal rationality, 39 Bolognese, 11314 and contagion, 1589 Democritean, 218 see also vivisection distillation, 206 distinction, 102, 106, 127 diuretics, 197 divinatio n, 44, 523, 64 divine law, 247 divine origins, 19 division, 137 division of doctri ne, 86 doctorate, 11617 doctors see physicians; see also Rational and Learned Doct or; university-trained doctors document of entry, 15 dogs, 220 Dominican friars, 789, 84, 90 Drake, Roger, 179 dress, 17, 44, 117, 198 drugs, 138, 206, 254 dubia , 103, 105 dura mater, 220 Eastern Empire, 5960, 62, 134 Edinburgh Medical Essays and Observations, 254 medical school, 253, 255 Society, 2535 university, 6, 204, 213, 225 editor, 144, 252 eel, electric, 1601, 163, 166 effects, 4, 31, 70, 78, 209, 248 necessary, 235 ef cient cause, 25 egg, 228, 2445 eighteenth century, 3, 172, 2001, 222, 245, 256 see also Enlightenment eirenicism, 226, 228, 247 elementary qualities, 18, 22, 43, 48, 51, 67, 85, 97, 101, 158, 160, 166, 215 attacks on, 1 94, 241 quanti cation, 95 see also four elements; manifest qualities elements, 226 ; see also elementary qualities; four elements elephants, 24, 29 eleventh centur y, 76 elites, 87, 118, 161 eloquence, 11617 embassies, 203 275 embryo, 124, 125 empiricism, 234, 37, 61, 106, 109, 172, 187, 190, 234 empirics, empiricists, 378, 41, 50, 53, 108, 150, 153, 197, 209 energia, 2413 engineers, eng ineering, 175, 203 England, 125, 172, 1856, 188, 196, 247 astrology, 132 chemical medicine, 206 commentators, 105 scienti c revolution, 222 universities, 89, 95, 1 82, 218 English language, 204, 255 Enlightenment, 2, 3, 5, 141, 201, 222, 2245, 2 32, 238, 241, 247, 250, 255 enormon, 243 Ent, George, 179, 219 enthusiasm, relig ious, 236, 238 entities, 30, 207, 209, 230 Epicureans, 170 epidemics, 121, 1501, 158, 162, 164, 199, 2312 see also contagion; diseases Erasistratus (c. 315240 BC), 27, 33, 369, 46, 47, 61, 63, 143 followers of, 445, 60 Erastus, Thomas, 166 ethic s, 1417, 86, 113 see also medical ethics Eudemus, 424, 45 Euripides, 52 Europe, 20 4 old and new, 131 see also northern Europe; southern Europe evacuation, 51, 114, 21 8 evil, 78, 2413 examinations, 91, 93, 11516, 200 exercise, 121 expectations, 1, 1 21, 1301, 146, 175, 203 experience, 18, 37, 50, 83, 109, 111, 147, 187, 208, 221, 2345, 242 and anatomy, 190 Aristotle, 50 long, 1112, 19, 26 and medicine, 18, 222 experiments, 190, 207, 210, 214, 223, 229 see also animal experiments; medical experiments expert witness, 123 expositio, 115 expulsion, 44 extended body, 239 external medicine, 120 eyelashes, 54

276 Index France, 74, 92, 120, 128, 138, 187, 193, 223 Frederick II of Sicily, 76, 84, 91, 94 free philosophy, 218 free will, 78, 159 freedom, 20 Freedom of Philosophising principle, 234, 241 French Disease, 133, 138, 150, 152, 1589, 1612, 165, 191, 206 French language, 204 friction, 244 Froidmont, Libert, 239 Fuchs, Leonard, 167, 2 12, 252 Fuggers, 152 function, 26, 39, 114, 149, 217 future generations, 38 Gabr iele de Zerbi, 136, 139, 146, 149, 222, 258 De Cautelis Medicorum, 145 Galen, 3, 5, 13, 20, 29, 324, 59, 61, 64, 70, 73, 83, 856, 107, 113, 119, 1401, 149, 157, 16 1, 167, 1714, 208, 222, 228, 2412 anatomy, 34, 39, 41, 48, 114, 142 birth, 34 and blood, 46, 177 and body, 39, 51, 114 clientpatron relationship, 36 commentaries o f, 48, 51, 612, 74, 104 competition, 35 demonstrations, 3943, 53 experiments, 39, 46 and heart, 177 and Hippocrates, 38, 436, 489, 512, 109 natural theology, 412 path ology, 230 Platonism, 136 prognosis, 43, 45, 47, 53 public disputation, 46 ratio nalism, 41 reputation, 434 three doctrines, 137 vivisections, 40, 423, 48, 102 writi ngs, 34, 47 see also Galenic texts; Galenic theory Galenic texts, 5, 601, 191, 20 4 Critical Days, 48 De Complexionibus, 51 De Sectis, 613, 104, 108, 114 De Sperma ta, 1234 De Usum Partium, 41, 49, 54, 102, 114 De Victus Ratione, 64 Difference o f Fevers, 48 On Affected Places, 41 On Crises, 47 Fabricius of Aquapendente, 176 facies Hippocratica, 12 facts, 71 facultas, 92 fa culties of arts, 130 faculties of medicine, 84, 912, 94 conservatism, 130 consoli dation of, 99 disputed questions, 104 graduation, 116 incorporated, 88, 923, 99, 118 power of, 109 faculty, 215, 241 faith, 54, 180 Fall, the, 111 fallacies, 15 fa me, 252, 257 family, 1516, 19 fathers, 1234 father-to-son education, 1516, 86 Fazio , Bartolomeo (d. 1547), 203 feast days, 102 feasts, graduation, 11718 fees, 1417, 68, 90, 1467; see also monetary rewards fermentation, 1907, 206, 227, 240 Fernel, Jean (1506/758), 1602, 1656, 171, 212, 223 fevers, 43, 199, 213, 217, 237 bres, 197, 21617, 220, 242 moving, 219 Ficino, Marsilio (14331499), 137, 159, 163 fteenth cen tury, 122, 131, 134 nal causes, 26, 165 ne structure, 190, 227 ngers, 41 rst princip les, 44, 61, 67, 80, 86, 163, 225 Florence, 128, 138, 203 Fludd, Robert, 179 uids , 21314, 216, 242 bodily, 227 see also liquids foetus, 123, 125, 163 food, 18, 46 , 50, 101, 177 forensic medicine, 122 Forl , Jacopo da, 124, 138 form, 256 formal ia principia, 162 forms, intension and remission of, 95 four elements, 18, 223, 4 3, 48, 165, 194; see also elementary qualities fourteenth century, 81, 84, 889, 9 9, 1035, 113, 119 Fracastoro, Girolamo, 1656 Syphilis, 165

