Kitabı oku: «The Greatest Benefit to Mankind», sayfa 17
SYPHILIS
European expansion produced the ‘Columbian exchange’, a highly unequal disease trade-off in which Columbus may have brought one killer disease back from the Americas: syphilis. This broke out in 1493–4 during a war between Spain and France being waged in Italy. When Naples fell to the French, the conquerors indulged in the usual orgy of rape and pillage, and the troops and their camp-followers then scattered throughout Europe. Soon, a terrible venereal epidemic was raging. It began with genital sores, progressing to a general rash, to ulceration, and to revolting abscesses eating into bones and destroying the nose, lips and genitals, and often proving fatal.
Initially, it was called the ‘disease of Naples’, but rapidly became the ‘French Pox’ and other terms accusing this or that nation: the Spanish disease in Holland, the Polish disease in Russia, the Russian disease in Siberia, the Christian disease in Turkey and the Portuguese disease in India and Japan. For their part, the Portuguese called it the Castilian disease, and a couple of centuries later Captain Cook (1728–79), exploring the Pacific, rued that the Tahitians ‘call the venereal disease Apa no Britannia – the British disease’ (he thought they’d caught it from the French).
That some of the Spaniards at the siege of Naples had accompanied Columbus suggested an American origin for the pox (or ‘great pox’, to distinguish it from smallpox). It certainly behaved in Europe like a new disease, spreading like wildfire for a couple of decades. ‘In recent times’, reflected one sufferer, Joseph Gruenpeck (c. 1473–c. 1532):
I have seen scourges, horrible sicknesses and many infirmities affect mankind from all corners of the earth. Amongst them has crept in, from the western shores of Gaul, a disease which is so cruel, so distressing, so appalling that until now nothing so horrifying, nothing more terrible or disgusting, has ever been known on this earth.
Syphilis, we now know, is one of several diseases caused by members of the Treponema group of spirochetes, a corkscrew-shaped bacterium.* There are four clinically distinct human treponematoses (the others are pinta, yaws and bejel) and their causative organisms are virtually identical, suggesting all are descendants of an ancestral spirochete which adapted to different climates and human behaviours.
What caused this terrible outbreak? Many epidemiological possibilities have been mooted. It is feasible that some American treponemal infection merged with a similar European one to become syphilis, with both initial infections subsequently disappearing. Others maintain that venereal infections had long been present in Europe but never properly distinguished from leprosy; treponemal infections (pinta, yaws, endemic and venereal syphilis) had, it is suggested, initially presented as mild childhood illnesses, spread by casual contact and producing a measure of immunity. With improved European living standards, treponemes dependent on skin contact had become disadvantaged, being replaced by hardier, sexually transmitted strains. Thus an initially mild disorder grew more serious. A related theory holds that the spirochete had long been present in both the Old World and the New; what would explain the sixteenth-century explosion were the social disruptions of the time, especially warfare.
Like the pox itself, the debate raged – and remains unresolved to this day. But whatever the precise epidemiology, syphilis, like typhus, should be regarded as typical of the new plagues of an age of conquest and turbulence, one spread by international warfare, rising population density, changed lifestyles and sexual behaviour, the migrations of soldiers and traders, and the ebb and flow of refugees and peasants. While Europeans were establishing their empires and exporting death to aboriginal peoples, they were caught in microbial civil wars at home. Bubonic plague bounced from the Balkans to Britain, malaria was on the increase, smallpox grew more virulent, while typhus and the ‘bloody flux’ (dysentery) became camp-followers of every army. Influenza epidemics raged, especially lethal being the ‘English sweat’ (sudor Anglicus) which struck in 1485 (delaying Henry VII’s coronation), 1507, 1528, 1551 and 1578, and was described by Polydore Vergil, an Italian diplomat in London, as ‘a pestilence horrible indeed, and before which no age could endure’. John Caius’s (1510–73) A Boke of Conseill against the Disease Commonly Called the Sweat or Sweating Sickness (1552) noted the copious sweating, shivering, fever, nausea, headache, cramps, back pain, delirium and stupor. It came to crisis within twenty-four hours, with very high mortality. It was thought even worse than the plague, for plague:
commonly giveth three or four, often seven, sometimes nine … sometimes eleven, and sometimes fourteen days’ respect to whom it vexeth. But that [the sweating sickness] immediately killed some in opening their windows, some in playing with children in their street doors, some in one hour, many in two it destroyed, and at the longest, to they that merrily dined, it gave a sorrowful supper.
