A touch of France : Theory and practice: European Renaissance medicine

by S. Daynes -Diallo, France

Renaissance medicine amalgamated the theory and practice of medical knowledge inherited from Antiquity and the Middle Ages. Although it built on much from the past, it also innovated—Renaissance medicine was determined to shake off its Medieval trappings. In spite of the fact that medicine in the 16th century did not experience a renaissance comparable to that seen in the arts—the medical revolution was still a century away—it could not fail to be caught up in the Humanist wave sweeping through Europe, and it made genuine progress as a result. While the Copernican revolution turned Medieval cosmology on its head, the Reformation undermined Catholic dogma and questioned the relationship between God and Man, and technical advances—spearheaded by printing—led to an unprecedented transformation in knowledge and practice, medicine swung between a form of Humanism that was extremely deferent to the Ancient Greeks and Romans, but which eventually opened the way for textual criticism, and an increasingly empirical form of clinical practice in response to the century’s two main scourges: epidemics and the arquebus—one natural, the otherman-made. It was also in the 16th century that medical fraternities organized themselves into institutions and prepared the ground formodernmedicine and the completion of the synthesis of theory and practice.

Medicographia. 2011;33:334-343 (see French abstract on page 343)

enaissance* medicine amalgamated the theory and practice of medical knowledge inherited from Antiquity and the Middle Ages. In response to the humanism of the age, its attitude constantly oscillated between atavism and innovation, which produced tangible progress and prepared the ground for the blossoming of modern medicine that occurred in the 17th century.

Prosthetic hand designed by French surgeon Ambroise Paré
(1510-1590), a specialist of battle medicine and royal surgeon to
four kings. From: Instrumenta Chyrurgiae et Icones Anathomicae,
by Ambroise Paré, published 1564.

© Wellcome Library.

The legacy of the past

The medical world of the Renaissance inevitably bore the stamp of its Medieval counterpart. Medicine in this era was a component of physica—the Latin echo of Aristotle’s ταφυσικα—incorporating the natural sciences, philosophy, and religion. It perceived the world as a macrocosm reflected in the humanmicrocosm, so that the laws governing the one also governed the other. The ambition of Renaissance man was to unveil and understand God’s creation across both spheres. Medical doctrine inherited the synthesis of three great intellectual traditions from the Middle Ages: the Arabic teachings of Antiquity, Christian doctrine, and Middle Eastern culture and science. The corpus of a Renaissance medical library comprised the works of Hippocrates (circa 460 – circa 370 BC), Aulus Cornelius Celsus (circa 25 BC – circa 50 AD), Pedanius Dioscorides (circa 40-90), and Galen (129-199/217), along with those of Avicenna (circa 980-1037), Averroes (1126- 1198), and the teachings of the Salerno School of Medicine from its heyday between the 10th and 13th centuries.

Medical science was based on the doctrine of humors expounded by Hippocrates and his “prophet” Galen. Being a microcosm of the universe, the human body was naturally composed, like the universe itself, of the four “fundamental elements” of earth, water, air, and fire. Each of these elements was in turn characterized by four essential “qualities”: hot, dry, cold, and wet. In addition, the human body was bathed in four “fluids” or “humors,” characterized by two essential “qualities” and one “fundamental element”: blood—hot and wet—was associated with air; phlegm—cold and wet—with water; yellow bile—hot and dry—with fire; and black bile— cold and dry—with earth. In normal circumstances, the humors acted in harmony to produce a healthy, “temperate” individual.

The Four Humours, from Quinta Essentia by Leonhart Thurneisser zun hurn
(1531-95/6) published in Leipzig,1574 (engraving) (b/w photo), German School, (16th century)/ private

© Archives Charmet/Bridge man Giraudon.

Dutch surgeon. 1569, oil on wood, 16×21 cm. Theodore M. Davis Collection, Bequest of Theodore M. Davis, 1915, The Metropolitan Museum of Art, New York.

Distributed by RMN/© The Metropolitan Museum of Art.

