Medicine in the early modern era was characterized by several distinctive features. First, the understanding of illness and its treatment was based on assumptions that were inherited from antiquity and differed conspicuously from our own ideas. Second, physicians comprised but one group among a host of healers who routinely competed with each other for access to patients. Thus, in contrast to medicine today, physicians neither dominated nor directed the care of most of the sick. Third, the delivery of health care was not centered in hospitals or specialized clinics. Hospitals certainly were a feature of early modern medicine, but their role in the delivery of health care was minor. Last, and perhaps most important, people in early modern Europe inhabited a social, cultural, and demographic environment in which death intruded itself far more frequently in the everyday lives of Europeans than it does for people living in the developed world today.
Patterns of Disease
Death was a common occurrence in the early modern period, a fact that colored nearly every aspect of social and cultural life. Nor was it just the elderly who expected to die; infants and children died at such high rates that someone could be counted fortunate just to reach the age of twenty-one, not to mention sixty or seventy. This depressing fact was not lost on contemporaries. "Of each 1,000 people born," wrote a German physician in 1797, "24 die during birth itself; the business of teething disposes of another 50; in the first two years, convulsions and other illnesses remove another 277; smallpox . . . carries off 80 or 90, and measles 10 more." Of every 1,000 people born, he concluded, "one can expect that only 78 will die of old age or in old age." Although we cannot verify the accuracy of these numbers, there is no disputing the appallingly high mortality rates they indicate. Available records of baptisms and burials from local churches suggest that in countries such as France and Denmark, deaths of infants (that is, children under the age of two) from all causes could climb as high as two hundred or more deaths per thousand births.
A variety of factors contributed to these high mortality rates, including the prevalence of malnutrition and intestinal parasites. Although these may have only rarely caused death directly, they undoubtedly weakened the body's defenses against disease. More directly responsible were infectious diseases like smallpox and measles, mentioned in the quotation above, along with other serious childhood diseases like diphtheria, whooping cough, and dysentery.
The most dangerous disease of all was the plague, which first struck various parts of Europe between 1347 and 1351 and returned to afflict almost every generation until the very end of the seventeenth century. The disease is believed to have begun in China and then spread along trade routes in Central Asia in the early 1340s. By 1346 it had reached the Crimean city of Caffa, and from there it was brought to Sicily and southern Italy. Once established there, plague spread, again along trade routes, to other parts of Europe. Skepticism has grown in recent years over whether the plague (caused by the bacterium Yersina pestis) was exclusively bubonic plague, induced in its victims by the bite of a flea, or whether it was mixed with a more dangerous airborne form known as pneumonic plague. It is possible too that one or more other diseases were also part of the mix. Whatever its precise cause, there can be no question that plague hit many parts of Europe hard. Over the entirety of Europe, it is estimated that the first onset of plague killed approximately 25 percent of the population, although actual mortality varied considerably from place to place. Even as late as the seventeenth century, outbreaks of plague continued to hit with devastating impact. In 1656–1657, the Italian city of Genoa lost 60 percent of its population of 75,000 to plague—a horrific, although unusually high, mortality rate—while between 1609 and 1611 about 42 percent of the residents of the Swiss city of Basel (population 15,000) caught the plague and 62 percent of those victims died.
A second serious disease, syphilis, appeared for the first time in Europe at the very end of the fifteenth century. While having nowhere near the demographic impact of plague in terms of deaths caused by it, syphilis was serious enough, especially in the virulent form in which it first appeared. The disease was first reported during the French army's campaigns in Italy during 1494–1495 (hence the common name given it, the "French Pox"), and from there it spread rapidly throughout Europe. Sufferers from syphilis, reported the German scholar Ulrich von Hutten in the early sixteenth century, "had boils that stood out like acorns, from which issued such filthy stinking matter, that whosoever came within the scent believed himself infected." The stinking stain described by von Hutten could have been more than just physical, for it was soon determined that syphilis was sexually transmitted, thus giving the disease extra significance as an apparent punishment for sinful promiscuity.
The Origins of Public Health
Historians once commonly believed that plague was a primary cause of the breakdown of medieval society and the transition to the modern era. Although this is no longer widely accepted, there is no denying that plague did have a powerful impact. Arguably the most significant of its effects was the stimulus it provided to the development of public health, and, more speculatively perhaps, to the more general idea that the purpose of government was to formulate policy, not just maintain order. The idea that the government could exercise a regulatory and policy-making function was certainly not unprecedented in the late fourteenth and early fifteenth centuries, but the horrific consequences of repeated plague outbreaks made matters of health a particular focal point of concern and regulation.