Index On the Opinions of Plato and Hippocrates, 49 Tegni, 74, 82, 967, 109, 115, 137, 1 68 Twenty Books, 61 Galenic theory, 87, 176, 178, 188, 201, 2267, 230 collapse of, 5, 2413 in Italy, 200 London College and, 1956 persistence of, 168 see also New Gal en Galenists, 197, 224 Galilei, Galileo, 21516 ganglia, 42 Garbo, Dino del, 90, 94 , 101, 104, 107, 112, 115, 119, 1245, 203 commentaries, 125, 128 disputations, 10 2 Garbo, Tommaso del, 90, 96, 1234, 127, 203 Gassendi, Pierre, 1867, 204, 219 gene ral statements, 96 generation, 96 Geneva, 194 Gentile da Foligno, 88, 90, 95, 10 1, 112, 115, 119, 125, 145, 227, 252 aphorisms, 11011 and authority, 140 commenta ries, 107, 128, 139 disputations, 102 nickname, 104 speculative nature, 127 and vision, 112, 127 gentlemen see gentry gentry, 198, 2002 geometry, 47, 78, 86, 110 , 124, 132, 187, 194, 205, 21417, 21920, 243 Gerard of Cremona (c. 111487), 75, 82, 100 German doctors, 202, 257 Germany, 93, 128, 139, 152, 254 courts, 203 univer sities, 148, 223 gifts, 90, 116 girls, 123 glands, 217, 227 Glasgow University, 148, 249 Glaucon, 53 glory, 12; see also fame; success gloss, 80, 1034; see also commentaries God, 668, 106, 107, 11011, 117, 125, 160, 166, 170, 1801, 205, 208, 21 1, 234, 2367, 249, 257 and body, 149, 179, 181, 201 Descartes and, 1734, 183, 249 good and evil, 78 law of, 186, 247 knowledge of, 251 277 and natural law, 161, 171, 247 neo-Platonists and, 163 Platonists and, 137 punis hment of, 121, 130, 140, 159 rationality of, 72, 186, 233, 236 see also Creator; Demiurge gods, 1516, 18, 20, 22, 51 Goldsmith, Oliver, 5 good, 78, 111, 243 Good Story, 2, 4, 12, 34, 44, 69, 87, 112, 121, 132, 203, 221, 233 Gorter, Johannes de, 22930, 238 graduation, 94, 97, 117 ceremony, 11618 symbols, 2012 grammar, 77 gr ammar schools, 117 gravity, 215, 229 Great Schism, 131 Greece, 228 Greek city-st ates, 14, 20, 23 Greek culture, 35 Greek doctors, 14, 18, 27, 356, 55 Greek histo rians, 259 Greek language, 5, 13, 35, 60, 63, 84, 87, 107, 134, 139, 200, 204 He llenists and, 131, 135, 141 texts, 65 Greek medical writings, 10, 27, 59, 76, 10 2 Greek medicine, 9, 17, 19, 55, 84, 135, 143, 212, 228 Roman view of, 356, 55 Gr eek philosophers, 19, 22, 28, 51, 205 pre-Socratic, 22 Greek philosophy, 35, 54, 249 Gregory, David, 215 Grotius, Hugo, 246 groups, 23, 1415, 31, 11718, 255 opposi tion to, 32 reputation, 16 Roman, 36 Guglielmo da Saliceto, 112 guiac, 140, 153 Guido da Vigevano, 121 guilds, 69, 72, 77, 122, 200 licensing, 91, 119 masters, 6 9 Hales, Stephen, 256 Hall, Matthew, 236 Halle, university of, 2334, 2367, 2468 Hal ler, Albrecht von, 205, 224, 248, 253, 2556, 259 Elementa Physiologiae, 255 and s oul, 256

278 Index Breaths, 48 De Natura Fetus, 1235 Decorum, 12, 1718 empiricists and, 37 ethical, 1 4, 144, 147 Law, 16 letters, 21 Oath, 1516, 86 Precepts, 14 Prognosis, 11, 18, 44 , 48, 51, 62, 73, 190 Prorrhetics, 45 see also Aphorisms historiae, 19, 23, 25, 2830, 37, 71, 259 see also Baconian histories; histories, medical historical approach , 23 histories, medical, 3, 48, 55, 1067, 171, 202, 212, 228, 2534 historiography, 34, 19 history, 1702 Hobbes, Thomas, 251 Hoffmann, Friedrich, 195, 206, 2336, 2389, 241, 2489, 254 Holland, 187, 222, 232, 247; see also United Provinces Holy Roman Emperor, 75 Homer, 11, 52 Hooke, L. J., 2501 hopeless cases, 1617 Horstius, Danie l, 194 Hospitaller Knights, 152 hospitals, 87, 151, 158, 199, 208, 232 records, 232 Western, 258 households, great, 1, 105, 113, 120, 252 Hugh of St Victor, 74 human improvement, 236 human nature, 246, 251 Humanists, 103, 122, 129, 1356, 138 , 159, 165, 167, 171 humours, 37, 43, 51, 64, 189, 215, 227, 230, 241 Hunain ibn Ishaq (c. 808873), 63 Hutcheson, Francis, Synopsis of Metaphysics, 249 Hutten, U lrich von, 151 Huygens, Christian, 215 hydraulics, 244 hypotheses, 213 ideas, 17 24 idols, 211 illness, 51, 97, 101 imagination, 153 