Читать книгу: «The Greatest Benefit to Mankind», страница 20

THE MIND

Renaissance humanism, mysticism, hermeticism and astrology fostered interest in the human soul, the spiritual fulcrum in a cosmos governed by supernatural forces – good and evil. It is not surprising, therefore, that one field in which Renaissance philosophy made a contribution to medicine was mental disorder. Theories remained complex, however. The neo-Platonist Ficino related melancholia to the sway of Saturn, but also to the action of black bile, the humour of genius and of depression.

Humanist moralists explored the mind, notably the French essayist, Michel de Montaigne (1533–92), twice mayor of Bordeaux. Suffering agony from a bladder stone^* and sickened by religious and dynastic bloodshed, he retired from the world to compose his mind in tranquillity, only to find himself haunted by ‘monsters’ and ‘chimeras’. Solitude sparked ‘melancholy adust’, a sick humour disposing his melancholic temperament towards madness. Composing his Essais (1580) was an antidote, a writing cure aimed at restoring balance through anatomizing his mind in quest of self-knowledge.

Montaigne kept his soul ‘at home’ in the body, studying both, hoping to grasp how man should live wisely and face death well. Yet in response to the old Socratic injunction of self-knowledge (‘nosce te ipsum’), he was sceptical: Que sçay-je? (What do I know?), he asked. Such themes were relentlessly pursued, not least by Shakespeare, whose contemporary, Robert Burton (1557–1640), described himself as ‘fatally driven’ upon the rock of melancholy and mixed philosophy and medicine. His Anatomy of Melancholy (1621) was a satirical flagellation of folly but also a serious medical inquiry which included the following causes of depression: ‘idleness, solitariness, overmuch study, passions, perturbations, discontents, cares, miseries, vehement desires, ambitions’, and hundreds more.

Philosophical medicine explored sickness of the mind and its synergy with the body. Mingling suspicion with sympathy, paintings and plays made much of fools, melancholies and madmen. ‘Bedlam’ acquired its notoriety, and Tom o’ Bedlam became a well-known figure, wandering the lanes, singing and begging. The period also brought the wave of mass hysteria and persecution known as the witch-craze. Despite the biblical injunction, ‘thou shalt not suffer a witch to live’ (Exodus 22:18), the medieval Church had long remained little concerned about witchcraft, but by the late fifteenth century this had changed, and a Papal Bull of 1484 condemned its spread and authorized a crackdown on its practitioners. Two years later, the Malleus maleficarum [Hammer of the Witches] of the Dominicans, Institoris and Sprenger, created a witchfinders’ handbook that passed through more than twenty editions and translations. Accusations spread, especially where religious conflict and social tension were rife, and trials and executions mounted till around 1650. As late as 1692 the Salem, Massachusetts, trials resulted in thirty executions, and witches were still occasionally being executed in parts of Europe on the eve of the French Revolution.

Nineteenth-century psychiatrists retrospectively diagnosed witches as mentally disturbed, their confessions of compacts with the Devil being the progeny of delusions and hysterical personalities. More recently, such charges have been levelled primarily at the witch-hunters, for whipping up mass hysteria. Though most early-modern doctors supported the prosecution of witches, a few were sceptical, and doubts were particularly expressed in the De praestigiis daemonum (1563) [On the Conjuring Tricks of Demons] of Johannes Weyer (1515 – 88). Weyer was the town medical officer of Arnhem in the Netherlands, and he warned against mistaking sickness for Satan. The Devil had no power over the body; so-called witches imagined the enormities they confessed, perhaps in the throes of fever. He insisted that the deeds of which they were accused – causing sudden death, impotence or crop failure – were natural occurrences. Witches were to be pitied and healed rather than harried and punished.

Felix Platter (1536–1614), dean of the medical faculty at the University of Basel, left extensive accounts of psychiatric disorders in his Praxis medica (1602) [The Practice of Medicine] and Observationum (1614) [Observations]. From a medical viewpoint he downplayed diabolical agency, though advising the use of amulets in cases of madness. He discussed hysteria and sexual disorders, described cretinism (then common in Switzerland), and advocated a basket of psychological, pharmacological and physical therapies. Occasionally at witch trials, medical and theological interpretations of insanity clashed. Yet it was not until the triumph of the mechanical philosophy that a naturalistic theory of mind gained ground, ruling out the supernatural element in mental illness.

