Daily Archives: 15 November 2006

Medical Professionalization in Medieval Europe, 1300s

On November 2, 1322, Madame Felicie was convicted of violating an ordinance that prohibited unlicensed healers from visiting, prescribing medications, or performing other duties for a patient, except under the guidance of a university-trained and licensed physician. The conviction was a major victory for the Paris Medical Faculty, a principal architect of the new medical pecking order, which had a pyramid-like shape. At the pinnacle was a relatively small coterie of the university-trained physicians; they practiced what we would call internal medicine. Beneath them were the general surgeons, who usually lacked academic training, although that was changing. By the early fourteenth century surgery was beginning to find a place in the medical schools. A surgeon could treat wounds, sores, abscesses, fractures, and other disorders of the limbs and skin. Beneath the general surgeon “was the barber surgeon, a kind of paramedic, who could perform minor operations, including bleeding, cupping, and applying leeches, as well as cutting hair and pulling teeth; next came the apothecary and the empiric, who usually specialized in a single condition, like hernias or cataracts. At the base of the pyramid were thousands of unlicensed healers like Madame Felicie.

To reflect their new eminence, in the decades prior to the plague, physicians began to adopt a more professional—that is, authoritative—demeanor and code of behavior. A cardinal “don’t” in the new medical etiquette was: don’t jeopardize your professional dignity by visiting patients to solicit business. “Your visit means you are putting yourself in the patient’s hands,” warned William of Saliceto, “and that is just the opposite of what you want to do, which is getting him to express a commitment to you.” A cardinal “do” in the new etiquette was to conduct a comprehensive physical exam on a first visit; the exam should include not just urinalysis, but a detailed medical history and an analysis of the patient’s breath odor, skin color, muscle tone, saliva, sweat, phlegm, and stool. Some physicians also cast a patient’s horoscope on the first visit. Another cardinal “don’t” in the new etiquette was to admit to diagnostic uncertainty. Even when in doubt, said Arnauld of Villanova, a physician should look and act authoritative and confident. For the uncertain physician, Arnauld recommended prescribing a medicine, any medicine, “that may do some good but you know can do no harm.” Another strategy was to “tell the patient and his family that [you are] prescribing this or that drug to cause this or that condition in the patient so that [they] will always be looking for something new to happen.” A third “don’t” in the new etiquette was volubility. Reticence conveyed authority, especially when combined with a grave manner; besides, said one savant, the physician who discusses his medical reasoning with the patient and his family risks letting them think that they know as much as he does, and that may tempt them to dispense with his services.

What made the university-trained physician such an impressive figure to laymen, however, was not only his authoritative bedside manner but his mastery of the arcanae of the New Galenism. Its signature principle was the theory of the four humors. For the ancient Greeks, whose thinking shaped so much medieval medicine, the number four was, like the atom, a universal building block. Everything, the Greeks believed, was made out of four of something. In the case of the physical world, the four elements were earth, wind, water, and fire; in the case of the human body, the four humors were blood, black bile, yellow bile, and phlegm. An important element in the humoral theory were the four qualities of all matter: hot and cold, wet and dry. Thus, blood was said to be hot and moist; black bile, cold and dry; yellow bile, hot and dry; and phlegm, cold and wet.

SOURCE: The Great Mortality: An Intimate History of the Black Death, the Most Devastating Plague of All Time, by John Kelly (Harper Perennial, 2006), pp. 167-169

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Human Rights Interventionism: A 1990s Flashback

The advocates of coercive interventionism have no qualms about questioning any reluctance to use force on the part of Western governments. Their response has been a consistent one of calling for more military intervention to protect human rights in Africa or the Balkans. Liberal broadsheets, like the Guardian, Independent and Observer, have been more than willing to editorialise on the need for a firmer approach. With editorials like ‘We Must Find the Stomach for Years of War over Kosovo’ and ‘There is No Alternative to This War’ the liberal press have outdone the tabloids in patriotic jingoism (Independent, 1999; Observer, 1999a). For these crusading ‘lap-top bombardiers’ even months of bombing in Kosovo was not enough. They consistently argued for ground troops and the resolve to spend more resources and effort in the struggle for human rights. Ardent interventionist Michael Ignatieff puts the case strongly:

Had we been more ruthlessly imperial, we might have been a trifle more effective. If General Schwarzkopf had allowed himself to become the General MacArthur of a conquered Iraq, the Iraqi opposition abroad might now be rebuilding the country; if the Marines were still patrolling the streets of Mogadishu, the prospects of moving Somalia forward … might be somewhat brighter; and if NATO had defended the Bosnian government with air strikes against the Serbian insurrection in April 1992 … [I]f after the Dayton peace accords of 1995, Western governments had simply taken over the administration of Bosnia … Bosnia might have been reconstructed on a more secure foundation. (1998:94)

SOURCE: From Kosovo to Kabul and Beyond: Human Rights and International Intervention, new ed., by David Chandler (Pluto Press, 2002/2006), p. 168

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