The ‘English sweat’ remains a riddle. Such calamities form a doleful backdrop to the Renaissance.
THE MEDICAL RENAISSANCE
From the fourteenth century Europe’s cultural and intellectual life was undergoing a mighty rebirth. First in the bustling commercial cities of Italy and later in transalpine courts, the arts and humanities were being restored to a brilliance unknown for centuries. Glory would be achieved, enthusiasts proclaimed, by burying the immediate past and emulating the ancients. New inventions were changing material culture: gunpowder, the compass and Gutenberg’s printing press. Books multiplied, and were cheered on by propagandists and educators.
Among these was the monk who quit his monastery, Desiderius Erasmus (1466–1536), who led European scholarship and culture for more than three decades. A supreme stylist, it was he who established Greek as the basis for literary and theological studies, not least through production of a restored Greek text for the New Testament. His example prompted others to produce the first Greek editions of the ancient medical authors, and he inspired young scholars and physicians to bring out the great Aldine edition of Galen (1525). He also took a keen personal interest in medicine, both as patient (he suffered from gout, kidney stone and hypochondria) and as author. His Latin versions of three of Galen’s works, The Protrepticus, The Best Method of Teaching, and The Best Doctor is also a Philosopher, were the first to be based on the Greek of the Aldine edition, and enjoyed huge success. Yet, if Erasmus promoted medical learning, he was dubious about doctors, echoing that earlier humanist, Petrarch (1304–74), who had written, ‘I have never believed in doctors nor ever will.’
Painters, philosophers and poets commended the beauty of the human form and the nobility of the human spirit, using the emblem of Vitruvian man, in which the idealized naked male human form was superimposed upon the cosmos at large. Above all perhaps, after centuries when the Church had taught mankind to renounce worldly goods for the sake of eternity, Renaissance man showed an insatiable curiosity for the materiality of the here and now, a Faustian itch to explore, know and possess every nook and cranny of creation. No wonder they became inquisitive about human bodies, which were judged to occupy a privileged status. According to the Venetian surgeon Alessandro Benedetti (c. 1450–1512),
The human body was created for the sake of the soul and stands erect among other animals, as established by divine nature and reason so that it might look upward more comfortably.… The heart was first created since it contains the principle of life and sense. Next came the brain and liver. Then nature, performing like a painter, sketched out the other members with a life-giving fluid; they gradually receive their colours from the blood, which is very abundant in man and stirs up very much heat.
Art and nature thus both drew attention to the body, and in an intellectual climate that revered the classics, no wonder there was a revival of ancient medicine. For centuries, of course, Galen had been god: the Arabs had synthesized his works and the medieval West had translated these into Latin. So why was there a need for a Galen revival?
Admiration for all things Greek was in the air. Spurred by the fall of Constantinople in 1453, Greeks like Theodore Gaza (fl. 1430–80) and his student Demetrius Chalcondylas (d. 1511) went to Italy, taking manuscripts with them and passing their knowledge to Italian humanists eager to believe that truth was at its purest in Greek sources: Plato, Aristotle, the poets and orators. These ideas were obviously applicable to medicine too, for were not its first oracles Greek?
‘Back to the sources’ (ad fontes) acquired a further incentive. From 1517 Luther and his fellow Protestants were reforming the Church by returning to the Bible as the well-spring of true religion. Every doctrinal formulation of the Catholic Church was to be rejected unless sanctioned by the Bible, and the study of Greek manuscripts, it was argued, would purify the understanding of scripture. A return to the sources promised the key to progress, and philology (the study of language) was vital to rescue truth before it was engulfed in oblivion and error. This awakening prompted a medical parallel.