immortality, 67 impetum facie ns, 2423 inception, 70, 116 Halley, Edmond, 215 Haly Abbas, 856, 97, 107, 152, 258 Pantegni, 65, 67, 74, 75, 856 Haly Ridwan, 107 handbooks, 169 Harvey, William, 45, 175, 182, 1967, 199, 2034, 218, 219, 222, 227, 229, 241 and Aristotle, 176 circulation discovery, 177 De Mo tu Cordis, 177 failure of, 175 and heart beat, 239 opposition to, 1789 support fo r, 17981 hats, 11617 health, 68, 80, 82, 97, 101 heart, 301, 38, 40, 423, 68, 176, 1 77, 1812, 217, 239, 244 action of, 216, 220 contraction, 177, 182 expansion, 176 see also blood; circulation of the blood heat, 18, 43, 51, 168, 2545 heathens, 17 01 see also pagans Hebrew, 100, 143 herbs, 64, 143 heresy, heretics, 67, 78, 147, 168, 180 Hermes Trimegistius, 137, 171, 205 hermetic tradition, 205 heroes, 32, 65, 701, 91, 97, 107 heroic commentators, 128 Herophilus (c. 330260 bc), 27, 29, 313, 379, 61, 63, 143 Highmore, Nathaniel, 187, 234 Hildric, duke of Wirtemberg, 1 67 Hippocrates, 5, 910, 1213, 1718, 21, 27, 32, 34, 37, 45, 64, 83, 856, 106, 125, 1 57, 168, 176, 190, 192, 207, 20910, 212, 219, 2279, 2402 criticism of, 208 Galen an d, 38, 436, 489, 512 language of, 49 Law of, 48, 10910 medical wisdom, 10, 74 method , 191 on parts of body, 216 prognosis, 47 rationalists and, 109 see also Hippocr atic texts Hippocratic texts, 912, 29, 33, 73, 104, 191, 204, 220 Airs, Waters an d Places, 16, 191 Ancient Medicine, 18, 37

Index incorporation, 77, 82, 90, 93, 99, 118 Index, 168 indexing, 229 individuals, 15, 121, 158, 189, 235 induction, 256, 50, 96, 137, 172, 210 infanticide, 16, 125 in fants, 51 inferences, 96, 186 in ation, doctrine of, 183, 216 information, 172 Inn ocent III, pope, 131 inoculation, 257 Inquisition, 150, 224 insolubles, 96 instan ces, 103; see also objections Institutes, 167, 188, 1935, 226 intellect, 153, 2034, 208 intension, 101, 190, 215 interpretation, 13, 33, 489, 1034, 106 in examinatio ns, 115 Isagoge, 73, 82, 86 Isidore, 81 Islam, 91; see also Arabic language and medicine; Arabs Israel, Israeli, 100 Italy, 65, 74, 79, 95, 97, 134, 1856, 2023 ch anges in, 131 disagreements, 145 exarchates, 59 Galenism, 199 graduation gifts, 116 heroic masters, 115 hospitals, 152, 208 Humanism, 138 mechanism, 218 studia, 77, 79, 90, 94, 133, 200 universities, 200, 208 ius gentium, 247 ius ubique doc endi, 90, 118 Jacobus de Back, 157, 179 James of Venice, 71 Jaume I of Aragon, 9 2 Jaume II of Aragon, 120 Jerusalem, Kingdom of, 84, 91 Jesuits, 150, 169, 173, 223, 225 Jews, 54, 59, 76, 134, 138, 1701, 2245 Joannitius, 73, 82, 100 see also I sogoge John, son of Serapion, 85 John of Alexandria, 612, 104, 114 John of Salisb ury (c. 111580), 689, 74, 84, 119 journals, 2534, 259 judgement, 50 Jurin, James, 2 57 jury principle, 259 279 Keill, John, 201, 21415 kings, 84, 120, 246 Kings College, Cambridge, 203 Kings Evi l, 231; see also Royal Touch knowledge, 2, 1011, 16, 1920, 245, 66, 99, 106, 114, 1 27, 168, 181, 189 certain, 26, 71, 234 demonstrable, 109, 186, 225 empirical, 23 hermetic, 149, 171 human body, 378 new, 30 observed, 50 practical, 173 revealed, 11, 20, 26, 54, 66, 150, 180 social uses, 4 specialist, 20 systematic, 150 tech nical, 17 theoretical, 50 see also ancient knowledge; learning Koran, 76 K hn C. G., 5, 204 u Kyper, Albertus, 179, 18790, 212, 234 lacteals, 181 language, 13, 24 , 35, 49, 102, 135, 200, 204, 255, 259 languages, 33; see also Greek language; L atin language; vernacular Languedoc, 78 larynx, 3942 Latin language, 5, 10, 1213, 54, 5960, 645, 85, 107, 135, 2045 Latin medical tradition, 5, 10, 20, 34, 526, 65, 8 5, 107, 180, 203 challenges to, 131 collapse of, 181, 204 continuity of, 129 for mation, 59 and Hellenists, 140 medicine and philosophy, 62 origins, 65 pupilmaste r relationship, 86, 98 law, 36, 68, 75, 80, 113, 139, 247 schools, 77 law courts , 1223 law of nations, 186, 247 law of nature, 186, 2467, 249; see also Natural La w lawyers, 91, 94 laymen, 121, 158, 232

