University Place

Marketing Medieval Medicine

– Welcome, everyone, to Wednesday Nite @ the Lab. I’m Tom Zinnen, I work here at the UW-Madison Biotechnology Center. I also work for UW-Extension Cooperative Extension, and on behalf of those folks and our other co-organizers, Wisconsin Public Television, the Wisconsin Alumni Association, and the UW-Madison Science Alliance, thanks again for coming to Wednesday Nite @ the Lab. We do this every Wednesday night, 50 times a year. Tonight it’s my pleasure to bring back to Wednesday Nite @ the Lab Walt Schalick. He’s with the Department of Orthopedics and Rehabilitation. He was born in Pittsfield, Massachusetts, as was my mother-in-law. [laughter] He attended and graduated from Roger Ludlowe High School in Fairfield, Connecticut, then he came to the Midwest to go to Washington University in St. Louis, where he studied both English and physics. Then he went back to the east coast to go to Johns Hopkins University, where he got a PhD in the history of medicine and his MD degree. Then he did a residency in pediatrics and rehab at Harvard in Boston. Then he was on the faculty at Washington University for a while, and then in 2007, he came up here to UW-Madison. Tonight he gets to talk with us about “Drugs, Books, and Patients: Marketing Medieval Medicine.” Please join me in welcoming Walt back to Wednesday Nite @ the Lab. [applause]

– All right, with that kind of a warm introduction, I can’t start a talk tonight without mentioning the passing of two very influential figures for me. Stephen Hawking, who I think very creatively passed away on Pi Day in England even though it was March 13th here. My daughter and I have spent many hours talking about Hawking’s work. And then T. Berry Brazelton, who was one of my teachers at Harvard and one of the extraordinary developmental pediatricians in the second half of the 20th century. Very influential to many people across the country and around the world, and the last 24 hours have been very saddening. We’ve all lost something. Both of them, though, were associated with universities and academia, and I think that played out with some of what Tom put into his email introduction. But the other marker for tonight is that it’s Pi Day. And happy Pi Day. This is my favorite cartoon about Pi Day. [laughter] “Pi what squared? Long John, you should be able to get this.” This cartoon is really great also for International Pirates Day. [laughter] And the great answer is “Arrr.” [laughter] My very creative 11-year-old daughter was wondering: if I’m talking about the Middle Ages and it’s Pi Day, do they do anything with pi in the Middle Ages? So I scrambled to come up with something. Pi, of course, was known in the Middle Ages because it was a letter in the Greek alphabet.

This is a manuscript from the 10th century with the letter pi that has nothing to do with the circumference and diameter of a circle, but it is from a manuscript talking about the distances and sizes of the sun and moon, both of which would be important with diameters and circumferences. However, there were scholars who concentrated on what we would consider pi, the ratio of the circumference and the diameter. Moses Maimonides, who may be known to a number of you, approximated pi as 22/7 in the 12th century. And Leonardo da Pisano, who is most well-known as Fibonacci for his series and a number of other equations in the 12th century, around 1220, estimated pi as about 3. 1418. So pi was at least modestly popular in the Middle Ages. But we’re not going to be talking about that tonight. I am a physician and a researcher in clinical research, so I always have to say that I have no financial disclosures. Most importantly for tonight, no medieval pharmacological company is paying me to push their products. [laughter] There are some leech purveyors who would like me to do a little work, but not right now. [laughter] When Tom and I had first talked about me giving a talk or more, I’d given him fifteen different topics, I think. He was very excited about the possibility of talking about plague. We’re not talking about plague tonight. [laughter] One of my former students brought this back from Italy, though. It’s a plague mask. My daughter was wearing it in the car. [laughter] And it was thought to frighten away the plague when people were going to visit those with plague and examine them. But that’s not what we’re going to be talking about. What we are going to be talking about is learning about medicine in the Middle Ages. For me, this, in part, starts with one of my trainees.

We were working in a newborn nursery together in St. Louis. He was a resident at the time, very clever young man. But he was really frustrated by how much I was making him learn and other people were making him learn. Not the least because he was looking at the explosion of medical knowledge, the positive medical knowledge, the positively geometric increase in a number of publications that were out there. How was he expected to learn everything? And the answer, of course, is you can’t. But trying to sift through how to read that medical knowledge in a creative way and absorb what you need in order to be able to help your patients is the key. So it’s quite a bit about skills. [cartoon]: “I can’t read, but I have excellent TV viewing skills.” Reading is important, but understanding how to manipulate information is the critical piece.