As early as 1348, the town council of Venice appointed three of its members as a special commission to devise measures against the plague that had broken out there, and, in general, highly developed Italian cities like Florence, Milan, and Genoa were among the earliest to formulate measures against the plague. Many European cities and principalities north of the Alps followed suit during the next 150 years. The measures taken by these boards included the institution of quarantine, a practice whereby plague victims were shut up in their houses, together with their families and servants, if they had any. Quarantine could also be placed on entire towns and cities, and because such bans could last for weeks or even months, a declaration of quarantine had serious consequences for trade and economic well-being. Plague ordinances further specified how those who had died of plague should be buried and what should be done with their personal possessions—clothing and bedding could be burned, for example. More controversially, they also prohibited public gatherings of different kinds, including church processions. Since such public gatherings were a major component of medieval Catholic spirituality, their prohibition by secular authorities was a recurrent source of conflict with the church.
Throughout the fifteenth century, most of the health commissions charged with dealing with plague remained temporary institutions, dissolving as soon as the threat posed by the current epidemic had subsided. But during the sixteenth century, more permanent health magistracies began appearing in northern Italian cities. The responsibilities given these boards gradually evolved to cover not only times of emergency but also the more routine supervision of public health. Justified by a desire to forestall future outbreaks of plague and building on prior medieval attempts to enforce sanitary standards in larger cities (in some cases dating much further back than the 1340s), these health boards began formulating more comprehensive sanitary measures to control such things as the cleaning of streets and dumping of wastes. Beggars and Jews, who were suspected of being transmitters of disease, were often singled out for unwelcome attention.
A somewhat different system evolved in German-speaking central Europe during the sixteenth and seventeenth centuries. There, towns and principalities began appointing a local physician or surgeon to the partially salaried post of physicus. Their primary responsibility normally involved providing medical care for the poor, but physici were also charged with enforcing sanitary regulations, instructing and supervising other practitioners, and conducting medical-forensic inquiries, among other functions. In effect, these practitioners served as the instruments for the enforcement of public health ordinances, while at the same time gathering information about local health conditions that could be transmitted back to the political authorities.
The Institutions of Care
To the extent that early modern medical care was centered in institutions of any kind and did not simply take place at the patient's bedside or in the practitioner's shop, hospitals provided that institutional setting. But this statement must be immediately qualified by noting that hospitals served almost exclusively the needs of the poor. Not until the early twentieth century, in fact, would people who were not poor begin using hospitals in any considerable numbers. Moreover, hospitals in the early modern era were not devoted exclusively to medical care, offering instead a spectrum of charitable support for the poor.
The roots of hospitals as integrated charitable/medical institutions go back many centuries, on the one hand to the social welfare needs of large urban centers of late antiquity and the early Middle Ages, such as Constantinople (modern-day Istanbul) and Baghdad, and on the other hand to the hospices established for travelers and the poor by early Christian communities. As monastic communities spread across the Christian world during the Middle Ages, many of them, especially those located on important trade routes or destinations for pilgrimages, established small infirmaries for sick members of their communities and travelers who had no other support during times of illness. Eventually, hospitals of varying sizes became an established feature of the urban landscape, funded by the charitable endowments of individual patrons or local religious organizations, such as confraternities.
By the sixteenth century, and especially in the wake of the Reformation, hospitals were confronted by significant new challenges. First, conversion to Protestantism often involved confiscation by the ruler of church properties, which deprived hospitals both of the assets that supported their operation and sometimes of the personnel who ran them. In England, Henry VIII's break with the Roman Church in the 1530s led to wholesale seizure of church properties, including those supporting the three London hospitals of St. Thomas, St. Bartholomew, and Bethlehem. This immediately threw the city's charitable services into chaos, and the city's leaders implored the crown to restore the funds necessary to operate the hospitals. This the crown did over the course of the next twenty years, yielding for London a total of five major hospitals: St. Thomas's and St. Bartholomew's for the sick poor; Christ's for orphans; Bridewell for the shiftless poor, and finally, Bethlehem (known later as "Bedlam") for the mentally ill.
The functional "specialization" displayed by different London hospitals was by no means the standard in the period, and many hospitals, such as the huge Allgemeines Krankenhaus in Vienna or the Julius-Spital in Würzburg, folded various charitable services into one institution. What they did share with the London hospitals was the specific range of charitable activities. Just as importantly, the hospitals of the sixteenth and seventeenth centuries displayed a new attitude about the poor. This attitude was reflected in a separation made between the "virtuous" poor, such as the aged, widows, and children, and the "shiftless" or "lazy" poor, a separation that still resonates in welfare today. In a period when the poor were increasingly viewed as a possible threat to social order, hospitals became places for housing the poor and removing them and their supposed threat from the streets. By 1700, this thinking had led in France to the founding of more than one hundred so-called hôpitaux-généraux (general hospitals), institutions in which the deserving and undeserving poor were rounded up together, with the former supposedly receiving benevolent shelter in their time of need and the latter corrected and improved by a combination of enforced labor and religious discipline.