280 Index Louvain, 179 loyalty, 104, 118 Lucius, emperor, 47 Lucretius, 1645, 174 lungs, 38 , 125, 181 Lusitano, Zacuto, 202 Luther, Martin, 148 Lutherans, 169, 224 Lyceum, 23, 29, 60, 80 lymph, 227 lymphatic vessels, 181 Macedonia, 289 Machaon, 107 mac hines, 42, 216, 227, 237, 239, 2434, 249, 2567 see also mechanism macrocosm, 18, 1 32 Madrid, 224 magic, 138, 164 magnet, 1603, 166, 174; see also compass Maitland, Charles, 257 Mallorca, Kindom of, 92 Malpighi, Marcello, 1956, 21718 Mandeville, Bernard, 245 Mandioso, Prospero, 202 manifest qualities, 1602, 164, 166, 214 mann ers, 198 manuscripts, 52, 64, 144 Manuzio, Aldo, 136 Marcus Aurelius, emperor, 3 , 356, 47 Marinus, 39 Mark of Toledo, 76 Marseilles, 152 Martianus, 44, 48 marvel lous events, 28 masters, 64, 69, 72, 77, 834, 89, 92, 97, 115, 145 of arts, 78, 7 9 disputations, 102, 104 graduation, 115, 117 migration, 94 teaching, 99, 118 ma teria medica, 64, 197 material cause, 25 materialism, 23 mathematics, 75, 78, 101, 124, 132, 161, 163, 197, 203, 210, 213, 225, 244, 248 Matteo, Filippo, 203 matt er, 23, 25, 42, 54, 163, 170, 174, 184, 2445 Matthaeus de Gradibus, 128 MD degree , 198; see also degrees, medical Mead, Richard, 199, 252 meaning, 96, 111 mechan ical philosophy, 157, 174, 182, 185, 196, 214, 226 Le Mort, Jacob, 206 learning, 1, 4, 10, 17, 34, 634, 100, 147, 167, 187 church an d, 180 survival of, 189 Leclerc, 171 lectures, 10, 23, 46, 168, 176, 199, 201 le gal systems, 246 legista, 113, 138 legs, 41 Leibniz, 236, 248 Leiden, 170, 1867, 205, 213 lemmata, 139 length see time Leoniceno, Niccolo (14281524), 1367, 13940 le prosy, 122, 130 liar paradox, 96 liberal arts, 24, 689, 789 liberal education, 200 librarians, 10, 27, 32 libraries, 32; see also medical libraries licensing, 13, 35, 70, 83, 91, 108, 119, 200 church, 90, 94, 116 faculties, 93 guilds, 91 teac hing, 116 life, 30, 4950, 80 misfortunes of, 19 ligatures, 46 light, 168 Lind, Ja mes, 257 Lipari, Michele, Triumph of the Galenists, 218 liquids, 215, 227, 240; see also uids literature, 28, 32, 138 see also medical literature Littr, Emile, 5, 204 e liver, 20, 30, 177 blockage of , 119 living body, 257 Locke, John, 192, 199 logic, 4, 256, 44, 49, 6972, 77, 834, 86, 91, 1023, 1056, 108, 112, 115, 128, 139 ch anges in, 956, 173 and medicine, 37, 109 new, 71, 834, 91, 99 old, 70, 83 and physical body, 96 Stoic, 37 logical consequence, theory of, 96 London College of Physici ans, 119, 1767, 188, 198, 219, 239 Galenism, 1956 membership, 198 and new philosop hy, 196 pharmacopoeia, 197 statutes, 196

Index criticism of, 215, 217 see also mechanism mechanics, 215, 242 mechanism, 230, 23 3, 2357, 23940, 243, 245, 248 particulate, 216 problems of, 245 see also machines; mechanical philosophy mechanists, 197, 257 medical education, 61, 68, 74, 79, 9 1, 128 aim of, 98 control of, 91 Jewish, 126 see also father-to-son education; m edical schools; schools; studia; universities medical ethics, 2, 12, 14, 146 med ical experiments, 3, 39, 46, 172, 1803, 192, 241, 2547, 259 Baconian, 220 geometri cal, 220 method, 176 modern, 258 Medical Instauration, 208 medical libraries, 10 medical literature, 45, 21, 32, 121, 202, 227, 259 guides to, 253 medical marketp lace, 68, 118, 120, 125, 246 medical professsion, 2, 91 medical research, 3 medic al schools, 60, 62, 69, 77, 85, 88, 1401, 170 Eastern, 62 French, 74 Hippocratic, 60 incorporated, 72 see also faculties of medicine; schools; studia; universiti es medical wisdom, 10, 1213, 17, 50 medicalisation, 1523, 221 Medicina Plinii, 55 medicine, 34, 73, 80, 93, 106, 197, 215 Aristotle and, 24, 27 and arts, 95, 195 autonomy of, 187 Christian objections to, 66, 68 conjectural nature, 187 crisis of, 4, 157, 159, 187 Descartes and, 174 Hellenism, 141 learning, 193 logical, 37 m echanical, 183 method, 191 and philosophy, 3, 19, 21, 36, 62, 801, 104, 169, 194, 206, 233, 247 281 and religion, 171 scienti c, 3 and scienti c revolution, 2223 and surgery, 112 teachi ng, 63, 77 translations, 76 see also ancient medicine; Latin medical tradition; new medicine; pre-scienti c medicine medicines, 70, 1001, 113, 143, 161, 206 mediev al tradition, 193 Melanchthon, Philip, 148, 169 membranes, 220, 242 memory aids, 86 men, 86, 123 mercury, 152, 206 Merton calculators, 102 metals, 206 metaphysi cs, 1623, 168, 249 method, 209, 212 Methodists, 37, 53, 63, 87, 108 microanatomy, 21718 microcosm, 18, 20, 132 microscope, 190, 215, 224 Middle Ages, 2, 9, 18, 24 , 29, 32, 52, 545, 61, 251 Alexander literature, 28 de nition of, 141 early, 64 medic al education, 74 prognosis, 52 terminology, 85 middle classes, 182, 188, 201 Mil an, 200 Milich, Jakob, 147 miraculous cures, 122 model answers, 106 modesty, 17, 86 Mondino deLuzzi, 90, 11314, 125 monetary rewards, 12, 1314, 24, 68, 91, 111, 19 8 monopoly, 92, 108 Monte, Giambatista da, 258 Montecassino monastery, 59, 65, 7 2, 75 Montpellier, 77, 84, 88, 923, 100, 116, 128, 2267, 230 chemical medicine, 20 56 Galenism, 178 new curriculum, 101 new philosophy, 193 moon, 124, 1323 moral phi losophy, 78, 251 morality, 98, 111 see also ethics; medical ethics Mornay, Phili ppe de, 1701 De Veritate Religionis Christianae, 170 morphology, 142, 149, 190 mo thers, 1234