And when I was in training, not this long ago, but we used this book. There were a number of texts that were popular for helping learn how to memorize stuff. This one started out with a dedication “to all long-suffering students because the aspiring medical student is confronted with a rapidly accumulating mass of information and is expected to memorize a considerable amount of it.” It turns out that this is not a new phenomena. Now, Mr. Peabody and Sherman might be taking us back to the 19th century, but tonight they’re going to take us back to the 1280s where we meet a character Jean de Saint-Amand, who was one of the first university professors of medicine at the University of Paris. There is a debate about what is the oldest university in the world. The real answer is the University of Bologna, but the Parisians won’t let me back into Paris if I don’t say that it’s the University of Paris, so it’s the University of Paris. That being said, “I, master Jean de Saint-Amand, have compiled this little work so that students who often lead sleepless nights searching for information in the books of Galen may be relieved from toil and anxiety and more quickly discover that which their thirsting and weary spirit longs to see, and, naturally, I sign to this work the name of [the Recollection of Memory].”

So this book by Jean de Saint-Amand, this is obviously a modern version of it, was an early exemplar of shipments text and a harbinger of what my resident was going to face in St. Louis. This seems predictably appropriate tonight. [laughter] But it’s especially appropriate for most of my talks. After that introduction, what we’re going to talk about is the rise of medicine in the Middle Ages, particularly focusing on texts and professors, and hopefully you’ll see why this is valuable. I’m going to then turn to some of the things we learn about this rise and apply it to the development of the medical marketplace, and particularly pharmacology, and if I don’t drag on too long, I have a coda about the rise of the medieval patient, which hopefully will interdigitate nicely. So everything here really starts with the growth of texts. If you looked in Antiquity, the two dominant medical authors were Hippocrates and Galen. Galen, in 2nd to 3rd century Rome, this is a modern edition of his work extending to 22 volumes. You can see this is an expansive work. Amongst other things, Galen is– My daughter is counting the number of volumes. [laughter]

Amongst other things, Galen was known for his ego. I’ve worked with some of the most extraordinary minds in medicine at Hopkins and Harvard and Wash U and here, and none of them have an ego anywhere remotely the size of Galen’s. If Galen walked into this room, we would all die of asphyxia. That being said, [laughter] he had good reason for his ego because he was productive and very insightful. However, most of his works were lost with the barbarian invasions and the fall of Rome. Now, amongst other things, the Visigothic, Ostrogothic, and other hoards were largely illiterate, didn’t read Latin, didn’t read Greek, and burned many of the libraries that were extant in Rome and elsewhere. However, there were portions of the west that continued to embrace learning. So in portions of Alexandria, in Egypt, and in Rome, Oribasius collected some of Galen’s material into what you can see is a six-volume set. In Byzantium, Paul of Aegina created, in the seventh century, a three-volume what you might consider a summary. And then, finally, in Persia, modern Iran, Avicenna created a one-volume extraordinary constellation of Galenic material.

But this was largely opaque to the Latin west because of the burnt libraries, except for a handful of monasteries. Now this is an image from the New York Times in 1996. I’ve always loved it because you’ve got this classic image of a monk wearing Rollerblades, going back and forth on a modern street. That embracing of what I would consider the modern was what many monks tried to do in a way. And their lingua franca, their medium for doing so, was Latin. When I studied at the Vatican for a while, my teacher, who was a Wisconsin monk who would become the pope’s Latinist, showed me the only ATM in the world programmed in Latin. I love it to tears. One interesting thing about it, it doesn’t use Roman numerals. Thank goodness, right? [laughter] Except for a handful of bank balances, it wouldn’t work very well. But Latin was the critical medium here, and whether original texts were in Hebrew or Greek or Persian or other languages, they needed to be translated in Latin for the monks and eventually for the students of medicine.

And if you look from the 7th century to the 11th century, we have a relatively linear number of increasing manuscript copies of works that appear. However, the number of texts that are encompassed by those manuscripts was increasing geometrically. And what I mean here is I could have one manuscript, but it might have a work from Galen and another from Hippocrates and a third from Aristotle and so on and so forth. So the one linear increase in manuscripts turned into a geometric increase in texts. And that continued to the 14th century and beyond, with or without Buzz Lightyear. [laughter] Under the weight of these increasing number of texts, we began to see changes in western culture and western medicine. Now, amongst those were processes that I’ve characterized as specialization, medicalization and textualization. The textualization is much of what we’ll be talking about tonight. Most of my students are used to hearing me say that everything starts in the Middle Ages, or at least everything important except you all being born. Certainly, specialization and proto-medicalization or medicalization, I think really do get their start in the Middle Ages, and we’re continuing to deal with those ramifications today.

If you looked across the European landscape in the 11th century and looked at the kind of healers that were out there, most of them would be apprenticed, illiterate, and rather ad hoc in their nature. Many of them would be itinerant. If they screwed up, the key would be to run away and not get caught. But as you move from the 11th century into the mid-12th and 13th century, you begin to see a change in that landscape. In particular, surgeons and physicians begin to separate off from each other. The physicians being more literate, more learned, more interested in deploying theory. The surgeons were all about using handwork, if you will, to get in, cut something out, and get away. Often, the image of the surgeon as a knuckle-dragger, somebody who is not quite developed enough. Our Dean has indicated we should not say these kinds of things, but there are still elements playing out today in the tensions between physicians, that is internists and surgeons. There is, in fact, one of Seisel’s four, no it’s one of Loeb’s four laws of medicine is never let the surgeon get your patient.