A window is offered onto the deranged by the case notes of the Revd Richard Napier (1559–1634), a contemporary of Shakespeare’s who specialized in healing those afflicted in mind and spirit. A high proportion of the afflicted visiting him suffered family troubles, financial insecurities and religious torments, and many believed they were bewitched. Of the 134 cases of deep depression this Anglican clergyman handled, fifty-eight were attributed to deep grief following children’s deaths (‘Much grief for the death of two children’, one parent related). Of Agnys Morton, who had murdered her illegitimate baby, evidently suffering from puerperal fever, Napier recorded,

This woman is distracted of her wits … went to make herself away, being tempted as she sayeth thereunto by the Tempter. Will not in any case say her prayers … Very ravenous and greedy, and will say the foul Fiend lyeth at her heart, that she cannot feed him fast enough.

Napier cast horoscopes in forming his diagnoses, and healed with a mixture of herbal remedies, prayer and counsel, often giving patients sigils and talismans. He may be regarded as one of the last Renaissance magi.

MEDICINE IN SOCIETY

Renaissance humanism benefited the doctor more than the patient. The new learning hardly helped physicians to cure diseases. But it gave the medical profession an elevated sense of its proper dignity, and though playwrights loved poking fun at the pedantic pomposities of costly and useless physicians, medicine grew more status-conscious, and more dismissive of its rivals. ‘All that falsely usurp this Title of Physitian’, declared Richard Whitlock, ‘take off their Visards, and underneath appeare Wicked Jewes, Murtherers of Christians, Monks, abdicant of their orders, &c. Unlearned Chymists, conceited Paedagogues, dull Mechanicks, Pragmaticall Barbers, wandring Mountebancks, Cashiered Souldiers … Toothlesse-women, fudling Gossips, and Chare-women, talkative Midwives, &c. In summe … the scum of Mankind.’

This heightened sense of dignity was marked in public recognition. Earlier tendencies towards the public employment of physicians continued. The code of criminal procedure promulgated for the Habsburg empire by Charles V in 1532, known as the Carolina, required judges to consult surgeons in cases of suspected homicide, and midwives in infanticide. A landmark in forensic medicine, the Code was adopted in much of continental Europe. Medical authors were keen to display their expertise in the courtroom. Paré explained how to recognize the signs of virginity in women – important because under ecclesiastical law non-consummation was one of the very few grounds for annulment of marriage – and the indications of death by lightning, smothering, drowning, apoplexy, poison and infanticide; he also showed how to distinguish between wounds given to a body when dead and alive.

Medical institutions continued to develop under royal and municipal patronage. In 1518 Henry VIII chartered the College of Physicians, granting it examining, licensing and policing powers over medical practice in London. (It became ‘Royal’ from the time of Charles II.) Unlike some European counterparts, however, the college did not succeed in extending its jurisdiction to a wider region, nor did it have control over the licensing of surgeons and apothecaries.

In health care provision in England, the sixteenth century brought a major setback. The dissolution of the monasteries and chantries (rapacious asset-stripping carried out in the name of religious reform by Henry VIII and Edward VI) resulted in the closure of almost all the medieval hospitals, which, even if they had provided little treatment, at least had afforded shelter to the aged, sick and incapacitated. A few institutions survived the Reformation, being re-established on a new, secular basis. St Bartholomew’s and St Thomas’s passed to the City of London after the Dissolution, as did Bethlem for treating lunatics. Despite its burgeoning population, rising to 200,000 by 1600, London long possessed only these three hospitals, not in themselves very large (in 1569 St Thomas’s housed 203 patients); beyond the capital, scarcely any medical institutions survived Henry VIII’s destructive greed.