282 Index natural principles, 47 natural theology, 412, 54, 234, 236, 247, 24950 natural wor ld, 4, 19, 23, 71, 78, 102, 174, 186; see also nature naturales, 80 naturals, 856, 226, 243 nature, 1920, 223, 41, 43, 46, 161, 171, 175, 180, 193, 208, 210, 230, 24 78 and anatomy, 114 meaning of, 66 as a principle, 68, 74 purpose in, 25 rational ity of, 42, 53, 165, 208 nature abhors a vacuum, 165, 175 nature-of-the-thing doct rine, 23, 43 Nedham, Marchamont, 206 neologisms, 135 neo-Platonism, 136, 138, 15 9, 1615, 171, 174 neoterics, 1667, 218, 245 nerves, 301, 33, 3940, 114, 136, 242, 25 6 complexion of, 114 bres in, 216 sensory, 42, 54 nervous system, 38 neuron, 301 n eutrality, 68, 82, 96 New Empirics, 108, 113 New Galen, 1012, 107, 127, 133 new m edicine, 224 new philosophy, 4, 190, 193, 196, 21819, 225, 249 new properties, 18 9 New Rationalists, 108 new rationality, 163 New World, 160, 171, 189 news, medi cal, 254 Newton, Isaac, 201, 204, 21213, 215, 225, 227, 229, 240, 245, 248 Optick s, 213 Nicholas the aggregator, 129 Nicolo da Reggio, 123 Nikon, 43 nineteenth cen tury, 3, 5 non-extended thinking soul, 239 Normans, 83 northern Europe, 77, 7980, 84, 105, 125, 179 church and medicine, 131 graduation, 116 natural philosophy, 97, 186, 193 universities, 93, 98, 118 nosebleed, 46 nosology, 229, 238 noxious matter, 244 numbers, numerology, 19, 124, 133, 164, 205, 214 motion, 20, 234, 301, 33, 174, 182, 216, 23940, 2434, 256 animal, 31 body, 244, 248 machine, 244 muscular, 244 natural, 71 nerves, 412 Newtonian, 215 perpetual, 239, 244 projectile, 244 quantity, 244 mountebanks, 197 moxibustion, 220 muscles, 31 , 40, 42, 114, 21617, 256 contraction, 256 intercostal, 39, 41 motion, 244 museum s, 250 music, 78, 86 Muslims, 76, 170; see also Arabs Naples, 94 natura, 53; see also nature natural causes, 43 natural history, 149, 191, 209, 250 Natural Law, 171, 186, 2468, 251 natural philosophers, 3, 105 see also philosopher-guardians natural philosophy, 4, 10, 18, 34, 37, 43, 47, 62, 66, 73, 789, 84, 86, 90, 113, 128, 130, 147, 165, 172, 176, 194, 210, 217, 234, 236 Aristotelian, 3, 24, 27, 6 2, 87, 91, 134, 150, 165, 169 changes in, 957, 168, 192 crisis, 45, 21, 114, 157, 163, 186, 204, 214, 217, 225 Descartes and, 173 disputed questions, 103 doctors and, 223 fundamentals, 85 and medicine, 3, 19, 21, 36, 62, 801, 104, 169, 194, 20 6, 233, 247 new, 161, 170, 201, 206, 212 and Newton, 214 northern, 97, 186, 193 rationality, 225 and religion, 169 schools, 60, 79 sinfulness of, 66 social func tion, 173 universities, 78, 989 see also new philosophy

Index numerus clausus, 118, 198, 200 Numesianus, 34 oaths, 15, 92, 168 objections, 103 , 115 removal of, 106 observation, 25, 32, 37, 50, 61, 109, 114, 125, 137, 172, 183, 1867, 211, 223, 227, 230, 242, 258 anatomy, 190 arrangement, 209 personal, 2 078 repeated, 189, 207, 209 occult, 138, 1601, 163, 166, 214 Ockham, William, 96, 127 omnipotence, 54, 66 ontology, 2301, 249 operations, 153 opinions, 71 opposite s, 48, 109, 160 oracles, 11, 13 oral tradition, 1011 organic compounds, 257 Organ on, 68, 173, 2089 organs, 31, 41, 63, 1746 Oribasius, 85 Otto, M. H., 2478, 257 Oxf ord University, 3, 7982, 89, 94, 97, 169, 182, 199, 21314 glosses, 1034 logic, 95 m edical degree, 198 medical faculty, 93 seal, 117 Padua, 945, 104, 128, 137, 139, 145, 150, 168, 176, 186, 200 and new medicine, 224 paganism, 29, 66, 137, 160, 2 05, 208 pain, 32 pamphlets, 181 war of, 252 Pantegni see Haly Abbas papal physic ians, 202 parables, 111 Paracelsus, 131, 14851, 171, 205, 211, 241 paradoxes, 289, 38, 166 parents, 124 Parigiano the Venetian, 179 Paris, 789, 88, 93, 95, 97, 105 , 118, 1278, 178, 188, 192 chemical medicine, 205 consortium, 69, 89 graduation, 11617 household doctors, 120 283 medical faculty, 923, 108, 130 natural history, 250 philosophers, 99 philosophica l society, 254 university, 3, 77, 80, 82, 92 particles, 1656, 1745, 178, 215, 226 particulars, 4, 50, 956, 108, 189, 207, 20910 parts, 39, 114, 190, 242, 248, 256 P ascal, Blaise, 215 pathogens, 231 pathology, 64, 216, 230 patients, 1213, 1516, 32 , 39, 44, 49, 84, 86, 119, 121, 202, 221, 2345, 2578 active role, 2456 age of, 44 a nd astrology, 134 and ethics, 113, 146 famous, 122 Patrizi da Cherso, Francesco (152997), 168 patronage, 49, 76, 188 patrons, 36, 199, 203, 223, 252; see also cl ientpatron relationship Paulus of Aegina, 85 Pavia, 200 payment, 118; see also mo netary rewards peer-group review, 2534, 259 Pelops, 39 perception, 237, 256 Perga mon, 345, 45, 47 peripatetics, 164, 215 persons, 164 persuasion, 12, 17, 45 Perug ia, 89, 94, 104, 119, 145 Peter of Cluny, 76 Petrarcha, Francesco, 95 pharmacy, 64 Philaretus, 73, 100 Philip VI of Valois, 121 philosopher-guardians, 20 philos ophy see natural philosophy phlebotomist, 48 physic gardens, 250 physica, 201 ph ysical causes, 18, 21 physical contact, 163 physical world, 22, 26, 66, 95; see also natural world; nature physicians, 1, 21, 27, 66, 80, 87, 105, 234, 245 Alex andrian, 32 attacks on, 55, 68, 111 church and, 90 clientpatron relations, 36 dis agreements, 119 ethics, 146