The first priority for medical humanists lay in sound new translations of original Greek texts, since the Arabic and medieval Latin editions were now judged incorrect and inelegant. Technical terms had been especially susceptible to adulteration. In 1492 Nicolaus Leoniceno (1428–1524), the doyen of Greek medical scholars at Ferrara, drew attention to this in his De Plinii et aliorum in medicina erroribus [On the Errors of Pliny and of Many Others in Medicine]. Criticizing Pliny’s muddling of plant names, Leoniceno ordered a critical re-examination of medical knowledge through revitalized study of the classics. He urged the recovery and editing of ancient Greek medical texts, and promoted scholarly yet stylish new Latin versions. Scornful of the folios used in medical teaching, he criticized Arabic works such as Avicenna’s Canon for corrupting the Greek treatises they purported to honour. It was he who provided the texts for the first Galenic works to be printed in Greek, and who published Latin versions of Galenic treatises, including the Ars medica.
Leoniceno delighted in exposing howlers resulting from inept scholarship, showing how mistranslations had clouded the terminology of diseases, plants and anatomy, with dangerous consequences – people would be prescribed the wrong drugs. One of the first treatises on syphilis, his De epidemia quam vulgo morbum gallicum vocant (1497) [On the Epidemic Vulgarly Called the French Disease] predictably denied it was new: he claimed classical texts should be scrutinized and provided a philological survey of Greek terminology for skin diseases.
In later years, much was done on texts and terms as part of a wider humanist attempt to dispel the medieval murk. Terminological exactitude was, for instance, crucial in a blood-letting controversy initiated by Pierre Brissot (d. 1522), who taught that the Greek texts of Hippocrates and Galen showed blood-letting was meant to be carried out on the same side as the source of illness rather than the opposite side, as in Avicenna’s corrupt versions.
In 1525 the Aldine Press in Venice, Europe’s leading printing house, published the complete works of Galen in Greek, a landmark in the retrieval of the pure word of the ancients. For workaday practitioners, it had little relevance, for few could read Greek; but they could use the new Latin translations, which after 1525 were mainly based upon the Aldine Greek. Galen’s On the Natural Faculties was published in 1523 in a new translation by Thomas Linacre (c. 1460–1524), physician to Henry VII, and in 1531 Johann Guinther von Andernach (1487–1574) published the newly discovered text of Galen’s On Anatomical Procedures, which sparked a reappraisal of dissection. During the sixteenth century an astonishing 590 editions of Galenic treatises appeared, the main publishing centres being Paris, Lyons, Venice and Basel. There was also a Hippocrates retrieval, the first humanist Latin edition appearing in 1525, and the first Greek edition, from the Aldine Press, a year later. In 1531 Guinther von Andernach, who was also one of Vesalius’s teachers, praised the times as those when ‘medicine has been raised from the dead’, because Hippocrates and Galen – until recently ‘almost utterly corrupt’ – had ‘at last been rescued from perpetual darkness’.
Greek texts were recovered: how did that affect medicine? It boosted the idea that ancient medicine was the true one and scholars its rightful guardians and interpreters. In Paris, the medical humanist Jacobus Sylvius (1478–1555) approached Hippocrates and Galen with religious awe, declaring ‘they had never written anything in physiology or other parts of medicine that was not entirely true’. His pedantry and Galen worship culminated in an Introduction to Anatomy (1555), vindicating Galen against Vesalius. If what the eye saw at dissections did not correspond with what Galen had reported, the fault lay not with Galen but with the corpse! Puny moderns could not be expected to show so perfect a body structure as that displayed by the ancients.
Like many contemporary physicians, Sylvius was a bookworm. His Order and Way of Reading Hippocrates and Galen (1539) was one of the earliest attempts to evaluate the authenticity of the Hippocratic Corpus, as well as suggesting the best way for students to approach Galen. His enthusiasm for recovering the true Galen was widely shared. He marks the shift from Arabic to Greek Galenism, notably in his treatises on pharmacology, where he demanded a return to Galenic purity. Galen’s remedies, he argued, were mainly composed of simples; the proliferation of compound medicines (ironically called Galenicals) was an Arab error. Not everyone, however, wanted to throw overboard the medical works of the Arabs and the medievals. Avicenna and Rhazes continued to be taught in most universities, and the tradition of medieval practica – handbooks listing disorders from head to toe with a description of symptoms and treatment – was too useful to be abandoned.