All of these institutions, even those resembling prisons and workhouses, offered treatment for the sick. By the eighteenth century, the curing of patients and their return to useful roles in society became more clearly the focal point of the hospital's identity. Although they remained charitable institutions, supported largely by private philanthropy or government subventions instead of patient fees, hospitals discouraged the admission of the chronically sick or aged, pregnant women and children—in short, the traditional clientele who had populated hospitals in previous eras. Instead, they focused on curing and releasing what came to be known later as the "laboring poor," those who held regular jobs and had fallen ill.
Medical Practitioners
Today, the treatment of illness is usually given by a physician, that is, someone with a university medical education in possession of an M.D. Although other people, such as nurses or pharmacists may be involved in this process, physicians direct it. In the early modern era, that was decidedly not the case. Physicians formed but one small group among a variety of healers, any of whom could be consulted in time of sickness.
Among the other healers who competed for access to patients, surgeons were probably the most prominent. Like physicians, surgeons were a recognized occupation, often organized in larger towns into guilds that supervised professional standards and trained apprentices in the craft. In both the popular imagination and in their own professional identities, physicians and surgeons were separated by their domains of practice: physicians treated internal ailments, while surgeons handled external maladies, including wounds. Physicians were not trained to cut patients most of the time, while surgeons made liberal use of the knife, even if they also administered medications. Their use of the knife is a principal reason why surgeons often were grouped together occupationally with lower-status barbers, who not only cut hair but also performed routine medical procedures such as bloodletting.
However, because the boundary between "internal" and "external" is by no means obvious in every case, many diseases, such as cancerous tumors and syphilis, were often treated by surgeons. Therefore, rather than seeing physicians and surgeons as having clearly demarcated areas of competence, it would be more accurate to understand them as having overlapping spheres of practice, where the choice of healer more often depended on factors such as personal acquaintance, reputation, and availability, and not on a calculation of which healer was most appropriate for any particular illness. Part of the distinction between physicians and surgeons can be explained in terms of social hierarchy. Because physicians were university educated and participated in the literate, Latinate culture of the urban and courtly elites, they tended to enjoy higher social status than surgeons. But neither the status of healers nor the choice of healer by patients was determined along a gradient of social hierarchy. Kings and bishops were just as likely as a common artisan to consult a surgeon when the need arose—although not, of course, necessarily the same surgeon.
The same point could be made for other established healing occupations, midwives and apothecaries. Midwives were women who attended births and cared for the mother and newborn child during the first days after birth. In principle, they were not supposed to treat patients outside the context of birthing or to administer drugs, apart from those useful during or immediately after labor. But, in fact, midwives were consulted more widely, especially by women, whose trust in the midwife would have been cemented by her assistance during their children's births. Apothecaries were dealers in herbal medications, grocers who knew how to extract the healing virtues from natural products. Physicians expected apothecaries to dispense medications to patients only on the orders of a physician. But here too, the prescribed division of labor was easily breached by apothecaries who believed that they could just as well (or better) determine the appropriate medicines to give people suffering from particular ailments. From the patient's point of view, the decision to consult an apothecary or midwife might depend on the same considerations as those mentioned above—personal acquaintance, local reputation and accessibility—as well as cost. In most cases, it cost considerably less to bring a midwife or apothecary in than a physician.
During the later seventeenth and eighteenth centuries, governments in various parts of Europe began paying a great deal of attention to how practitioners were trained and to keeping practitioners from infringing on others' domain of work. Surgeons, whose training had always swung between guild apprenticeships and university-based anatomy theaters (although surgeons did not routinely hold M.D. degrees), increasingly saw their training based in the newer hospitals or specially instituted surgical academies. The training and qualifications of midwives and apothecaries likewise came under closer scrutiny, and in a number of places they were required to submit to licensing examinations. The establishment of a separate licensing examination for physicians after awarding the M.D. also came into much wider use, when, for example, in 1651 the electorate of Bavaria created a collegium medicum that was authorized to examine every physician who wished to practice in its territory.
The practitioners described here by no means exhaust the full range of healers present in early modern society. These other healers are represented, in part, by folk healers, who deployed a wide range of traditional therapies. The use of magical or religious invocations in treating illness, of course, was probably not a rare occurrence at this time. In addition, the early modern period was populated by a host of itinerant drug peddlers, stonecutters, and sundry charlatans who sold special talents or products in the medical marketplace. By the mid-eighteenth century, and as a result of the dramatic expansion of the press, medical products and services participated in a booming advertising market.