284 Index practice, 4, 14, 50, 72, 86, 106, 112, 120, 189, 208, 212, 229, 242 ideal, 113, 153, 191 reason and experience in, 111 and theory, 127, 153, 195, 207 traditiona l, 196 practitioners, 108, 11819, 126, 188 by royal assent, 83 Praxagoras of Cos, 31 precepts, 210 prediction, 1113, 43, 45, 512, 73, 75 astrological, 1323 see also prognosis, prognostication pregnancy, 1234 pre-scienti c medicine, 1 previsio, 52 Primrose, James, 187, 204, 218 principles, 4, 18, 23, 30, 81, 109 physical, 37 s ee also rst principles printed books, 129, 144, 147, 160, 252 privileges, 1517, 93 procedure, 110, 209 professional behaviour, 2 professional bodies, 92, 259 prof essional structure, 1 professional symbols, 202 prognosis, prognostication, 11, 16, 34, 44, 512, 645, 67, 73, 76, 100, 147 Arabic, 75 astrological, 1323 denial of, 45 Galenic, 43, 45, 47, 53 Hippocratic, 51, 73 progress, 171 proofs, 195 prospe rity, 224 Protestant countries, 4, 233 Protestants, 14850, 169, 171, 180, 186, 20 5, 224, 251 proverbs, 11 providence, 52 Prussia, 201 psyche, 30 Ptolemy, 28, 32 public disputations, 17, 46; see also disputed questions public speaking, 26 pub lishers, 5, 129, 252 Pufendorf, Samuel, 249 pulse, 51, 53, 73, 86, 1003, 177 pump , 175 pupils, 13, 44, 65, 70, 86, 97, 145; see also students purging, 208, 235 p uri cation, 206 physicians (cont.) failure of, 130 and gentility, 202 greed of, 111 medieval, 910 , 14 numbers of, 118 and philosophy, 84 pre-faculty, 82 punishment of, 84 and sc ienti c revolution, 2223 self-justi cation, 232 training, 70 types of jobs, 203 see a lso practitioners; Rational and Learned Doctor physics, 96, 225, 243 physicus, 2 1, 67 physis, 20, 41, 53, 66 Pico della Mirandola, Giovanni, 134, 138, 159 Pieti sts, 2367 piety, 171 pigs, 401, 220 Pitcairne, Archibald (16521713), 213 plague see Black Death planets, 124, 130, 1323 plants, 24, 67, 191, 217, 22930, 250 Plato, 2 0, 223, 24, 28, 30, 3940, 49, 54, 60, 114, 135, 137, 241 Republic, 20 Timaeus, 20, 39 Platonism, 53, 1367, 161, 168, 214; see also neo-Platonism Plemp, Vobiscus Fo rtunatus, 179 pleurisy, 53 Pliny, 11, 28, 35, 545, 1367, 13940 Natural History (His toria Naturalis), 147 Plusquam Commentator, 112, 252; see also Turisanus Plutarc h, 241 pneuma, 301, 46 Pneumatist sect, 37 pneumatology, 249 Podalirus, 107 poetr y, 138 poets, 165 points, 115 poisons, 1612, 166, 214 politics, 93 Polybius, 32 poo r, the, 1201, 131, 147, 149, 192, 258 pope, 75, 77, 84, 90, 246 Portugal, 77, 223 postmortem examination, 113, 123, 159, 220 powers of substances, 18990

Index purpose, 23, 256, 78, 133, 1645, 170, 1745, 238, 251, 256 Pyrrhonism, 4, 186, 208, 212 see also scepticism quadrivium, 86 quali cations, 70, 114, 11617, 198 qualities , 51, 70, 138, 214 intension and remission, 1012 see also elementary qualities qua lity, 51, 70, 163, 215 quanti cation, 95, 101 quantity, 51, 70, 244 quarantine, 158 questions, 1023, 125 see also disputed questions quodlibets, medical, 102 Ration al and Learned Doctor, 1, 4, 10, 18, 44, 65, 79, 867, 113, 120, 157, 161, 203, 22 1, 233, 252 challenge to, 151 crisis of, 4, 188 and Galen, 34 graduation, 117 ra tionality, 24, 26, 33, 701 rationalists, rationalism, 378, 41, 50, 613, 867, 108 and Hippocrates, 109, 228 see also rationality rationality, 13, 19, 24, 34, 39, 42, 49, 52, 70, 71, 110, 117, 189, 233, 2545 anatomical, 27, 33, 39, 41, 63, 114 and Demiurge, 52 and nature, 53, 208 types of, 102 see also new rationality; reason Ravenna, 612 Ray, John, 236, 249 reading, 211, 253 reason, 1, 37, 39, 50, 106, 1 10, 172, 181, 208, 211, 222, 2345, 2378, 2478, 251 and anatomy, 114 and human natur e, 246 and nature, 19 in practice, 111 see also rationalists; rationality reason s, 13 recurrent laryngeal nerves, 412 Reformation, 131, 147, 171 reformers see Pr otestants refutations, 71 regimens of health, 121 Regius, Henricus, 179, 1834 reg ulation, 91, 188 285 religion, 15, 52, 167, 169, 171, 179 religious metaphors, 111 religious texts, t ranslation of, 76 remedies, 