Disharmony resulted in illness and disease. Thus an excess of all four humors, especially blood, gave rise to “plethora” (forming the doctrinal basis for bloodletting), while the relative excess of a single humor produced a state of “cacochymy.” The humors were complemented by three spirits animating the body: the “natural” spirit residing in the liver, the “vital” spirit in the heart, and the “animal” spirit in the brain. The aim of Renaissance medicine was to understandmore about these humors, recognize their disharmony in patients, and correct them with a set of defined interventions and long-established remedies.

A medley of medical professions and skills

The three guilds of physicians, apothecaries, and surgeons formed the basis of the practice of Renaissance medicine. Over the century, they gradually established themselves into separate institutions, but not without clashes and competition. In addition to these three professions at the top of the medical hierarchy, headed by physicians, 16th century citizens could also access the services of a huge spectrum of artisans prepared, in the absence of the three notables, to undertake medical interventions based essentially on practical experience and folk wisdom. Although Renaissance physicians came from a wide range of social origins, the possession of a university doctorate of medicine conferred a relatively exalted social status on its holder. Attachment to the university was associated with a number of privileges, an oath, and obligations. In provincial cities without a university, organization into corporations or colleges ensured the integrity and protection of the physicians’ guild.

Nevertheless, the gulf in status between the ennobled senior court physician and the provincial physician, or between the private physician of an important figure such as a prince, prelate, or minister and the town-council physician caring for paupers, was huge. In general, however, physicians confined their practice to an urban and well-to-do clientele.

Physicians dressed austerely, in black cassock and cloak, turned down cuffs and collar, and wide-brimmed hat. Above all they were men of letters who taught natural science and literature in universities or at the Collèges de France. They tended to be humanists and poets, and were far more adept in doctoral discourse than in clinical practice or intervention, which they delegated to students, barber surgeons, or even apothecaries.

In France, apothecaries joined with grocers to form the second of the six merchant guilds. Like physicians, they enjoyed important privileges in the Renaissance period, which also came with obligations and an oath very similar to that of the current Hippocratic oath. Pharmaceutical studies had been organized since the previous century into several years’ apprenticeship crowned by the presentation of a “masterpiece,” according to the term’s original meaning: a piece of work produced by an apprentice aspiring to become a master craftsman in his chosen guild. Apprenticeship was supplemented fromthe second half of the 16th century onwards by the teaching of theory that foreshadowed that dispensed in modern schools of pharmacy. Apothecaries dressed similarly to physicians, whom they served by dispensing their prescriptions.

Interior of a pharmacy (fresco), Italian School, 15th century/Castello di Issogne,
Val d’Aosta, Italy.

© Giraudon/Bridgeman Giraudon

Germany, beginning of 17th century. Ecouen, Musée National de la Renaissance.

© RMN/René-Gabriel Ojéda.

The professional world of surgery during the Renaissance was extremely complex and beset by conflict, the primary although not exclusive source of which lay in the contempt that had been shown for this “manual” discipline by physicians since the Middle Ages: in the 13th century, at a time when medical science was still the privilege of churchmen, Canon 18 of the Fourth Lateran Council forbade the “shedding of blood.” This amounted to the de facto exclusion of surgery from both churchmen’s medical practice and the university curriculum. Thus secularized, surgery was left to surgeons, who taught it in schools that varied in the nature of their relationships with the universities.

The second source of conflict in the world of surgery lay in the huge disparities in knowledge and practice within the profession, from the educated master of surgery at the pinnacle of the profession to the barber surgeon, who had learned his craft on the job and who was licensed to practice minor surgery, bloodletting, and the dressing of wounds, at the bottom. In the struggle to obtain recognition for their profession, both groups had to fight off antagonism and encroachment from the university-trained medical profession throughout the 16th century. Below both these groups—mainly in the countryside, but also in towns and villages—a whole range of practitioners served the swathes of population denied access to a physician or surgeon, whether for geographic or financial reasons.