But this separation between the literate and learned, if you will, and the adept manually or dexterously became an important feature of western medicine, and it was promulgated in large measure by the birth and growth of the universities. Amongst all of the medieval inventions, I would argue universities were the cardinal. They’ve had the longest lasting impact in many ways and the widest ranging impact. Under that impress, we also saw a separation out of a third kind of player: the apothecary. The apothecary as pharmacists as we might think of them today, and I should say Dr. Greg Higby is in the audience. The American Institute of the History of Pharmacy on campus is an extraordinary resource for researchers and for folks on campus. But the apothecaries were critical players in this landscape precisely because they were a little bit in between. They were interested in practical application, but they were also interested to a degree in the theory and diagnosis of diseases. But they separated themselves off from the tensions between these other two players, still distinct from the apprenticed healers, that flat period we saw in the earlier part of the Middle Ages, and still distinct further from another character, the herbalist, a highly- itinerant figure who would carry a bag of herbs or gather herbs on the roadside to sell from town to town to try and make whatever money they could.

Finally, barbers were actually medical practitioners at the time. The idea of bleeding was critical. Who was going to do the bleeding? Physicians in theory could but they increasingly eschewed that kind of manualist activity. Surgeons could certainly be invoked to do it, but barbers would be the ones who would be out there doing it the most because there were many of them. They would offer some sort of medical assistance. As we move from the 11th into the late 13th century, you see these characters beginning to assemble into what becomes a professional pyramid. That pyramid becomes substantiated in the late 13th and early 14th century. And in this format in fact impacts western medicine well into the 20th century. Whether it impacts beyond is hard to tell because of the consumer rights movement. But that being said, physicians tended to prop themselves up on top of this pyramid, surmounting surgeons and apprenticed healers and barbers.

And you can see I have dashed lines in here to indicate that there were some porosity between these boundaries. There were surgeons who tried to go or went to medical school to become more literate and theoretical. There were physicians who tried to more applied activities. Apprenticed healers would do whatever they could to rise up in status. But this pyramid, as I say, continued and was in fact evidence to Andreas Vesalius in his great “De Fabrica,” where he indicated that the pyramid was alive and well and part of his motivation for raising anatomy up to its next level. So if we’re seeing specialization as part of this western landscape, what about the other themes that I argued for? Medicalization was certainly there. I’m going to trip through these slides very quickly. I could easily spend about 20 minutes on each, so I apologize and I’m happy to return to it in the Q&A afterward. But if you look backwards to the Greek east and to portions of the Greek west, there were early versions of what we might consider medical institutions, the nosokomeion was a sick house that was intended to be to support poor people who were ill. And then there was a travelers’ house.

They were coincident. Sometimes they would overlap in their nature, but either of these institutions could offer some medical-like support, nowhere near what we would consider to be hospital-level care. But they tended to be more religious in orientation. As the western church grows in influence from late antiquity into the early middle ages, church buildings become co-opted features for these kinds of care. Monasteries, basilicas, and cathedrals all provide care for the poor, for travelers, and to some degree for those who are ill. But the primary support is prayer. Food is offered, protection is offered, and, to a lesser degree, medical support, but prayer is the top of the list. This will begin to change over time. The history of hospitals is extremely intricate but grossly for our purposes tonight. If you look from Greek and Roman antiquity all the way into the high and late Middle Ages, you see a gradual transmutation of these kinds of institutions from homes or facilities for people who are itinerant or poor gradually increasing from more interest in the sick, becoming more what we might call medical institutions today and eventually training institutions.

Part of that impress is also the growth in number of these facilities. So this is perhaps hard to see, and I apologize for the lights, but this is a rough outline of the number of English hospitals that were founded from 1066 forward. And you can see, again, a partial geometric feature. Many of these facilities across western Europe would be founded by individuals or by groups with a religious intent but increasingly with a medicalized interest. And if you look at the number of beds that were available, in England at least, we’ve calculated that somewhere between 2,000 beds for two million population, so one in a thousand, up to a possible ratio of one to 500 or one to 600 beds per population would be around. And that’s not far off from where we are today. Again, in the United States, hospitals are declining because of medical market forces, but they’re still critical features. That all being said, the Htel-Dieu in Paris is the oldest hospital in France, founded in the 7th century. It was run by the church. By the 11th century, the church was not happy with early practitioners, and they were evicted, if you will, from the hospital.