35, 41, 55, 64, 86, 150, 1523, 210 remission, 102, 19 0, 215 see also four qualities Renaissance, 14, 17, 32, 34, 65, 84, 128, 136, 13 8, 141, 145, 161, 167, 170, 2512 hospitals, 258 reputation, 1315, 17, 434, 523, 73, 120, 199, 201 group, 16 loss of, 145 neo-Platonists and, 164 Res Latina, 140, 16 5 residence, 11617, 133 resolutio, 125 resolution, 137 respiration, 3940, 47, 256 re stauratio, 125 Restoration, 195, 199 reviews, 254 rhetoric, 10, 26, 29, 77, 98 r hubarb, 166 rights and duties of man, 247 ring, 117 Rinteln, university of, 223 Riolan, Jean (the Elder, c. 15381605), 1624, 171, 205 Riolan, Jean (the Younger), 1789, 192, 2045, 217 Riverius, Lazarus (15891655), 178, 1934, 227 Institutes, 1935, 2 26 Robert of Chester, 76 Roger of Hereford, 132, 144 Roger II of Sicily, 91 Roma n Empire, 131 Roman Law, 75, 151, 246 Romans, 35, 55 Rome, imperial, 5, 11, 28, 345, 39, 42, 45, 47, 75 clientpatron relationship, 36 doctors, 35 medical sects, 3 67, 1078 prognostication, 44 see also Latin medical tradition; Roman Law; Romans R osetti, J. T., 2403 Rosicrucians, 206 royal decrees, 912 Royal Society, 190, 196, 223, 254 Royal Touch, 17980; see also Kings Evil Rudbeck, Olaus, 179 rules, 1516, 8 6, 102, 110, 146 rumours, 279, 61

286 Index signs, 634, 67 simpliciter, 97 sin, 66, 68, 180 sixteenth century, 5, 1023, 129, 1 31, 1589, 171, 200, 252, 258 Sloane, Sir Hans, 254, 257 smallpox, 2578 Smollett, T obias, 245 Smyrna, 34 social uses, 4 societies, 2545, 259 Society, 251 Society of C hemical Physicians, 196 Socrates, 20, 22, 25, 241 rule of , 137 sodality, 161 soli ds of the body, 21516, 220, 227, 230, 240, 242 Solon, 52 soothsaying, 51, 53; see also divination sophists, 17 Soranus of Ephesus, 29 soul, 20, 31, 66, 678, 110, 17980, 183, 23740, 243, 245, 249, 256 Aristotle, 24, 30, 81 and body, 168, 189 Car tesian, 174, 184 faculties, 190 Galen, 43 neo-Platonic, 163 philosophy and, 62, 66 Plato, 23, 28, 30, 40, 137 Reformation and, 148, 169 southern Europe, 77, 84, 98 graduation, 116 medical faculties, 93 universities, 118 see also Italy spagy rical remedies, 206 Spain, 60, 75, 77, 91, 153, 185, 2234 specialists, 120 species, 166 Speculator, 112 speech organs, 39 Spener, Philipp Jakob, 236 sperm, 123 spi nal cord, 31, 39, 41, 220, 256 Spinoza, Benedict, 251 spirit, 301, 2267, 241, 243, 249 Stahl, Georg Ernst, 2378, 240, 243, 248, 256 starvation, 46 statements, 96 s tatistical methods, 3, 257 status, 36, 112, 116, 153 St Andrews University, 148 St Petersburg, Imperial Academy, 254 Salamanca Univer sity, 224 Salerno, 59, 65, 834, 91 school of, 72, 74, 88 saliva, 227 salus, 259 S antorini, Giovanni, 21718, 2434 Sauvages, F. Boissier de, 230, 2389 Sbaraglia, Giov anni, 217 Scaliger, J. C., 166 scepticism, 168, 186, 192, 207, 212, 214, 219, 22 7, 233 scholars, 32, 63, 71, 74, 76 migration of, 934 see also masters; teachers s cholastic, 84, 88, 125, 13941, 143 scholastic medicine, 92, 101, 108, 112, 126 sch ool of thought, 60 schools, 1314, 19, 38, 5961, 65, 87, 126; see also medical scho ols; studia; studium generale sciences, 3, 105, 125, 187, 2579 theoretical, 106, 195 scientia, 52, 193 scienti c revolution, 196, 216, 2223, 225, 250 scienti c writing, 259 Scot, Michael, 76 Scotland, 232 scrophula, 180, 2312 scurvy, 257 seasons, 19 2 secondary bodies, 85 secondary causes, 159, 163 secret agents, 203 secretion, 217, 238 seeds, 164, 166 self-promotion, 144, 252 semen, 124, 163 Seneca, 241 Senn ert, Daniel, 166 senses, 23, 40, 114, 168, 193; see also experience; observation sensory images, 204 Sentences, 107 sentience, 30, 256 septum, 181 Sergius Paulu s, 43 Servetus, Michael, 181 seventeenth century, 3, 169, 171, 1801, 197, 205, 20 7, 214, 218, 222, 233 Severino, Marco Aurelio, 179, 219 Severus, 43 Sicily, 834, 91 sickness, 82 Siena, 94, 152

Index statutes, 77, 93, 201 Parisian, 80, 93 Steno, Nicholaus, 217 Stephen of Antioch, 85 Stevenson, John, 254 Stilling eet, Edward, 236, 249 stimuli, 256 Stoics, 28, 3 7 stomach, 42 structure, 190, 246, 248 structures, 32, 216 stuma, 2312 students, 77, 86, 8990, 94, 114, 116, 167, 182 competition for, 104 Protestant, 150 studia, 904, 118, 128, 145 see also schools; medical schools; studium generale; universi ties studium generale, 7980, 889; see also studia style, 259; see also language su balternation, 812, 989, 109 substance, 174, 184; see also powers of substances sub tlety, 15964, 166, 213 success, 1, 14, 203, 221, 251, 2579; see also clinical succ ess suction, 175 suffocation, 227 suicide, 16 sun, 124, 132, 163 surgeons, 188, 200 surgery, 39, 41, 