Shortcomings in institutional medical provision in England and elsewhere may have been counterbalanced, thanks to the development of printing, by the growth of writings popularizing health advice. These sprang largely from the regimen and hygiene traditions incorporated within the Salernitan Regime. Such works, stressing the non-naturals, instructed readers to monitor their constitutions. Andrewe Boorde (c. 1490–1549), an ex-monk turned physician, offered rules in his Compendyous Regyment or a Dyetary of Healthe (1547). He began by prescribing where to situate a house, how to organize a household, what to eat and drink and what to avoid, and what exercise to take, before moving on to more detailed physical methods of preserving and restoring health. The non-naturals were also stressed by Andre du Laurens (1558–1609), physician to Henri IV and professor at Montpellier. In 1597 he published a book translated as Discourse of the Preservation of the Sight; of Melancholic Diseases; of Rheumes and of Old Age, which contended that the causes of ageing were mental as well as physical: ‘Nothing hastens old age more than idleness.’ Early in the seventeenth century, Sir John Harington (1561–1612) brought out a popular English translation of the Regimen sanitatis Salernitanum. Addressed to King James, The Englishman’s Doctor (1608) provided health advice to all:

Salerne Schoole doth by these lines impart

All health to England’s King, and doth advise

From care his head to keepe, from wrath his heart,

Drinke not much wine, sup light, and soon arise,

When meate is gone, long sitting breedeth smart:

And after-noone still waking keepe your eyes.

When mov’d you find your selfe to Natures Needs,

Forbeare them not, for that much danger breeds,

Use three Physicians still; first Doctor Quiet,

Next Doctor Merry-man, and Doctor Dyet.

Temperance was the message of the highly successful Discorsi della vita sobria (1558–65) [Discourses on the Temperate Life] of Luigi Cornaro (c. 1464–1566), which he wrote in his eighties. Cornaro maintained that a temperate life would enable the body’s finite supply of vital spirits to last until life ebbed peacefully away between the ages of five and six score. Practising what he preached, he attributed his longevity to moderation, exercise, keeping his mind occupied and heeding his diet. Old age aroused great interest. In 1635, William Harvey performed a postmortem on Thomas Parr (c. 1483–1635), supposedly the oldest man in England. Brought to London, he was presented to Charles I and exhibited at taverns, but the smoky London atmosphere proved too much and he expired, allegedly at the ripe age of 152.

Printing made other sorts of health literature more widely available. Obstetrics and babycare books began to appear in many languages. The earliest published midwives’ textbook written in the vernacular, Eucharius Rösslin’s (d. 1526) Der Swangern Frawen under Hebammen Rosengarten (1513) [Garden of Roses for Pregnant Women and Midwives] appeared in English as the Byrth of Mankynde (1540) and was still in use in the eighteenth century. Its frontispiece pictures the mother in labour among relatives and midwives, groaning on a birth stool, while the attendant astrologer gazes through the window to cast the baby’s horoscope.

Thanks to printing, stronger links were forged between medicine, learning and culture. Humanism’s preoccupation with recovering the learned medicine of the ancients proved, however, a mixed blessing, and scepticism towards the profession remained deep-seated: ‘Trust not the physician, his antidotes are poison,’ warns Shakespeare’s Timon of Athens. During the following century medicine was to build a new scientific basis.

* Unlike syphilis, gonorrhoea is an ancient disease. An Assyrian tablet speaks of thick or cloudy urine, and the Hippocratic writers refer to ‘strangury’, that is, blockage of the urethra. There was no effective cure until sulfonamides became available in the 1930s.

* The ontological view of disease as produced by distinct entities had a few classical antecedents. In Timaeus Plato had compared diseases to creatures, and Varro (116–27 BC) had spoken of animals too small to be seen by the eye, ‘which by mouth and nose through the air enter the body and cause severe diseases’.

* The heyday of eponyms was the seventeenth century, with Aselli’s pancreas, Graafian follicles, Haversian canals, the circle of Willis, Tulp’s valve, Bartholin’s duct and glands, and many lesser ones.

* Montaigne wrote, ‘I am in the grip of one of the worst diseases – painful, dreadful, and incurable. Yet even the pain itself, I find, is not so intolerable as to plunge a man of understanding into frenzy or despair. At least I have one advantage over the stone. It will gradually reconcile me to what I have always been loath to accept – the inevitable end. The more it presses and importunes me, the less I will fear to die.’