Folk wisdom based on a combination of magic, religion, and time-honored empiricism enabled everyone either to treat themselves or to consult someone more experienced, higher born, better educated, or better off who was prepared to treat a fellow human being out of charity or neighborliness. Thus, folk remedies, charitable acts by priests or members of religious orders, and recommendations and cure-alls endorsed by ladies in the aristocracy or bourgeoisie were available alongside healers, sorcerers, soothsayers, astrologists, and peddlers of potions. Together they formed a motley army of charlatans purveying an illicit and generally peripatetic medicine that was condemned by the university medical authorities. In addition to this array of dubious practitioners, not forgetting the constant and insistent recourse to faith (ranging from regular devotion to supplications to healer-saints, not to mention a whole gamut of processions, prayers, pilgrimages, and penances), there existed a number of artisans who plied a specialist trade across the class divide: bonesetters, peripatetic barbers, lithotomists (extractors of human kidney, bladder, and gall stones), specialists in hernias and cataracts, toothdrawers, and midwives.

Regulated university medical training

Renaissance universities comprised four faculties. Students had to pass through the first, the faculty of arts—where they studied grammar, the humanities, rhetoric, and philosophy—before they could accede to any of the other three major faculties (theology, medicine, and canon law).

From the 13th century onwards, the faculty of medicine was separate from the faculty of arts. Access required the degree of Master of Arts, accompanied by a certificate of baptism in Paris, but granted “regardless of nationality or religion” in Padua.

The university course consisted of three consecutive qualifications: baccalaureate, degree, and doctorate. The cycle was variable, but generally extended over some ten years. Although in practice some provincial physicians only had a baccalaureate or a simple certificate, in theory none were allowed to practice medicine without having obtained a degree. A doctorate, on the other hand, opened the door to recognition within the profession and to employment on the university teaching or administrative staff.

Studies were conducted in Latin. They consisted essentially of reading and analyzing the texts from Antiquity, mixed increasingly with those of more contemporary authors. In the early 16th century, theoretical teaching was structured around the study of “natural things” (anatomy, physiology, botany), “non-natural things” (hygiene and diet), and “contra-natural things” (pathology and therapeutics). Theoretical learning was supplemented by practical sessions in botany and anatomy. Paris, Montpellier, Padua, and Bologna were the major 16th century universities and were all originally founded in the Middle Ages. These major centers of learning were not isolated, however. For example, France numbered over twenty faculties of medicine or medical study centers. Students liked to travel from one center to another to study and accumulate qualifications from each.

A number of private medical teaching establishments coexisted with the faculties. In Paris, some colleges that taught medicine gradually merged with the university, such as the Colleges of Tricquet and Cornouailles; similarly, in Montpellier, there was the College of the Twelve Physicians. There were also schools of surgery (colleges of Saint Cosmo), which gradually became incorporated into universities. The Collège de France, set up in 1530 by François I, boasted a chair in medicine from as early as 1542.

Botanical drawing from the Great Herbal of Leonhart Fuchs (1501-166): De Historia Stirpium Commentarii Insignes (1542).

© Chelsea Physic Garden, London, UK/The Bridgeman Art Library.

Universities were thus not the only institutions that taughtmedicine. But in addition to teaching and conducting research, they had other prerogatives. For example, they were consulted on issues of general interest to the State, such as public health and hygiene. They also produced the majority of physicians employed by royalty. Universities were also given the duty of overseeing apothecaries, barber surgeons (to a lesser extent), and midwives.

A change of intellectual direction: medical Humanism

Humanism informed the entire Renaissance, most visibly in the arts and sciences. Positioning Man and human values at the center of thought, the new philosophy was characterized by a return to the writings and practices of the Ancient Greeks and Romans, deliberately breaking from the supposed legacy of the Middle Ages. The change of intellectual direction that took place initially in Italy between the late 14th and mid-15th centuries spread rapidly throughout Europe. Humanism took its name from the Latin humanitas, meaning the “humanities” or the study of Latin and Greek in the broadest sense: the idea was to follow the paths laid down by the Ancient Greeks and Romans in knowledge, ethics, philosophy, and politics.

