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9-08-2015, 17:08

The studied body: anatomy and medical theory

Melancholics and young women suffering from green-sickness were not the only ones whose outer body revealed their inner state, for humoral theory explained physical health and illness as well as one’s mental state. Newer ideas about anatomy that developed in the seventeenth century also connected the mind and the body. Learned writers, fi rst Andreas Vesalius and then many others, criticized the prevailing Galenic understanding of anatomy and physiology. In several works, the English anatomist and royal physician William Harvey (1578–1657) demonstrated that the veins and arteries are one system, with the same blood being pumped throughout the body by the heart. Based on dissections, experimental proof, and logical argument, Harvey explained the workings of the heart muscles, the function of the valves in the veins, and the path of blood through the heart. He saw blood as even more important than it had been in the Galenic system, however, identifying it as animate and linking it with the soul. Harvey also viewed semen as powerful, and suggested that an egg found inside a female could become fertilized at a distance without physical contact, in the same way that magnets exerted their energy across space. Galileo Galilei (1564–1642) and Pierre Gassendi (1592–1655) studied the physical principles of bodily processes: how the pores secreted, how the mouth and stomach digested, how blood fl owed through the blood vessels. They, and others, thought about the body in mechanical terms: as, in Galileo’s terms, an assemblage of small machines. Just as machines need oil to prevent friction and pumps need a free fl ow of liquid to work properly, they reasoned, the body needed a free fl ow of various fl uids to maintain good health. These were now observable fl uids such as blood, digestive juices, and glandular secretions rather than the Galenic four humors, however, with illness described in terms of blockages, restrictions, and obstructions, rather than imbalance. Later medical writers studied respiration, with Joseph Priestley (1733–1804) and Antoine-Laurent Lavoisier (1743–94) identifying the “vital air” carried by the blood as oxygen, necessary for both life and combustion. The work of anatomists and medical writers was made easier by improvements in the microscope undertaken by Dutch lens-makers, especially Anton von Leeuwenhoeck (1632–1723). Leeuwenhoeck’s microscope allowed him to see single blood cells circulating through capillaries (an action that Harvey had not been able to explain) and spermatozoa (what he called “animalcules”) in semen, demonstrating that something physical was clearly responsible for fertilization. The latter discovery led Leeuwenhoeck to argue that each sperm was the seed of an individual, and that sperm contained the full formative structure of the embryo, including its sex. This “spermatic” view of embryology was countered by “ovists” such as the Swiss physiologist Albrecht von Haller (1708–77), who thought that the embryo-in-miniature existed preformed in the female ovum. Ovists were often ridiculed by the male scientifi c community, however, and were limited by the fact that the mammalian ovum had not yet been defi nitively identifi ed. Both of these “preformationist” positions also had to explain how the embryo’s future children could be contained within it, and then that embryo’s within it ad infi nitum, a puzzle that led back, in both serious and satirical works, to the ovaries of Eve. This conundrum contributed to a recognition that somehow both parents must be involved, but not until the identifi cation of the ovum in 1827 – a remarkably late date given its size relative to that of spermatozoa – would the modern view of conception begin to emerge. The mechanical view of the body as a system of hydraulic and pneumatic machines was opposed in the eighteenth century by “vitalists,” some of whom asserted the importance of the soul as a “life-force” or “life-principle,” and others of whom located this life-force in the body itself. The latter group often based their arguments on research on the nervous system and on the ability of plants and some animals (such as starfi sh) to regenerate body parts that had been severed. Good health, for these vitalists, was a matter of stimulating or “exciting” the nervous system and allowing muscles to freely contract and expand. Some anatomical research was conducted by individuals with positions at university medical schools, but in general the critique of Galen did not translate immediately into a rejection of the notion of humors in the training or practice of physicians. The older humoral notion of the body’s physiology could also be combined with newer ideas in eclectic ways, with anatomical theorists blending and balancing mechanism, vitalism, and other theories in their attempts to explain how the body operated.