Self-possession in the face of sickness, he believed, was crucial. Physicians were of little use: ‘no doctor takes pleasure in the health even of his friends,’ he remarked; this was a long-standing humanist jibe.

CHAPTER IX THE NEW SCIENCE

THE DREAM OF RENAISSANCE HUMANISTS was to restore medicine to its Greek purity, but a counter-view gained ground in the seventeenth century as the ‘moderns’ confronted the ‘ancients’: medicine could thrive only if the deadweight of the past were cast off. After centuries of stultifying homage to antiquity, a fresh start was needed. This was a subversive doctrine indeed, but support could be drawn from the Reformation: if Luther could break with Rome, how could it be impious to demand the reformation of medicine? Such revolutionary impulses first found expression in the work of the iconoclastic Paracelsus.

PARACELSUS

Meaning ‘surpassing Celsus’, Paracelsus was the cocksure name adopted in his early thirties by Theophrastus Philippus Aureolus Bombastus von Hohenheim (c. 1493–1542), a medical protestant if ever there was one – though, ironically, he never formally abandoned his native Catholicism. Paracelsus was born in Einsiedeln, Switzerland and educated by his physician father in botany, medicine and natural philosophy. Around the age of twenty he briefly studied medicine in Italy but subsequently led the life of a wandering student. All the while he picked up knowledge from artisans and miners (‘I have not been ashamed to learn from tramps, butchers and barbers’), observed and thought for himself, and acquired a taste for the esoteric. The writings of Trithemius (1462–1516), an occultist who aspired to the wisdom of the mythic Hermes Trismegistus, convinced him of the workings of invisible powers as spiritual intercessors between God and man in an enchanted cosmos.

Paracelsus’s off-beat education marked a drastic break with the orthodox university medical curriculum built on canonical texts; it helps explain how he repudiated Galenism and came up with new disease concepts in a twenty-year career that made him the scourge of the medical Establishment: ‘When I saw that nothing resulted from [doctors’] practice but killing and laming, I determined to abandon such a miserable art and seek truth elsewhere.’ But while there is no denying Paracelsus’s break with the past, the common portrayal of him as the founder of scientific medicine is misleading, for his creed always involved mystical and esoteric doctrines quite alien to today’s science. He thus appears a paradox. For while subscribing to popular beliefs and folk remedies, and lapping up the lore he heard from peasants about the nymphs and gnomes haunting mines and mountains, he also championed new chemical theories, dividing all substances into ‘sulphur’, ‘mercury’ and ‘salt’. Yet these must be understood not as material elements but as hidden powers.

Paracelsus’s fundamental conviction was that nature was sovereign, and the healer’s prime duty was to know and obey her. Nature was illegible to proud professors, but clear to pious adepts. His teachings on remedies thus drew on the popular doctrine of signatures to identify curative powers: the orchid looked like a testicle to show it would heal venereal maladies, the plant eyebright (Euphrasia officinalis) had been made to resemble a blue eye to show it was good for eye diseases. Paracelsus was perhaps influenced by radical Protestantism and its faith in a priesthood of all believers: truth was to be found not in musty folios but in the fields, and in one’s heart. Yet though he displayed a fiercely independent temper, kowtowing to none, unlike Servetus he cannily avoided getting ensnared in Reformation politics.

His fisticuffs mentality comes out clearly in his sublime contempt for academic pomposity: ‘I tell you, one hair on my neck knows more than all you authors, and my shoe-buckles contain more wisdom than both Galen and Avicenna.’ In 1526 he was appointed town physician and professor of medicine in Basel, a post requiring him to lecture to the medical faculty. This he did not in the customary Latin but in German, wearing not academic robes but the alchemist’s leather apron, and his manifesto pronounced that he would not teach Hippocrates and Galen, since experience alone (which included his intuitive flights) would disclose the secrets of disease. Jeering at orthodox physicians, and taking his cue from Luther, he then publicly burned Avicenna’s Canon, the Bible of learned medicine, along with various Galenic texts on St John’s day (24 June 1527). All this was quite unheard of.