But by the 13th century, they came back with surgeons in tow. And that became then the dominant backbone of medical support in the Htel-Dieu for the rest of its existence. So what I’m arguing for is a progressive process of secularization with administrators, practitioners, and municipalities supporting these institutions. But medicalization doesn’t stop there in the Middle Ages. If you look at leprosy, for example, who labeled a leper in the Middle Ages starts out with a priest. The local priest, the most learned figure in small towns and villages across western Europe, would be able to label somebody has having leprosy or not. However, by the early part of the 14th century, the church actively hands over that labeling activity, that diagnosis, to medicine. And these are but two of many examples of medicalization within western European history. So what we’re seeing with this pyramid in the 13th century are two broad processes. One is specialization and the other is medicalization. The force that tends to drive this pyramid up vertically is textualization. The more learned you are, the more you’re able to deploy arcana, the higher you are up on this pyramid. On the other hand, the force that tends to drop the pyramid down and make it more horizontal is competition. Those who are below want to find a way to creep up, which then spreads out material. So what is this textualism I’m talking about? The rise of textualism comes about in large measure because western culture, at that point in the early Middle Ages, was an oral culture. If you think of Beowulf, anybody who’s read or heard it or seen a movie, Beowulf is largely an oral poem that was eventually written down. Think Homer in a similar way. Most medieval medicine was also orally transmitted. And it’s frustrating for us as medievalists to want to unpack that information because if it wasn’t written down and nobody survived that long, we don’t know what was said. We do know, though, that the power of oral transmission was critical to medicine up until the 13th century through examples likes this.

Gilles de Corbiel, who was a royal physician for Philip Augustus, argued that “Meter reinforces memory,” but “Prose, in fact a lasting speech, furtively freeing frankness, confuses memory, spawning the confusion of ignorance.” It was because so much written down is hard to understand. It’s hard to flip through. Mostly you were dealing either with manuscripts or occasionally scrolls. It was hard to look for an index or a table of contents because they hadn’t been invented. But as Brian Stock, a medievalist at the University of Pennsylvania in the late 19th or 20th century argued, man began to think of facts not as recorded by texts by as embodied in text. A transition of major importance in western culture was the rise of systems of information retrieval and classification. As fact and text moved closer together, searchability shifted from memory to page layout. And I would argue that this is a technological breakthrough of significant proportions, not surprisingly the guy I’ve worked on the longest, Jean de Saint-Amand, played a role in that. So as a professor at the University of Paris, he wrote this “Recollection of Memory.” It was divided into three core parts. Oh, and I should say it exists in at least 58 manuscripts from the 13th to the 15th century, making it a medical bestseller at the time. I don’t know what Amazon would have done with a number like 58. But the “Recollection of Memory” was divided into three core parts. The first was a series of abbreviation of the books of Galen and Hippocrates. They were summarized and provided a mechanism for medical students to learn these books quickly. Think CliffsNotes. I can say CliffsNotes to this audience and you guys get it. Most of the students today don’t know what a CliffsNote is. [laughter] So the second part was a concordance.

So it was a concordance of 4400 Galenic, Aristotelian, and Hippocratic statements that were arranged alphabetically and broken up by topic into 582 topics from abstinence to hydromel. Now, when I say concordance here, I’m not talking about an online concordance but an actual textual concordance. It turns out that the biblical concordance was invented around 1250 in Paris. If you think about theological professors starting at the University of Paris, and to some degree ministers and preachers, having access to just the right quotation from the Bible, not only from memory, could be an extremely useful tool or process. So Persian scholars invented the biblical concordance. That was a great technological breakthrough as well, and Jean de Saint-Amand working in Paris at the University of Paris, saw the concordance being applied to Bibles and said, “Why can’t I do this with Galen and Hippocrates?” Well, there’s a big barrier that he had to face. There were plenty of Bibles floating around, but remember, they’re all on manuscripts. Manuscript, just think about any time you’ve ever had to copy notes by hand from somebody else. Your handwriting is different from the person you’re copying. The number of words you put on the page are different, and so it’s not like the pagination is the same from copy to copy.

Well, that was true for manuscripts, too. So unlike the Bible in which everybody knew it by chapter and verse, for Galen and Hippocrates you had to find a citational system that would work. What Saint-Amand did was argued that you could divide each section of Galenic and Hippocrate works into a beginning, middle, and an end, A, B, and C. And he would use as the cornerstone for citational references so you didn’t have to have page numbers. You could list ballpark where the quotation was going to be. And each of these sections then would play out over and over again with each of the texts he would examine. Well, his innovation was wildly successful. It was picked up by scholars from the mid-12th and mid-13th century well into the 15 century. These are mostly the different authors I’ve read through over time. And in many ways, his concordance-based system became something like an early version of the World Wide Web. It’s a library, kind of an early version of the web. This hypertexting, if you will the hyperlinking, between one source and another became crucial. So what Saint-Amand innovated in was CliffsNotes, the concordancing system, stealing it from the Bible and moving it into medicine. He creates this uniform system of citation. And while he didn’t invent medical alphabetization, he certainly pushed it to its extremes at the time. All right, so these were innovations in the first two parts of his work. The third part is where I think it gets a little interesting. The Areolae was a guide for understanding drugs. And here he tried to play out for students how drugs work by operations, how they work in different body parts from head to toe, breaking them up alphabetically below that. He focused on laxatives, which we’ll get to in a minute, and then he talked about how to compound drugs from simple drugs.

