Medical Marketplace
Medical Marketplace
Home Remedies. Most people in the modern world experience medicine either in a physician’s or dentist’s office, a local clinic, or a hospital. However, in Renaissance Europe educated physicians were few, clinics as such did not exist, and hospitals served mainly as shelters for the poor and provided only limited medical care. University-trained physicians and surgeons in the late Middle Ages numbered no more than ten to fifteen per ten thousand inhabitants and were concentrated in larger towns and cities, where their expensive services were utilized chiefly by the elite. The bulk of healing was done at home, not by medical doctors making house calls but by family members, by men and women of the community who were experienced in folk ways and had empirical knowledge of herbs, or by a whole range of professional healers who made up what historians call “the medical marketplace.” These healers included apothecaries, bonesetters, oculists who removed cataracts, lithotomists who removed bladder stones, midwives, barber-surgeons, and other specialists. Medical treatment was not a sustaining profession for many healers, so they often combined it with other activities. The early apothecaries, for example, were often put into the same guilds as grocers and spice traders.
Organization. Medieval guilds, which incorporated to protect craftsmen and merchants from the uncertainties brought by an unregulated free market, served as models for providers of surgical and medical care as well. The Doctor of Medicine degree (M.D.), like other advanced university degrees, was an educational credential, conferring upon the holder the right to teach. In order to elevate medical practice to a high professional standard, M.D.s in urban areas formed colleges of medicine, which functioned like craft guilds. Surgeons and barber-surgeons, whose services were generally limited to bloodletting and simple surgical procedures, also organized into colleges or companies. They sought to control licensing and limit the number of practitioners, thereby defining both the quality and the cost of medical care.
Measures of Control. In the largest cities, such as London and Paris, the various colleges of surgeons, physicians, barber-surgeons, and apothecaries constantly strove to defend their privileges while seeking to encroach on competing professionals. In seventeenth-century London, for example, the College of Physicians frequently engaged in lawsuits against unlicensed physicians, as well as barbers and apothecaries who persisted in diagnosing illnesses and prescribing remedies, which was legally the province of the trained physician. In other places, particularly Mediterranean cities such as Venice, the colleges of medicine had a vertical organization similar to the textile guilds, and included physicians and surgeons. In Venice, the guilds were also supervised by the republic’s government, which resulted in a better-regulated, if less open, system of health care.
Physicians and Surgeons. The higher orders of medical care—surgeons and physicians—had not always been so distinct. When medicine began to emerge as a learned craft in Salerno, Italy, during the ninth to the eleventh centuries, surgery was a prominent part of the curriculum. The inclusion of medicine in the university curriculum in the thirteenth century combined with teachings from the newly recovered writings of Galen of Pergamon and Aristotle— ancient Greece’s most prominent medical and philosophical writers—helped physicians define medicine not only as the craft of healing, but also as a philosophical subject. Galen had emphasized that the physician should be well grounded in Aristotelian philosophy, and university medicine became oriented more toward theoretical training as physicians increasingly viewed surgical procedures as a lower-order, nonintellectual pursuit. Although medical and surgical training were not completely divorced in the southern universities, such as Bologna (Italy), even there professional distinctions developed, with surgery occupying a subordinate position in the social and educational hierarchy. In the North the gulf between physicians and surgeons was much more radical and complete. In fifteenth-century Paris, for example, surgery was not taught at the university. M.D.s were expected to command medical philosophy and offer diagnosis and therapeutic advice to the patient and leave the cutting, salving, bandaging, and bloodletting to the surgeons and barber-surgeons. For their part, surgeons sought to lift their own educational status, sometimes requiring students to learn Latin and, increasingly in the fifteenth century, demanding that students attain firsthand anatomical knowledge by attending annual dissections.
Clinical Experience. During the sixteenth century, efforts by humanist physicians to reunite surgery, drug-making, and medicine according to the ancient Greek ideal met with limited success, although they produced some noteworthy advances in anatomical knowledge. Andreas Vesalius, perhaps the foremost anatomist of the century, instructed surgeons by anatomical demonstration at Bologna, while a physician lectured on theory. However, the separation between physician and surgeon did not discourage Vesalius from confronting his students with observational facts that ran counter to Galen’s teachings. Vesalius published On the Architecture of the Human Body (1543) and brought active anatomical research to a new level. Of greater benefit to the surgeon, however, was the increased frequency of military campaigns. These excursions provided both employment and opportunity to experiment with new procedures, and led to the gradual transformation of the large general hospitals, such as the Hotel Dieu in Paris, from hostels into treatment facilities for the poor. As Europe’s population increased and as the poor migrated to the cities, these institutions offered physicians and surgeons alike the chance to gain clinical experience that was unrivaled in the private sector.
The Value Of Dissection
The same year that Andreas Vesalius published his epoch-making On the Architecture of the Human Body (1543), he produced a more concise version (or Epitome), intended for the student dissector. His approach in that text is similar to his fuller treatment, but more direct, less detailed, and lacking the many expensive woodcuts that made the Architecture so costly. The following section from the preface to Epitome explains why Vesalius thought that such a book was needed.