Scholarly study did not just give medical writings a classical authority and style; humanism spurred innovation as well. With the proliferation of medical discourse created by print culture, questions arose as to how medicine should be structured, taught and practised. Fifteenth-century medical teaching had become centred on the ‘affections’ (the ill happenings) of the body in terms of symptoms and cures, usually in a head-to-heels order; and the tried and tested practica supplied guides to diagnosis and remedies. But that hardly passed the crucial Galenic test: the conviction that therapy had to be rationally connected to aetiology. The practica contained little on disease causation, and failed to satisfy another Galenic requirement: the view that therapy should take into consideration the distinctive characteristics of each patient – constitution, temperament, strength, age and environment. Galen’s Methodus medendi [Method of Healing], extremely influential once it was available in Thomas Linacre’s translation (1519), declared that physicians had to assess not only the cause of the illness but all aspects of the patient.
Attempts were made to overcome this problem through that characteristic Renaissance solution, the application of method, an idea dear to the French philosopher Peter Ramus (1515–72). Scholars set about reducing Galenic medicine to ‘method’ and therefore certainty. The logical approach, they insisted, would help the physician to choose the correct ‘indications’ and so get the therapies right. The humanist faith in printed texts and academic methodologies encouraged encyclopaedic systematization, which could descend into the vain and verbose pedantry satirized by playwrights; Ben Jonson has one of his characters complain:
When he discourseth of dissection,
Or any point of Anatomy: that hee tells you,
Of Vena cava, and of vena portam,
The Meseraicks, and the Mesenterium,
What does hee else but cant? … Who here does understand him?
Giambatista da Monte (1498–1552), professor of the practice of medicine at Padua, was a pioneer of the new methodology. His ‘universal method’ involved proceeding, by systematic division and elimination, from the general to the particular, from broad disease classifications to specific disorder. His book helped the doctor to run through all possibilities until a full account of the indications for cure was reached.
The idea of a foolproof method for applying Galenic medicine to the individual (the parallel with computer diagnosis comes to mind) was taken further by Sanctorius Sanctorius (Santorio: 1561–1636), professor at Padua. In his Methodi vitandorum errorum (1603) [Methods for Avoiding Errors], he urged, echoing da Monte, that medicine should not begin with particulars; one had to work from general concepts, which were to be divided and divided again. What was being promoted was a teaching device exalting learning above empiricism.
Academic medicine was not totally conservative and in thrall to Galen, however; some new ideas were proposed about disease causation and remedies. Debates flared as to whether the traditional humours and temperaments could explain all sorts of illness. New diseases like the pox and the English sweat seemed to call for something beyond the old model of temperamental imbalance. And what of the influences of the heavens, or magic? Astrological powers, like the stars or moon, were ‘occult’, and thus by definition lay outside the Aristotelian-Galenic philosophy which addressed the natural, sensory world; they gained intellectual credit, however, from the neo-Platonic, Hermetic and magical currents popularized through such authors as Marsilio Ficino (1433–99) and Pico de la Mirandola (1463–94). Hidden qualities and sympathies which defied Aristotelian categories might be at work, such as magnetism and the electric discharge of the torpedo fish. These were explained by recourse to ‘occult qualities’ or to the action of what was known as the ‘whole substance’.
Occult qualities were suspect in the eyes of many learned physicians, for they were the stock in trade of quacks, magicians and heretics. Nevertheless, thanks in part to the Platonic revival with its edifying vision of grand cosmic spiritual powers – and the undeniable fact that Plato preceded Aristotle and so was more ‘pristine’ and pure – they took hold.
Consider the career of Jean Fernel (1497–1558), one of the ornaments of the Paris medical faculty, who vowed there were some things ‘beyond the power of the elements’ (i.e., beyond Galen). Fernel devoted himself to philosophy, mathematics and classical writers such as Cicero, and wrote two major works of theoretical medicine. One was published in 1542 as De naturali parte medicinae [On the Natural Part of Medicine], reappearing in 1554 as the first book, Physiologia, of a general treatise, Medicina, which also included sections on pathology and therapeutics (Fernel introduced the terms ‘physiology’ and ‘pathology’). The other was a speculative dialogue, De abditis rerum causis (1548) [On the Hidden Causes of Things], in which two friends, Brutus and Philiatros, question the physician Eudoxus on the ‘hidden causes’ of certain diseases. In particular they ask: Is there not something in disease which is divine? The discussion ranges widely over the philosophical basis of medicine.