How to mix things. Why did he choose this topic? If he was so innovative in these other areas, why was pharmacology so important to him? Well, in part it’s because of the growth of the apothecary. The rise of fixed shops scattered throughout Paris and western Europe began to drive a growing clientele, a market if you will, into the doors of the pharmacist, and physicians saw this. Now, it’s hard to detect these kinds of changes because very few apothecaries at this time wrote anything. Where they appear– and it’s almost tax time– is in tax rolls. Now, if you’re insane enough to go through 13th and early 14th century tax rolls, like I am, you do find apothecaries popping up. And, intriguingly, they’re both men and women who appear in a number of different tax systems. There are a number of different ways of deploying this information, but the key things for me are the relative numbers of these practitioners, and you can see, in general, the apothecaries outside of the more itinerant figure were important in terms of numbers. They were also, however, often paying the most taxes. If you work off of a simplistic principle that if you pay more taxes, you probably made more money, which in the United States today may or may not be true.

Thank you, Warren Buffett. It meant that apothecaries tended to be the most numerous and the best off in terms of finances. So I would argue that there was a kind of pharmaceutical pyramid that was establishing itself in western Europe at this time with apothecaries above those itinerant healers and herbalists below. They can then fold into that broader professionalizing pyramid. Again, physicians, as we’ll see, were still arguing that they were in charge, but everybody else played out below that. There’s one other thing you can derive from these boring tax rolls, and that’s geography. So most of the people who paid taxes had to indicate where they were in Paris. And, intriguingly, there were two clusters of apothecaries. In Les Halles, which was the great marketplace on the right bank of Paris, and on the le de la Cit connecting the, I’m sorry, on the Petit Pont connecting the le de la Cit to the university. And it’s there that I think we see possible motivation for what’s going on. At that time, the little bridge, the Petit Pont in Paris, was very much like the Ponte Vecchio. It’s a bridge that spans the Seine, but it’s not just a bridge, it’s a structure that holds buildings. And many of those buildings were apothecary shops. So as the university masters were walking from the university to the le de la Cit where both Notre Dame and the Royal Palace were, they would constantly be passing apothecaries selling their wares. And some examples that we can see appear from literature of those trying to sell medications. “Gentleman, my lords, everybody here, small and great, young and old, you’re in good luck. I’m not trying to fool you. You’ll realize that yourself before I go. So sit down, be quiet, and listen to me if it doesn’t bore you. I am a doctor, and I’ve traveled in quite a few countries. The Lord of Cairo retained me for more than a summer. I stayed for a long time with him, and I earned a lot of money. Good people, I’m not one of those poor moralizers nor one of those poor merchants of simples who come before the churches with their poor, unstitched cloaks, carrying boxes and bags, and stretch out a carpet to show their wares. There are some merchants of pepper and of cumin without having even as many bags as the others. Know you this, I am not one of them. Rather, I am in the service to a lady named Dame Trot of Salerno.”

So this is actually a poem from the 13th century describing a wandering merchant of herbs, but it certainly evokes the nature of the barker. My wife and I were in New Orleans a number of years ago, passing along Bourbon Street to some rather interesting– passing by some rather interesting establishments. And at one point, one of the barkers yelled out to us that we should come in and see a family show. And we were puzzled by this. We didn’t go in, but we asked him, why is it a family show? He said, come in, see the show, go home, have a family. [laughter] The idea was to bring people in to see things. Now, [inaudible] poem here highlights two intriguing features. Besides the bombastic nature of it, the Lord of Cairo evokes this notion of the exotic, the overseas, the Egyptian here. And the other is Dame Trot of Salerno. So Trotula of Salerno is a very nebulous character. It’s likely that she was a real person but not the person who authored a number of texts. Nevertheless, her notoriety at this point was sufficient. And a reference to Salerno, which was one of the first medical schools, not universities but schools, in the west plays out how these barkers of pharmaceutical products would try to evoke people to come and buy their wares. This didn’t go unnoticed by university faculty.

Roger Bacon, one of our early, obviously not a vegetarian by his name, but one of our early what we might call scientists, was a bit of a gadfly, complained a lot about how everybody was dumber than he was, and amongst the complaints he made was about physicians. “The ordinary doctor knows nothing about simple drugs, but entrusts himself to ignorant apothecaries, concerning whom it is agreed by these doctors themselves that they have no other purpose but to deceive. The apothecaries cheat them in various ways. One is in the price of drugs, and, as a result, the patients are overcharged. Likewise, in the quality of drugs.” And he goes on and on and on. What we’re seeing here is the development of a bimodal culture. On the one hand, we have the theoretical elite, literate, learned physician, and, on the other hand, a practical, lay, orally-driven culture playing out in the marketplace, at least in part, around pharmacology, which leads us to regulation. I got started in this because I was interested in what was happening in the royal courts around medicine. There’s a great deal of work to be talked about here, but these are effigies of French kings.