It is a charge to be laid most gravely at the door of the mob of physicians that they perform their duty so carelessly in distinguishing the parts of the human body that not even enumeration is made use of in learning them. For when, beyond the function and use of each part, its location, form, size, color, the nature of its substance, the principle of its connection with the other parts, and many things of this sort in the medical examination of the parts may never be sufficiently perceived, how many can be found who know even the number of the bones, cartilages, ligaments, muscles, and veins, arteries, and nerves running in a numerous succession throughout the entire body and of the viscera which are found m the cavities of the body? I pass over in silence those pestilent doctors who encompass the destruction of the common life of mankind, who never even stood by at a dissection: whereas in the knowledge of the body no one could produce anything of value who did not perform dissections with his own hands as the kings of Egypt were wont to do and in like manner busied himself frequently and sedulously with dissections and with simple medicines, Whence also those most prudent members of the household of Asclepius [that is, physicians] will never be sufficiently praised, who, as children in the home learn reading and writing, so they exercised the dissection of cadavers and, learning in this wise, under the happy auspices of the Muses, they bent to their studies. . . . Indeed, those who are now dedicated to the ancient study of medicine, almost restored to its pristine splendor in many schools, are beginning to learn to their satisfaction how little and how feebly men have labored in the field of Anatomy to this day from the times of Galen, who, although easily chief of the masters, nevertheless did not dissect the human body; and the fact is now evident that he described (not to say imposed upon us) the fabric of the ape’s body, although the latter differs from the former in many ways.”
Source; Andreas Vesalius, The Epitome of Andreas Vesalius, translated by L. R. Lind (New York: Macmillan, 1949), pp. xxxiv–xxxv.
Improved Hospitals. Medieval hospitals in the West were originally Christian charitable hospices that provided basic food and shelter for the poor and for travelers, though sometimes rudimentary medical care was also provided. Hospitals as institutions that focused primarily on treatment emerged earlier in the Byzantine and Islamic worlds than in the Latin West, owing to the greater continuity of classical traditions and, in Byzantium, to the maintenance of centralized imperial order. The Pantokrator Hospital, founded in Constantinople in the twelfth century, was arguably the first well-staffed hospital in Christendom, with separate wards for men and women, wards for patients with different kinds of ailments, and a professional medical, administrative, and operational staff. Hospitals that served a dual medical and instructional function were also a part of medieval Islam and may have served as examples for the Latin West. Knowledge of both Byzantine and Islamic health care filtered into the West, as crusaders returned from the Holy Land or from Constantinople.
Specialized Facilities. The first true hospitals of Latin Europe evolved from hospices in the city states of northern Italy in the fourteenth century. This type of institution gradually spread north in the fifteenth century. Specialized facilities for isolating lepers (lazarettos) were prevalent earlier but were not mainly treatment oriented. Leprosy declined in most parts of Europe during the fourteenth century, and the larger lazarettos were adapted to house and treat victims of plague during the centuries that followed. These were temporary public health measures that were utilized when epidemics of bubonic plague were declared, and not continuous, permanently staffed health care centers. However, beginning in northern Italian cities such as Florence, Milan, and Venice, specialized institutions were maintained for other designated segments of the population: the old and infirm, abandoned and victimized women, unwed mothers, and orphans. Such hospitals did not exclusively serve medical purposes, nor were they intended for those who could afford treatment at home.
Training Centers. By the fifteenth century, large general hospitals, such as Florence’s Santa Maria Nuova, began to provide regular medical care for those who could not afford it at home. In France the Hotels Dieu that were established in Paris and in major provincial cities shifted toward caring for the sick poor. One hospital was even founded in colonial Quebec to provide for the natives and the immigrant poor. In England, hospitals continued to have an ecclesiastical foundation, such as London’s St. Bartholomew’s Hospital, but there, too, they served an increasingly clinical function, more so in the seventeenth and eighteenth centuries. Not until the late Enlightenment (1750-1800) did northern municipal hospitals begin to serve as routine training grounds for clinicians, and then medicine and surgery were again brought together in the service of both healing and medical research. In both these areas, Italy and Spain were ahead of their northern neighbors, but by then Bologna and Padua (Italy) were surpassed by Leiden (Holland), Paris, and Vienna as Europe’s most prestigious centers of medical training.
Sources
Ole Peter Grell and Andrew Cunningham, eds., Health Care and Poor Relief in Protestant Europe, 1500-1700 (London & New York: Routledge, 1997).
Margaret Felling and Charles Webster, “Medical Practitioners,” in Health, Medicine and Mortality in the Sixteenth Century, edited by Webster (Cambridge & New York: Cambridge University Press, 1979), pp. 165-235.
Guenter Risse, Mending Bodies, Saving Souls: A History of Hospitals (New York: Oxford University Press, 1999).