The Humanism of the Renaissance was thus characterized by a desire to return to the writings and practices of the ancients stripped of their Medieval dross: these writings had, after all, been translated, annotated, and added to throughout the Middle Ages. Humanists in all branches of knowledge therefore embarked on the vast undertaking of rereading, reanalyzing, and republishing the texts of Antiquity that had been handed down to them. In medicine, for example, the last quarter of the 15th century saw the republication of De re medica by Aulus Cornelius Celsus, along with central works by Hippocrates and Galen.

Frontispiece of De Re Medica by Aulus Cornelius Celsus (Rome, ≈1st century BC/1st century AD). Published in Paris by Chrestien Wechel, 1529.

© BIU Santé—Bibliothèque Inter-Universitaire de Santé, Paris.

Dissection scene from De Proprietaribus Rerum, by Barthélemy l’Anglais (vellum). End 15th century. Bibliothèque Nationale, Paris.

© Archives Charmet/The Bridgeman Art Library.

Consequently, the entire century witnessed a vast dissemination of Humanist thought, aided and abetted by the development of printing in particular, but also by university teaching and Humanist practice. Magnificent testimony to themovement comes in the form of manuscripts and printed works specifically composed and published for the great Humanist libraries founded by princes and prelates, kings and emperors, and the religious foundations of which the universities were a part. Two compendia of Greek and Roman surgical writings organized by the celebrated Florentine physician Guido Guidi (aka Vidus Vidius [1508-1569]) for the Humanist library of François I and illustrated by the Florentine artist Francesco Salviati (1510-1563) are exemplary in this regard. This sublime work, published in 1544, was a crystallization of the scientific and artistic excellence to which Humanists aspired. Reproduction of its plates throughout the 16th century to adorn multiple works on allied topics, such as those by the French royal surgeon Ambroise Paré (circa 1510-1590), provide a perfect illustration of the dissemination of the Humanist movement.

Emergence and celebration of anatomy as a discipline

The Renaissance updated the practice of anatomy to Humanist times. Anatomical dissection, a practice inherited from Antiquity, had been officially conducted in Italy since the 13th century and in France since the 14th century. The papal bull issued by Boniface VIII in the 13th century had secured its approval by the Church for the sole purposes of legal autopsy and university demonstration.

At the start of the 16th century, dissection was only used in university teaching to illustrate the writings of Antiquity. Its role and status grew steadily throughout the century. It began to be performed outside universities, for instance, in independent colleges, at the Collège de France, in schools of surgery, by private individuals (students and barber surgeons), and also by artists. The practice was almost always illegal, but generally tolerated. The details of cadaver provenance remain murky. Andreas Vesalius (1514-1564) is believed to have fetched his supplies from the multistorey gibbet of Montfaucon in what is now the 10th arrondissement of Paris. Other objects of dissection included animals, colleagues, and even friends (who could thus be said to have bequeathed their bodies to science!). An additional source of bodies was pauper cadavers from hospices.

The most remarkable expression of the new anatomy was the masterpiece by Vesalius, De humani corporis fabrica libri septem. Published in 1543, the same year as De revolutionibus orbium coelestium by Copernicus, it incarnated the urge to question the all-powerful work of Galen and its reverential exponents, which had begun at the turn of the century with the first pre-Vesalian anatomists: members of the Padua School, the English Humanist Thomas Linacre (circa 1460-1524), and the Paris School, one of whose graduates, Charles Estienne (1504-1564), produced (some time before 1539) De dissectione partium corporis humani. This work was very similar to Fabrica, except that unlike Vesalius, Estienne did not engage a pupil of Titian to take care of the illustrations.

Such fastidiousness was emblematic of the Vesalian revolution: at the same time as Vesalius was insisting on the necessity of the teaching of anatomy and the superiority of handson experience over medical scripture and its associated iconography, he was calling on one of the great art workshops of his day for illustrations, regardless of the expense. After all, it was the workshops of Leonardo da Vinci, Verrocchio, Michelangelo, and Dürer that had pioneered the study of anatomy, in terms of representing the human body, in the very early Renaissance. These studies originated mainly fromLeonardo’s workshop and were unknown to immediate contemporaries. But their direct influence was displayed for all to see in Fabrica, in an explosion of magnificent yet elegant detail that symbolized the quest for meaning by an entire epoch obsessed with the human body.