If you look at the staffing of the royal courts around medicine, most of this material I’m not going to break down, but I’m happy to in the Q&A. There’s a growing number of physicians at court, to a certain degree, a growing number of surgeons at court. And, increasingly, those physicians come from the University of Paris. Now, within that structure, the kings become susceptible to influence. I’m not going to draw parallels to the other side of the country right now, but there’s a lot that we can learn from the Middle Ages. Court physicians and surgeons at least, I would argue, took the opportunity to influence kings to begin to adapt the marketplace in a way that they thought was better. Not the least, the royal surgeon was put in charge of all surgical practice in Paris in the late 13th century, and, as we’re about to see, the physicians were right with them. “Excellent, sir. Now, can you tell me which is Sonic Cola and which is the laxative?” [laughter] I mentioned laxatives before with Jean de Saint-Amand work. Well, it turns out there are a number of examples of people dying from what I will call laxative abuse in the Middle Ages.

Bernard de Cabanes, in 1331, gave a laxative to a certain Lord Franciscus, and he was a hosteler of St. Victor and he died. Two others died in Montpellier from laxative use. And another apothecary had theriac, which was a compounded medicine which included a laxative quality to it. He digitally manipulated his nose, which is a nice way of saying he picked his nose. He changed color, immediately lost consciousness, and had to be rescued by Bernard of Gordon. Now, I should say that while there are different variations on the theriac story, the key here is somebody who’s selling drugs doesn’t know he’s dealing with a dangerous substance, and that’s the key point to take home because the doctors here said they knew better. And as they were teaching pharmacology, Jean de Saint-Amand among them, they began to say that they could see dangers for the marketplace and something should be done about it. In fact something was done about it. In a sequence of ordinances from the kings of France from 1311 into the mid-14th century, we see a growing regulation of pharmaceutical activities in France.

Part of this, I would argue, is based on the growing interest in side effects by Jean de Saint-Amand and his cohort. There are three texts on laxatives from the 1220s to 1260s in Latin. And almost none of the prescriptions refer at all to side effects. But when you get to Jean’s work, it jumps up to about 45%. All right, if the universities physicians, and those who follow them, will continue to do this, if the university physicians are talking about side effects, does that matter in the court? Well, I would say, yes. So in 1352, we have a text associated with the King of France, who argues that “no one, of whatever sex or condition in Paris, its town or suburbs, shall henceforth make or advise the making of or dare to administer any medicine which is alternative, laxatives, syrup, lecturary or laxative pills of any sort for fear of death from the flux that will come from aggravating bad symptoms.” The activity of this administration “belongs to experts”, the university professors. They must be “masters or licentiates” in medicine, “in the said science of medicine at Paris or some other university. And unless a medicine was ordered by the advice and direction of some master or other person, it’s inappropriate otherwise.”

What I would suggest that we’re seeing here is the university dominance of knowledge, concern over side effects, and now it’s being put into law. This is, I would argue, also the birth of over-the-counter medicines because while some drugs are so dangerous that they can only be prescribed by a physician, others are not. These are the ones that have to get prescriptions, the others might not be. And this same sequence is promulgated in the series of legislations that I’m showing here, focusing in particular on both opiates and laxatives. Now, we’re in the middle of an opiate epidemic, but opiates in the Middle Ages and laxatives in the Middle Ages were different because this is not drugs that were standardized in terms of their creation. They had wide ranges of dosing even though they were prescribed in the same way. And, in fact, laxatives could be extraordinarily dangerous drugs to take, provoking profound diarrhea, dehydration, and death. The masters of university medicine were also charged to examine drugs being held by apothecaries. So they had to examine all medical laxatives and opiates which are stored for any long duration of time before they are then “compounded, and ascertain that they are still good and fresh and not corrupted,” that is not becoming dangerous. “It’s just a correction, dad. The fundamentals are still good.”

Corrections actually are part of this story because of texts. Please don’t bother reading all of this. The key points from this slide are there was a text called, “The Antidotary of Nicholas.” It was generated somewhere before 1244, in theory by a certain Nicholas at the request of his students. The students are obviously at this point. These selective remedies are listed alphabetically, and, in some ways, there’s an effort to standardize basic units of weights for the prescription and to describe how to create large quantities of medicine. This is a text that’s designed for somebody who’s not terribly sophisticated with drugs but needs to deal with relatively standardized doses and large quantities. Apothecaries, pharmacists. It rapidly became the most important text of its sort, both in Paris and throughout medieval Europe, and became required reading for medical students in 1271 in Paris, in no small measure because they needed to know what pharmacists were doing. In 1322, the University of Paris faculty pronounced on practice that whenever apothecaries dispense any recipes coming out of “The Antidotary of Nicholas,” whether they’re laxatives or opiates, ignoring other kinds of drugs, they should not prepare them until they’ve shown them to the aforementioned dean of the medical faculty.