The treated body: medicine and public health

Medicine as practiced was even more diverse than medical theory, in terms of both the approaches of medical practitioners and the range of practitioners available, though all practitioners regarded their work as important for individuals and for society at large. The highest-status – and highest-paid – medical practitioners were university-trained physicians, whose course work remained largely theoretical and all in Latin until the eighteenth century, when a few daring professors began to lecture in the vernacular. Physicians were in charge of the internal body, so their advice was sought for illnesses that appeared to come from within, such as fevers. After the fourteenth-century outbreaks of the plague and of other epidemic diseases, towns and cities, fi rst in northern Italy and then elsewhere, appointed offi cial city physicians or boards of medical commissioners. These individuals were charged with developing and enforcing measures that would limit the spread of disease – quarantining infected houses or streets, disposing of corpses and the belongings of the dead, prohibiting public gatherings, and setting out cordons sanitaires , “sanitary cordons” around uninfected areas. At fi rst these commissions disbanded once the threat posed by an epidemic had passed, but by the sixteenth century northern Italian and German cities often made these positions permanent, and charged physicians with the routine supervision of public health. City physicians and commissions developed (and tried to enforce) sanitary regulations about the disposal of waste, supervised other medical practitioners, and investigated reports of new diseases. In the seventeenth century, some cities, territories, and states expanded the role of these boards – often called a collegium medicum – to include developing and offering a licensing examination for any physician who wanted to practice in the area. Offi cials in centralizing states slowly came to regard a large and healthy population as essential to the well-being of the state, and called for the keeping and study of better vital statistics, including birth, death, and morbidity rates, as a basis for health policies. Hospitals were increasingly viewed as important institutions for maintaining public health. In the centuries before 1450, hospitals were primarily charitable institutions whose main function was caring for the spiritual and physical needs of the ill, infi rm, mentally ill, or elderly poor; they gave such people beds, food, and a (relatively) clean place to die. Many cities also had leper- or pest-houses for those with contagious diseases; with the advent of syphilis in the 1490s, special “pox-houses” were set up in German and Italian cities for those who were infected with this new disease. Medieval hospitals and pest-houses were often small privately endowed institutions that were ineffi ciently run. City governments, fi rst in Italy and then elsewhere, gradually consolidated these into large general hospitals over which they exerted stricter oversight and control. Like the poor in general, residents in these hospitals were often divided into “worthy” and “unworthy.” Care for the latter group – which included vagrants and beggars who were sometimes rounded up off the streets against their will – involved enforced labor and strict moral discipline. Even the “deserving” poor, such as widows and orphans, might be expected to work as much as they could while in the hospital, however, for work was viewed as spiritually fulfi lling, and thus as contributing to the healing process. Treatment for illness was always a part of hospital care, and during the seventeenth century mercantalist ideas about the importance of a growing and productive population led to more attention to strictly medical issues within hospitals. Regular rounds in hospitals examining and treating patients gradually became a part of medical training, with physicians recording their clinical experiences in casebooks. Medical reformers emphasized the role that hospitals could play in research and the rehabilitation of workers and soldiers. In Britain, philanthropic “alliances against misery” began to open voluntary hospitals in the middle of the eighteenth century, describing their function as the maintenance of public health and vigor as well as the treatment of individual illness. The impact of public health measures and improvements in hospitals was limited, however. London, Genoa, and other cities saw devastating outbreaks of the plague in the middle of the seventeenth century, with smaller outbreaks continuing in western Europe until the early eighteenth and in eastern Europe until the later eighteenth century. Even after the plague had disappeared – and the reasons for this are not entirely clear – infectious diseases such as cholera still killed huge numbers of people, especially in crowded cities. Not until the early twentieth century would anyone who was not poor generally enter a hospital, for they remained places most people exited feet fi rst.