Fernel was a reformer of Galenic medicine who interwove other philosophical and Christian strands. His physiology had recourse to the four elements; to the qualities; to the action of innate heat, found only in living things; and to a subtle substance, mediating soul and matter, which he called spiritus (spirit), present only where there was life; his emphasis upon the workings of spirit owed much to Platonists. Fernel’s Medicina synthesized classical, medieval and Renaissance medical thought. By integrating Galenic medicine into wider Renaissance visions, his work achieved phenomenal popularity: ninety-seven complete editions or translations appeared between 1554 and 1680.
The problems posed by ‘new diseases’ forced Galenic theory to adapt. Debate raged about the nature and cause of syphilis. In his Tractado contra el mal serpentina (1539) [Treatise on the Serpentine Malady], the Spanish physician Ruy Diaz de Isla (1462–1542) judged that the great pox had been brought back from the New World, claiming he had treated Columbus’s pilot in 1493. In 1530 the Veronese physician and humanist Girolamo Fracastoro (Hieronymus Fracastorus: 14781553) published his Syphilis sive morbus gallicus [Syphilis or the French Disease], describing in verse the disgusting symptoms and treatment of the disease to which he gave the modern name. The poem tells the story of a shepherd named Syphilis who, for insulting Apollo, was punished by a ‘pestilence unknown’, which brought out ‘foul sores’ upon his body that could be washed away only with quicksilver. Fracastoro offered a clear if poetical diagnostic portrait. While the disease ‘arose in the generative organs’, it would then ‘eat away the groin’ or race through the whole body. Severe pain arose in the bones; eruptions appeared, and ‘unsightly scabs break forth, and foully defile the face and breast’.
In his more theoretical De contagione et contagiosis morbis curatione (1546) [On Contagion and the Cure of Contagious Disease], Fracastoro developed the ideas of the Greek atomist Epicurus and the Roman philosopher-poet, Lucretius, to explain contagious diseases in general by the presence of ‘seeds’, which could infect by contact at a distance, or by ‘fomites’, substances such as textiles which harboured and transmitted ‘disease seeds’. It is not likely that he thought of the seminaria (imperceptibly small particles) as micro-organisms – rather he imagined something more like a leaven or spores. A contagious disease like syphilis was, however, specific, retaining its character in person-to-person transmission.*
Whatever the cause, syphilis had to be treated – but how? Quacks offered nostrums, but the basic therapy, as recommended by Fracastoro, was the classically impeccable bleeding, together with the application to the sores of unguentum Saracenicum, a mercurial ointment long used for skin eruptions like scabies and leprosy (‘a night with Venus, a lifetime with mercury’, people quipped). Controversy raged as to how mercury cured – or rather seemed to bring improvement – but most agreed that by means of the copious salivation and sweating it raised, aided by fires and much ‘rubbing and tubbing’ in special heated barrels, the poison would be expelled. Humoralists argued that the pox produced an excess of phlegm; hence, mercury, which provoked evacuant drooling, seemed the right intervention. Therapeutic hyperthermia (induced fever) long remained popular.
Mercury treatment involved the isolation, tubbing and sweating of the patient for up to one month, though in that process the ‘cure’ might become almost indistinguishable from the disease, as mercury produced drastic side-effects, including gum ulcerations, tooth loss and bone deterioration. Given the lethality of syphilis, these side-effects could be viewed in a favourable light: had not Hippocrates taught that desperate diseases needed desperate cures? For those wary of mercury and seeking gentler specifics, sarsaparilla was recommended, as was guaiacum bark (see below). But nothing was truly effective against a frightening new disease associated with sex and partly responsible for the bleak, puritanical and often misogynistic mood pervading contemporary sermons and plays. ‘How long will a man lie i’ the earth ere he rot?’, asks Hamlet: ‘Faith,’ replies the grave-digger, ‘if he be not rotten before he die, as we have many pocky corpses now-a-days.’ The syphilis threat led authorities to close bath-houses and brothels and to victimize prostitutes; Henry VIII shut down the London ‘stews’. Many believed that it was God’s will that a disease due to vice should wreak great havoc – a view which has surfaced again today with AIDS.