11213, 11920, 143, 190 suspicious deaths, 122 Sydenham, Thoma s, 1912, 209, 229 syllogisms, 256, 48, 701, 103, 109 Sylvestris, Bernard, 74 sympat hy, 1656, 174, 214 symptoms, 12, 16, 192, 232, 258 Syriac, 63 systems, 218 systole, 176 forceful, 177, 179 taboos, 27 Tabor, John, 23940 Taddeo Alderotti, 88, 90, 9 7, 115, 122, 128, 138, 203 Talbot, Dr, 246 teachers, 13, 1517, 34, 601, 65, 71, 74 , 80, 84, 86, 89, 108, 118, 128, 140, 225, 235 career, 99 classroom techniques, 623 disputations, 104 guilds, 69 287 nicknames, 104 payment of, 90 and pupils, 145 university, 77 see also heroes; ma sters; teaching teaching, 17, 19, 32, 5960, 63, 85, 258 collaborative, 104 commen taries in, 62 disputations, 103 dissection, 113 faculties, 92 languages of, 204 licence, 116 philosophy, 104 withdrawal of, 93 Tegni see Galenic texts teleology , 114, 238 Telesio, Bernardino (150988), 168, 194 De Rerum Natura, 168 tertulia, 185 Tertullian, 29 Teuthras, 467 textbooks, 72, 82, 89, 100, 182 texts, 14, 37, 5 6, 701, 81, 87, 93, 103, 115, 125, 139, 144, 153, 252 abbreviation of, 63 glosses , 104 Latin, 107 law, 76 reception of, 76 scholarly use of, 63 selections, 72 su rgical, 112 teaching, 62, 100 translations, 76 use of, 64 see also books; commen taries theatre, 149, 181, 250 theism, 251 theologians, 68, 99, 107, 164, 169, 184, 235 theology, 68, 76, 79, 93, 110, 118, 137, 235 faculties, 84, 90 Theophilus, 73, 1003 theory, 25, 35, 48, 50, 55, 61, 645, 70, 73, 76, 86, 161, 192, 211, 223 B aglivi, 219 crisis in, 159, 222 disputed questions, 103 Haly Abbas, 85 and indiv iduals, 1589 Newtonian, 213 and philosophy, 4, 18, 128, 210 and practice, 98, 108 , 112, 127, 153, 189, 195, 207, 229, 242 rationalists and, 109

288 theory (cont.) sexual matters, 1234 synthesis of, 2256 therapy, 101, 114, 121 ther mometer, 224 thesis, 183, 184 thirteenth century, 3, 71, 77, 812, 88, 913, 1001, 10 3, 119 thorax, 39, 412 throat, 39 thymos, 30 time, 10, 4950, 61, 63, 70, 967 titlepages, 252 Toledo, 75, 224 archbishop of, 76 Torricelli, Evangelista, 215 Torrig iano, Pietro, 90; see also Turisanus Toulouse, 789 towns, 1, 65, 69, 93, 118, 120 , 151, 188 university, 79 traction, 42 tradition, 180 training, 2, 70, 77, 84, 1 18 translations, 56, 5960, 635, 712, 74, 125 from Arabic, 85 funding, 76 transmissi on of texts, 76 translators, 76, 82 treatment, 216 Trinity, 170 trivium, 77 trus t, 52, 64 truth, 13, 40, 106, 172 natural, 180 tuberculosis, 231 tumours, 2312 Tu risanus, 104, 203 Plusquam Commentum, 104; see also Torrigiano, Pietro twelfth c entury, 668, 71, 74, 76, 88, 99100 Index new, 99100 northern, 93, 98 Spanish, 91 see also colleges; faculties of medicine; studia university-trained doctors, 1, 70, 108, 112, 120, 145 urine, 43, 65, 100 , 125, 132, 199 uroscopy, 67, 73, 1312 ut nunc, 967 uterus, 123, 125 utility, 195 Ut recht, 183 vacuum, 165, 175, 229 Valencia, Kingdom of, 912 valves, 177 Van Helmon t, Jean Baptiste (15791644), 2056, 211 Van Swieten, Gerard, 224, 232 veins, 45, 17 7 venesection, 457 Venice, 122, 145, 150, 178, 201 veri cation, 115 vernacular, 5, 149, 204 verse, 11, 165; see also poetry vertebrae, 32 Vesalius, Andreas, 4, 1413 , 1489, 169, 222, 252 vesication, 208 Vesling, Anton, 179 vessels, 214, 216, 227 veterinary medicine, 35 via moderna, 128 violence, 122 virtuosi, 182 virus, 159 vis insita, 248 vision, 127 vitalism, 257 vivisection, 27, 29, 31, 172, 176, 183 Alexandrian, 301, 55 Galen, 40, 423, 48 human, 27, 38, 63 rumour, 61 voice, 3940 v oluntary hospitals, 258 vomiting, 197 Vulpius, Johannes, 2001 Walaeus, Johannes, 179 Wallis, John, 215 war, 47 water, 216; see also liquids weather, 209 West, th e, 65, 76 Western Empire, 59 uncertainty, 208, 212 United Provinces, 172, 1856, 223, 250; see also Holland univ ersal age, 131 universals, 1089, 189 universities, 77, 834, 90, 101, 108, 126, 131, 138, 167, 170, 203, 223, 225, 235 Cartesian philosophy, 183 Catholic, 223 contr oversies, 181 French, 198 Italian, 200, 208 and Law of Nature, 2467 natural philo sophy, 3

Index Western scholars, 22 whole substance action, 1612, 166, 214 Whytt, Robert, 256 will , 239 William of Conches (c. 1085after 1154), 67, 74, 78, 111 William of England, 1323 Willis, Thomas (162075), 1979, 238 career, 198 patients, 199 wisdom, 20; see also medical wisdom Wiseman, Richard, 231 Wittenberg University, 147, 166 Wolff, Christian, 236, 248 women, 86, 126; see also childbirth; pregnancy words, 106, 112, 164 world, eternity of, 170 wounding, 122 wounds, 32, 86 written word, 11, 47 Zerbi see Gabriele de Zerbi zootomia, zootomy, 180, 219 289