SOURCE 22 Lady Mary Wortley Montagu on inoculation against smallpox

Innovations in medical treatment often came through individuals who learned through observation, not formal training. Local medical practitioners in several parts of the world, including the Ottoman Empire, West Africa, and probably China, recognized that survivors of smallpox did not contract the disease again. They thus took pus from the sores of a smallpox sufferer and intentionally scratched it into the skin of a healthy person, a process called variolation (from variola, the Latin term for smallpox), or inoculation. That person became infected with what was hoped was a mild case of the disease, and was thus protected, though it was diffi cult to determine the proper dosage, and some inoculated people died. The Royal Society of London heard about this practice in the early eighteenth century, but it got its best boost from Lady Mary Wortley Montagu (1689–1762), an aristocratic English woman whose husband was sent as the British ambassador to the Ottoman Empire in 1717. Lady Montagu had been scarred by smallpox as a young woman, and was intensely interested when she watched Turkish women inoculate their children, writing about this in a letter to a friend: I am going to tell you a thing, that will make you wish yourself here. The small-pox, so fatal, and so general amongst us, is here entirely harmless, by the invention of engrafting, which is the term they give it. There is a set of old women, who make it their business to perform the operation, every autumn, in the month of September, when the great heat is abated. People send to one another to know if any of their family has a mind to have the small-pox; they make parties for this purpose, and when they are met (commonly fi fteen or sixteen together) the old woman comes with a nut-shell full of the matter of the best sort of small-pox, and asks what vein you please to have opened. She immediately rips open that you offer to her, with a large needle (which gives you no more pain than a common scratch) and puts into the vein as much matter as can lie upon the head of her needle, and after that, binds up the little wound with a hollow bit of shell, and in this manner opens four or fi ve veins. The Grecians have commonly the superstition of opening one in the middle of the forehead, one in each arm, and one on the breast, to mark the sign of the Cross; but this has a very ill effect, all these wounds leaving little scars, and is not done by those that are not superstitious, who chuse to have them in the legs, or that part of the arm that is concealed. The children or young patients play together all the rest of the day, and are in perfect health to the eighth. Then the fever begins to seize them, and they keep their beds two days, very seldom three. They have very rarely above twenty or thirty [smallpox sores] in their faces, which never [leave a permanent] mark, and in eight days time they are as well as before their illness. Where they are wounded, there remains running sores during the distemper, which I don’t doubt is a great relief to it. Every year, thousands undergo this operation, and the French Ambassador says pleasantly, that they take the small-pox here by way of diversion, as they take the waters in other countries. There is no example of any one that has died in it, and you may believe I am well satisfi ed of the safety of this experiment, since I intend to try it on my dear little son. I am patriot enough to take the pains to bring this useful invention into fashion in England, and I should not fail to write to some of our doctors very particularly about it, if I knew any one of them that I thought had virtue enough to destroy such a considerable branch of their revenue, for the good of mankind. But that distemper is too benefi cial to them, not to expose to all their resentment, the hardy wight that should undertake to put an end to it. Perhaps if I live to return, I may, however, have courage to war with them. Montagu did have both of her children inoculated, and on returning to England wrote essays in popular journals and letters to powerful individuals urging the practice. Most religious and medical authorities opposed inoculation, however, and many of the general public were suspicious. At the very end of the eighteenth century, Edward Jenner (1749–1823), an English surgeon (his medical degree was honorary, and was awarded to him when he was sixty-four), learned from local farmers that people who had had cowpox (vaccinia) were immune to smallpox. Jenner experimented with cowpox inoculations – he called them vaccinations – and these were largely successful, though the practice was not widely accepted until after Jenner’s death. From Lady Mary Wortley Montagu, Letters of the Right Honourable Lady M–y W–y M–e: Written During her Travels in Europe, Asia and Africa… , vol. I (Aix: Anthony Henricy, 1796), pp. 167–9; letter 36, to Mrs. S. C. from Adrianople, n.d. University-trained physicians were expensive, and hospitals were dangerous, so people more regularly consulted with surgeons for various types of ailments. In theory, surgeons were to treat the outer body and physicians the inner, but in practice surgeons often treated illnesses such as syphilis or cancerous tumors as well as externally visible problems. Before 1700 surgeons were generally trained through a guild system rather than at universities, so they did not hold an MD degree and were not referred to as “doctor.” They were trained to use knives and other instruments in their practice – something that university-trained physicians rarely did – and so were often grouped together in a guild with barbers, who might also do routine bloodletting along with cutting hair. Though the occasional dissection that university medical students observed as part of their training was usually done by a surgeon (with the professor lecturing as the surgeon did the actual cutting to reveal body parts), the training of surgeons did not involve regular dissections. The status of surgery improved in the eighteenth century, however, in keeping with ideas that practical experience and experimentation were effective teaching tools. Surgeons were given more training, sometimes in hospitals and sometimes in special surgical academies, and surgery was added as a course of study in some medical schools. Along with physicians and surgeons, apothecaries regularly provided medical advice along with medications made of herbs, minerals, metals, salts, and many other ingredients. Apothecaries were trained through apprenticeship, and were supposed to dispense drugs only on the advice of a physician, but in practice they often acted on their own. Their medications included, and often mixed, ingredients understood to heal in different ways: some “sympathetically” mimicked the illness, such as the spotted plants prescribed to cure measles; others worked astrologically, by drawing on the power of an alignment of the stars and planets; others operated through alchemical processes, such as the mercury, sulfur solutions, or drinkable gold ( aurum potabile ) that contained the secret “elixir of life”; others worked only when certain phrases were repeated or prayers said as they were ingested. Most ingredients, especially those that poorer people could afford, were natural plant and mineral products whose effects had been discovered over centuries of trial and error. Knowledge about such treatments might just as easily be handed down from father to son, or mother to daughter, as through guild training, so that much medical treatment was carried out by people with no formal training, but simply a reputation for effectiveness. Physicians, surgeons, and apothecaries sometimes objected to, in their words, these “quacks and charlatans” practicing medicine; these objections had more force once formal licensing procedures were instituted, with city councils and other governing bodies ordering unlicensed practitioners to stop dispensing medicine, or at least to stop charging if they did so. The complaints of professionals could not stop people from treating illness in their own homes, of course. Cookbooks, herbals, and household guides contained huge numbers of recipes for the treatment of everything from colds to the plague, and home remedies were the most common way of handling illness.