Scenes of medical life during the Renaissance. Frontispiece of Der Gantzen Artzenei, by Johann Eichmann (Dryander) (1500-1560), published by Christian Egenolph, 1542, Frankfurt
am Main. Engravings outside frame— upper left: doctor examining a patient’s urine; upper right: bloodletting; main engraving, clockwise from top left: examining a bedridden patient; selection, picking,
and preparation of medical herbs; discussion among doctors; apothecary preparing medicines.

© BIU Santé—Bibliothèque Inter-Universitaire de Santé, Paris.

Anatomy thus came into its own in the 16th century, as pictorial representation, descriptive treatise, and clinical method. It was to retain its central status for centuries to come. In addition, by encouraging the investigation and elucidation of the human body, the commitment to research and empirical method that drove Vesalius and those who came after him put clinical intervention and hands-on experience back into the heart of medical practice, thereby opening the door to the surgeons.

Surgical progress: the impact of the arquebus

Surgery in the 16th century was marked by the beginning of a rise in the social status of surgeons and the normalization of their profession. In addition to celebrated anatomists and surgeon-physicians such as Vesalius, a number of barber surgeons helped their specialty to recover its scientific status. Under the direct challenge of their century’s two main scourges—epidemics and the first firearms—these surgeons led a revolution in surgery that extended way beyond the battlefield and the hospitals where they practiced.

Battlefield surgeons such as Paré, their most celebrated representative, were also responsible for the extensive dissemination of surgical knowledge. In direct contrast to the illiterate caricatures disdained by faculty physicians, they produced surgery and anatomy manuals in vernacular language, which were often richly illustrated and went hand in hand with Humanists’ dissemination of knowledge in similar areas.

It was the battlefield that generated the major surgical advances of the 16th century. Surgeons routinely joined army units, replacing the charlatans that had been used up to that time. Their presence was a necessary response to the increasing violence of battle due to the development of shortrange firearms—the arquebus, then the musket—and the novel wounds they produced.

Paré introduced new methods of treating multiple wounds, and a new approach to firearm wounds. Like the personal physician to Henri III, Laurent Joubert (1529-1582), the Swiss surgeon Félix Würtz (dates uncertain), and Hans von Gersdorf (circa 1455-1529) in Strasbourg, he also had an interest in amputations, prostheses, and orthopedic corrective techniques, making some striking contributions in these fields. He published his studies in a large number of works with illustrations combining realism, clarity, sobriety, and a talent for disseminating knowledge. The works are also a treasure trove of the surgical arsenal of the time, only very rare items of which have come down to us. They are particularly valuable for identifying contemporary surgical implements because these can be difficult to tell apart from the tools used by butchers, huntsmen, and even gardeners.

Anatomy of human veins and arteries. From
De Humani Corporis Fabrica, by Andreas Vesalius,
published by J. Oporinus in Basle, 1543.

© Wellcome Library.

Surgical instruments. From La Méthode Curative des Playes, et
Fractures de la Teste Humaine, by Ambroise Paré, published in
1561 by Jehan le Roer, Imprimeur du Royès Mathématiques, Paris.

© Wellcome Library.

Philippus Theophrastus Aureolus Bombast von Hohenheim, or Paracelsus 1493-1541). Swiss physician, pharmacist, botanist, alchemist, and astrologer. Oil on wood, 72×54 cm. Paris, Louvre Museum.

© RMN/Hervé Lewandowski.

Ordinary medical practice

On the ground, far from the lofty heights of major surgery and anatomical research, there existed during the Renaissance, as at any other time, ordinary medical practice comprising a set of medical interventions and remedies. Patients were attended in their homes by all levels of practitioner, whether by the prestigious doctors of medicine, who once at the bedside mutated into practicing physicians, or by the humbler physicians themselves, along with their assistants (apothecaries, barbers, and students). The consultation consisted of eliciting and interpreting signs and symptoms, issuing recommendations as to diet or hygiene, performing medical interventions, and writing an extemporaneous prescription for medication.