Ideas of Health and Illness
The dominant medical thinking of the early modern period saw health as dependent on a particular balance in the body's four humors, known conventionally as blood, phlegm, black bile, and yellow bile. Each individual humor, in turn, manifested a distinctive combination of qualities from the pairs wet/dry and cold/hot. Thus, blood was believed to be hot and wet, yellow bile, hot and dry, and so on. The balance of humors required to maintain health was highly individual, depending on someone's age, sex, local environment, diet, work, lifestyle—in principle, almost anything could influence health. Excessive exercise, for example, could cause the body to heat up, resulting in an excess of blood or yellow bile. Scholars, on the other hand, were thought to suffer from particular diseases resulting from their having too little exercise and too much brainwork. The prevention of illness and its cure depended in principle on the same idea, whereby the practitioner sought to maintain or restore the proper humoral balance. The application of many treatments, such as the use of bloodletting or emetics (agents that cause vomiting), can be understood as working in this way.
Over against these doctrines concerning pathology and therapeutics must be set a partially separate set of ideas concerning what we now call physiology, the functions of the living body. The body's functions were thought to be governed by three principal organs: the liver, which converted nutritive juices produced by digestion into blood, which was then sent via the venous system to all parts of the body and nourished it; the heart, which mixed air taken in by the lungs with some blood, producing vital spirit, which was distributed throughout the body by the arteries and governed vital processes such as motion, breathing, and digestion; and the brain, which produced animal spirits, responsible for the higher functions of sensation and consciousness, and which traveled throughout the body via the nerves. Although not entirely divorced from the humoral doctrines that molded thinking about health and illness, the theories governing physiology were formulated to answer a distinctive and separate set of questions, such as what breathing does or how the movement of muscles occurs.
The source of many of these ideas was a collection of writings attributed to the ancient Greek physician Hippocrates (c. 460 B.C.E.–375 B.C.E.), especially as interpreted by the later Greek physician Galen (129–199? C.E.). Very few of Hippocrates' and Galen's writings were available in Latin translation during the early Middle Ages, but a far richer view of Hippocratic and Galenic medicine started appearing in Latin-speaking Europe at the end of the eleventh century, when translations of Arabic medical writings were made in southern Italy and Spain. These encyclopedic compendia of ancient medicine became the basis for medical teaching in the universities that began appearing at the end of the twelfth century.
By the early sixteenth century, medicine was a widely accepted part of the university curriculum, with the teaching of theory and practice based largely on Hippocratic and Galenic precepts, as interpreted and synthesized by medieval Muslim scholars. A second wave of translations, beginning in the late fourteenth century and inspired by the humanist cultural program for the restoration of classical antiquity, produced a wave of Latin translations from ancient Greek manuscripts, bypassing the mediation and (so the humanists claimed) the barbarism of earlier Muslim translators and commentators. The output from all this effort is astonishing: between 1500 and 1600, there are said to have been approximately 590 different editions of Galen's writings. To a surprising extent, these new translations from Greek sources did little to change the curriculum or the dominant medical theories. Yet in one important area, anatomy, the recovery of Galen's writings, especially his On Anatomical Procedures (first published in 1531), a guide to dissection, did lead to dramatic changes in medical thinking.
The conduct of dissections as part of the teaching of anatomy was a well-established, if also a sporadic, part of the medical curriculum. Well before 1500, medical scholars had used dissection as a means of engaging in critical dialogue with their ancient and medieval Muslim predecessors, to the extent that these sources were available to them. The appearance of On Anatomical Procedures in Latin translation, however, gave to humanistically inclined physicians an impeccably ancient source of authority for the practice of dissection, as well as practical tips for doing so. Consequently, anatomy and the practice of dissection acquired a status far exceeding what it had enjoyed before, and knowledge of human anatomical structure became a focal point of research interest. This burst of activity culminated with the publication of De Humani Corporis Fabrica (1543; On the structure of the human body), by Andreas Vesalius, the most renowned anatomist of the era. Vesalius's richly illustrated text presented itself as an extended critique of Galen's claims about anatomy, offering its readers a far more visually concrete picture of the body than anything previously available.
The critique of Galen's anatomical ideas, however, did not translate immediately into a broader abandonment of his physiology, in part because his theories about the body's functions made a great deal of sense in the context of physicians' experiences with the bodies of their patients. Only in the greatly changed circumstances of the seventeenth century, when a new generation of scholars deployed a new "mechanical" philosophy based on experiment to overthrow the entire edifice of ancient natural philosophy and the kinds of explanations it offered, did physicians shift from engaging in their centuries-long critical dialogue with their ancient sources to thinking about the body's functions in ways that departed significantly from ancient models. The most important among these later physicians was William Harvey (1578–1657), a highly skilled anatomist and experimentalist whose carefully designed investigations into the function of the heartbeat, published in 1628 as Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus (An anatomical essay on the motion of the heart and blood in animals), directly attacked the physiological role assigned to the heart by Galen, suggesting instead that the heart acts as a pump, distributing blood to the body through the arteries and receiving it back again from the veins.
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—THOMAS H. BROMAN