Bloody-mindedness aside, Paracelsus’s significance lay in pioneering a natural philosophy based on chemical principles. Salt, sulphur and mercury were for him the primary substances. These did not completely replace the Aristotelian – Galenic system of qualities, elements and humours, but he considered them superior because they were in alchemical terminology ‘male’ – that is active and spiritual – whereas the elements were ‘female’ and passive. His ‘tria prima’ are to be understood not as material substances but as principles: solidity or consistency were represented by salt; inflammability or combustibility by sulphur; and spirituousness or volatility by mercury. Drawing on the occult, he associated diseases with the spirits of particular minerals and metals: ‘When you see erysipelas, say there is vitriol. When you see cancer, say there is colcothar’ (peroxide of iron). But he also boldly deployed metals and minerals – mercury, antimony (stibium), iron, arsenic, lead, copper and sulphur – for therapeutic purposes, together with laudanum (tincture of opium).

Embodying spiritual and vital forces, Paracelsus’s chemical principles explained living processes. These depended upon what he called archei, the internal living properties controlling processes like digestion; and also semina or seeds deriving from God, the great magus (magician) who orchestrated nature. The agents of disease, on the other hand, might be poisonous emanations from the stars or minerals from the earth, especially salts. His belief that there were as ‘many diseases as pears, apples, nuts’, and that each disease had a specific external cause sounds like an anticipation of ontological doctrines, but it must be remembered that he saw the essence of disease as spiritual.

Paracelsus ridiculed hidebound practices. Sickness was to be understood not by conventional urine inspection (uroscopy) but by chemical analysis using distillation and coagulation tests. He also enjoyed mocking innovations championed by others. Dissection, for instance, was worthless ‘dead anatomy’, for it could not reveal how the living body functioned. He died before Vesalius published his Fabrica, but he would probably have deemed it not worth a sausage. True physiology had to discover the nourishment each body part needed, while to fathom pathology stellar influences had to be probed and the presence of abnormal quantities of salt, sulphur and mercury tested. By disparaging humoral balance and stressing the prime role of particular organs in health and disease, he countered Galenist constitutionalism with a new notion of specificity and a pathology of disease as invasion from outside.^*

He interpreted familiar diseases in new ways. Take gout, regarded by Hippocratic medicine as a classic humoral imbalance involving defluxion into the foot (‘gutta’ means ‘flowing’). Paracelsus read gout not constitutionally but chemically, seeing it in terms of the wider category of ‘tartaric disease’ (diseases of incrustations). In De morbis tartareis (1531) [On Diseases of Tartar], he proposed that some local external factor, such as water supply, might produce the characteristic chemical deposits in the joints. He boasted patriotically that in Switzerland, ‘the most healthy land, superior to Germany, Italy and France, nay all Western and Eastern Europe, there is no gout, no colic, no rheumatism and no stone’. Gouty nodules, he maintained, consisted of calcined synovia or an excremental salt (tartar) coagulated in a joint. Since the tartar coating wine casks was a product of fermentation, such material could be compared to bodily deposits like gallstones, kidney stones, and the dental incrustations still known as tartar. Bodily tartar was thus derived from food and released through digestion. In some individuals it failed to be excreted, tending instead to be transformed by ‘spirit of salt’ into stony substances like calculi or gouty tophi. This theory of ‘tartarous disease’ was one of the earliest attempts to advance a chemical aetiology for a malady.

Paracelsus sneered at bookworms (‘not even a dog-killer can learn his trade from books’), and his copious writings taught that truth was to be found not in libraries but in the Book of Nature, and issued a health warning: ‘the more learned, the more perverted’. Personal experience was what counted – ‘he who would explore nature must tread her books with his feet.’

However ambivalent such views – Paracelsus was the classic dogmatic anti-dogmatist, the humble chap convinced everyone else was wrong, the inveterate scribbler who told readers to close their books – his commitment to the discovery of truth through observation and experiment was a breath of fresh air. And it became the inspiration of the new medicine emerging in the ‘scientific revolution’ stirring at about the time of his death: 1543 brought not just Vesalius’s De fabrica but also Copernicus’s De revolutionibus orbium coelestium [On the Revolutions of the Heavenly Spheres] with its revolutionary heliocentric astronomy.