In addition to the patient interview, the consultation used the following techniques to elicit signs and symptoms: inspection and interpretation of the pulse, urine, and feces, and in some cases blood; and assessment of the patient’s “heat” (temperature), appearance, and complaints. Once interpreted, the condition could be treated with a variety of interventions: bleeding, enema, and cauterization, selected according to the most propitious planetary movement or sign of the zodiac. The documentary evidence for the ordinary medical practice described above is fairly extensive. In particular, it is backed by an impressive catalogue of iconography. It is also documented in brilliant detail in the remarkable diary of Jean Héroard (1551-1628), physician to Louis XIII, which is held at the Bibliothèque nationale de France.

Apothecaries and their therapeutic arsenal

Designed to restore humoral harmony, the therapeutic arsenal available in the Renaissance was boosted by new ingredients from the Americas (such as tobacco or the hardwood lignum vitae) and by increasing trade relationships with other distant lands. The basis of apothecary practice nevertheless remained the Antidotarium by Nicholas of Salerno (12th century), along with numerous pharmacopoeias, compendia, and recipes.

The remedies made up by apothecaries against physicians’ prescriptions fell into three main classes, termed “alterative,” “evacuative,” and “specific.” Although almost all were of plant or animal origin, some preparations were mineral (ie, metals such as the antimony prized by Paracelsus [1493-1541], pearls and precious stones, marble, crystal, chalk, and various earths) and a few were of human origin (eg, milk, blood, bone, urine, excrement, and a mellified human mummy confection known, in a variety of spellings, as mumie). Distillation was increasingly used to obtain active ingredients and led to advances in medicinal chemistry. Panaceas were taken as infusions, decoctions, tinctures, syrups, pills, preserves, and confections (the most famous of which was the theriac of Andromachus [1st century] or theriaca Andromachi). Alternatively, they were applied top- ically as ointments, cerates, plasters, poultices, or eye salves; inserted as suppositories or pessaries; or pinned to the clothes or attached to the skin as powder-filled bonnets and sachets.

Theriac jar, 1641, Italy.
Science Museum, London. Theriac was a syrupy medicine originally prepared in Ancient Greece in the 1st century AD as an antidote for animal bites and poisoning, then as a panacea. It was made of over 60 ingredients, some highly exotic such as dried viper and opium, and used throughout Europe until the 18th century, and as late as 1884 in France.

© Science Museum, London/Wellcome Images.

Explosion in the dissemination of medical knowledge

The discovery and rapid development of printing proved extraordinarily effective in disseminating medical science and distributing the texts required for its practice: antidotaria; manuals of surgery, day-to-day medicine, and pharmacy; and almanachs of planetary movements and signs of the zodiac to guide the selection and timing of interventions. As Humanist scholars, physicians saw the dissemination of medical knowledge as an honorable mission. Writing in everyday language also made them accessible to humbler colleagues: French or German editions of works by Paracelsus, Jean-François Fernel (1497-1558), or Paré could be read by apothecaries and barber surgeons. Humanist reinterpretations and republications of works by the ancients (to which some physicians, such as Niccolo Leoniceno [1428-1524], devoted themselves almost exclusively) not only transmitted the knowledge inherited from Classical antiquity along with some critical reflection, but were also paralleled by the dissemination of a rich body of contemporary literature that improved rapidly in terms of illustrations and structure as the century unfolded. Thus, 16th century medicine may not have undergone a true Renaissance, but it was nevertheless a true child of its time. Viewing its twin Classical and Medieval inheritance through the prism of Humanism, it inevitably reflected the influence of contemporary religious and philosophical debate. In addition, it managed to bring about a synthesis of the key components in its heritage and, thanks to some remarkable men, to prepare the ground for the blossoming of modernWestern medicine the following century. _