Bob Golden would not want to have to do this job, I can tell you. “And when they prepared them, they should write upon them the month when they were made, and if they become corrupted, one should dispose of them. The masters of the apothecaries, the leaders of their guild, must maintain a corrected copy of The Antidotary of Nicholas,” to make this possible. Where did those corrections come from? They came from Jean de Saint-Amand. So Saint-Amand wrote a text called “The Exposition,” or commentary on “The Antidotary of Nicholas.” It was even more of a bestseller than his other work in terms of copies. It was highly sophisticated. It was well read at the University of Paris. In fact, copy was owned continuously by the medical deans of the University of Paris down to the current day. And it became the basis for correction of that copy that would be used by the guild hall for apothecaries in Paris.

Why am I talking about laxatives and opiates? Well, in very concrete ways, they were dangerous drugs, but they were also intriguing drugs because they acted in contrast. If you think about medieval medicine as the four humors and the four qualities, blood, phlegm, black bile and yellow bile, and hot, cold, wet, and dry, opiates and laxatives worked in contrasted ways. Opiates worked through cold therapy and laxatives, if you will, through wet. They created a balance point. And opiate would bind you up. We think of it as being sedating and analgesic. But opiates in the Middle Ages, the primary effect that was noticed was they made you constipated. If, on the other hand, you have laxatives that loosened you, those two will run in contrast. Contrast with a perfect topic for medieval universities professors to argue about over and over again, and they did so. So while this is not a harbinger for what we see with the opioid crisis today, nevertheless this constellation of features shows the medieval marketplace around medicine, opiates and laxatives, playing out in creative ways and the control of texts becomes the basis for market regulation.

So what I’ve argued so far, and I think we’re going to get to our coda, is in the setting of medicalization, of specialization, and textualization, the medical book as a technology was crucial to controlling the medical marketplace. And Jean de Saint-Amand I think was arguably one of the most important figures for that, not the least because he was involved in concordancing and alphabetizing and summarizing and CliffsNoting and standardizing and, something we didn’t talk about, he generated a number of tables to make it easier to digest information. In part, then, this was all about control of medical texts and students and then the marketplace. I think there’s another argument to be made here. This is a little bit beyond where I’m going, but I’m at least going to throw it out. The growth, development, and substantiation of the marketplace, at least in the context of the university, changed things in another way. That horizontal pyramid we saw was all about individuals. The university becomes a corporate institution, an identity, a collective, that’s not about one person about many. And Avner Greif, who’s a brilliant economic historian of the Middle Ages at Stanford, has talked a little bit about marketplace dynamics and gain theory. And I would propose that with the creation of the university and the medical school within that university, we begin to see figures thinking not just for their short-term gain but the long-term gain of the collective activity of the medical school.

“I try not to judge my doctors by the artwork in their waiting rooms, but, you know. . .” What you see is a growing number of images in the Middle Ages of doctors holding books. Books become an emblem of power and certainly of knowledge. And it’s not surprising to me that Jean de Saint-Amand, in a signal copy of one of his texts, is holding a book and holding it outward. He’s going to teach you how to use this text. And that, I think, is emblematic of what was going on. So let’s try and do the coda quickly, but this is recent work I’m doing but it blends in nicely, I hope. “Actually there’s nothing wrong with me, but by the time I get to see doctor there probably will be.”

Why are patients patient? Well, it turns out this is not as easy a question to answer as I had originally thought it was. The word itself, patiens, comes from Latin. Comes in English by way of old French and beyond. But it turns out that in Latin most of the meaning of patient is about enduring and suffering. It’s not about being patient in the simplistic sense we think of for the subject of medical gazes. And if you look at classical Latin, classical Latin authors do not talk about the patiens being a subject of the medical gaze. And yet this word is spread throughout vernaculars in western Europe. So where’s it coming from? Remember that slide before, it all begins in the Middle Ages. The historical thesaurus of the Oxford English Dictionary is an extraordinary source. A little hard to use but very, very useful. If you look for all references to being a patient in English and how they spread out over time, it turns out that most of them are variations on this one. It’s basically, think “Princess Bride,” the sickie. “How’s the sickie today?” It’s the sick person. The ill one. All these variations are exactly that. The “Sickman” in the 14th century. The “malade,” coming from French, right? All right, so if we’re not seeing it in English here, where is this coming from? There are now large databases of Latin authors that you can scroll through, better than tax rolls in 13th-14th century Paris but still very complicated. I’ve only found 130 uses, in a broad sense, to patiens in older Latin, and few to none of them actually talk about the patient as we think of it. Rather, even going into the high Middle Ages, most of the time the original Latin will talk about an egrum or igrum, which means a sickie. Modern translators don’t know what to do with this.

In fact, I think most of the time we don’t think about it. We just translate it as patient. But that’s not what this word is. It’s the sick person. So where does patience come from? I think it actually comes from philosophy and theology. So the patiens we see playing out as a scientific concept in an early portion of the late Middle Ages in philosophy as a structural causative argument. There are two qualities to an event. There’s an active participant and a passive participant. The agens is active; the patiens is passive. The agens does something to the patiens. You can see this is cosmology, you can see in philosophy. It turns out in theology it’s also in grammar. I think I included this slide. I don’t think I cut it. It’s also in sexuality. Given my daughter’s in the room, I will let your minds run with that. And lately, it comes to medicine. Now I think these guys are all playing together. They’re playing together in the university context, and the physicians hear about it and they adopt it. And we’ll see that in a minute.

I’ve got to do the grammar thing. It’s the Latinist in me. So you’re probably all familiar with direct and indirect objects and subjects of a sentence, or the active case if you will. But it turns out that when you put something into a passive voice, the active and passive role stays the same. So if the ball was hit by me and I hit the ball, I’m still the agens; the ball is still the patiens. But one is a direct object and one is a subject in one sentence versus the other. So chomp on that for a few minutes and think about the cat and mouse. In theology, this story plays out in intriguing ways, especially around art. So if you look at images of Christ up until the mid to late 13th century, it’s usually Christ as a triumphant figure on the cross. But as we move into the 14th century, it’s a suffering Christ. And as that transition occurs, there’s widespread interest in imitating Jesus on the cross, in suffering, which is why you see the flagellants appearing. Not flatulence, but flagellants. [laughter] At least attempt to have a little scatological humor with the laxatives. [laughter] So Christus patiens makes the concept of patiens very important at this time. Philosophy, as I said, is deploying it in wide measure. Thomas Aquinas, one of the most influential figures in scholastic thought, argues for the importance of patiens and passio. We see other players, from Grosseteste to Buridan, in science using patiens and agens as explanatory markers. So as we move from Antiquity into the 14th century, this concept is floating around, and, as I say, doctors grab hold of it. From the mid-13th century forward, most of my guys begin to use the term patient. I think from there it propagates outward.

Jean de Saint-Amand uses it at least 35 times in what I would consider a modern form. In one case, “In a burning fever or hypochondriacal apostemes, if there’s a pain in the front of the head and the patiens is 35 years old or less, expect a flux from the nose.” A near contemporary, Henri de Mondeville, a Royal surgeon in France, used the term in at least 262 modern ways. One of my favorite of his quotes is: “Patients ought to obey the surgeons in all things pertaining to the care of their diseases.” This is perfect. What he’s doing is making the sickie passive. Passive to the practitioner. He’s asserting his dominance in this role. And in a similar vein, it radiates out from Latin into the vernaculars. This is but one of many examples I’ve found.

In the Canterbury Tales, “He kepte his pacient a ful greet deel in houres by his magik natureel.” What happens then is patient moves out of academia and into the wider culture and marketplace. Google Ngrams are great. They’re not really accurate, but it gives you the broad sense that patient takes off fairly significantly. It spreads into a variety of languages. So what am I going to conclude with? One of my friends and colleagues, one of our friends and colleagues, Michael McVaugh, a marvelous historian of medieval medicine, has tended to see medievalists break into one of two camps. You either see continuity or discontinuity. Clearly, I’m a continuist, right? My graduate school adviser, Jerry Bylebyl, was a marvelous heart vein scholar, but one of his brief dabbles into medieval history looked at the birth of the term physician distinct from doctor. So almost alone among western languages, English uses physician. Most of the languages that are romance in origin use doctor.

Why? It’s because when English physicians broke off from natural science and natural philosophy, they wanted to keep some of the reputation of the physicist, think Stephen Hawking, and that term as physica. We became physicians. Not physicists but physicians. If we think about the pyramid I showed you before, I think it’s intriguing. The terms that characterize the marketplace most coherently, the practitioner, the physician, and the patient, are created in the 13th century in the Middle Ages. And it’s at that time that we see proto-medicalization. I suppose at one level this is not surprising since this is the time when vernacular languages are really getting their legs under them and breaking away. It’s also the time when secular institutions are growing and governmental bureaucracies are being established. It’s also when the university is setting up its pins. Being patiens, being patient, as a patient, is certainly time honored, and I think it’s at the root of much of our more recent culture.

I think our modern contemporary translators are still struggling with that, and as I’ve been spreading the word around about this, I’m hoping to see it change in terms of translations. But I would also argue that we’re going through a minor transformation ourselves. With the consumer rights movements in the 1960s and 1970s and following, patients are becoming clients. They’re no longer patients as much as they used to be. And with that change, it means something is different. Our relationship to the practitioner is different and our role is different, which I hope provokes us to ask more questions. Why are patients patient? “Mr. Wilcox, back in the little room. You haven’t waited nervous and half-naked the required 50 minutes for the doctor to see you.” [laughter] I’m going to end it there, and I thank you for your patience.
[applause]