Preface: "The Most Difficult Thing"
When a person falls seriously ill, the very nature of the event demands that something be done. Over 2000 years ago in ancient Greece, the author of the Hippocratic treatise Tradition in Medicine argued that the art of medicine came about because sick people did not recover by using the same regimen as the healthy, but required special treatment. Such treatment may come from many different sources— doctors, magi, midwives, or nurses— but before there can be cure or consolation there must be a meeting of the minds between the healer and the sick. The consultation is the very stuff of medicine, even in this day of large research laboratories and routine tests. It is a place of uncertainty about the future, a chaos that calls for a decision. The physician is prepared for his decision by virtue of his possession of a head full of ideas that allow him to make something intelligible of the potentially overwhelming sprawl of clinical detail. Thomas Sherley, a royal physician to Charles II of England, understood the challenge of clinical medicine when he spoke of "the most difficult thing in the Art of Physick, viz. the application of general precepts to particular subjects and persons."
This book examines the consultations of Sir Theodore Turquet de Mayerne (1573-1655),
a court physician to the early Stuart kings of England. After serving Henry
IV of France, Mayerne came to England in 1611, drawn by the patronage of James
I. He was already widely renowned, both for his Huguenot convictions and for
his belief in chemical medicine, enthusiasms that he would nurture in England.
An immensely colorful figure, Mayerne seems to have known everyone. He proved
a man of many projects, performing diplomatic tasks for King James, mixing
paints for the great artists of his day, and selling cosmetics to the great
ladies of the court, all while passionately pursuing the secrets of alchemy.
His practice earned him the respect of his contemporaries. Fellow physician
Baldwin Hamey singled out Mayerne's brilliance as a clinician, noting that
in his consultations, "where the virtue of the physician chiefly shines,
he performed them admirably. Indeed, in a disease he immediately brought together
what was to be known and to be done." Hamey exaggerated, for Mayerne's
perceptions were not always immediate, but often the result of considerable
deliberation.
Much of that deliberation was recorded in Mayerne's remarkable casebooks,
the Ephemerides morborum (Diaries of Disease). More than twenty large
volumes of them now reside at the British Library, handsomely bound, written
mostly in the doctor's distinctive hand, the pages slightly browned with time.
Mayerne toyed with the idea of publishing them, but died before his papers
were set right. As I began to familiarize myself with the documents I came
to believe that the most astonishing thing about them was the fact that they
existed at all. Among the written casebooks of seventeenth-century practitioners,
Mayerne's notes are unusually full, rich, and complete. He began using a distinctive
four-part form for his case notes early in his practice, and he continued
to use it for almost fifty years. Why did Mayerne bother to keep careful medical
records when most of his contemporaries did not? Convinced that the documents
were extraordinarily important to their author, I began to ask what they could
tell us about clinical medicine. Like many such documents they have a tendency
to fall suddenly silent at crucial moments, ignoring repeated requests for
more information. That is, they might record what the doctor thought
about the case, but they do not always show what he told the patient,
or, sometimes, even what he did to the patient. Still, Mayerne's careful
records allow a privileged and intimate look into the mind of an accomplished
practitioner.
Tracing the rise of medical modernity, older historians placed Mayerne in
the shadow of his fellow royal physician, William Harvey. Within the historical
profession, as well as external to it, recent events have encouraged a host
of new approaches and topics. Medicine is now likely to be examined in its
relation to political power, religious ideas, schools of thought within natural
philosophy, and the social and economic context in which it existed. Much
path-breaking work has been done to identify the number and kinds of practitioners
in various societies, to examine the claims that certain groups made to represent
a profession, to chart the emergence of a medical marketplace, and to show
how patronage affected the medical arts. The history of science has also moved
in a similar direction, as scholars began to pay attention to the parts of
early modern natural philosophy that did not fit in with nineteenth-century
positivistic understandings of science-- most famously, the traditions of
hermeticism and alchemy, abandoned by later centuries, but important to natural
philosophers from Copernicus to Newton.
External to the historical profession, while it is clear that the last few
decades have seen ever more technological progress in medicine, they have
also seen a partial unraveling of older understandings of the relationship
between physician and patient and a higher level of patient dissatisfaction—one
that cannot be entirely explained by increased and excessive expectations
on the patient's part. Historians and medical sociologists have traced the
roots of some of this dissatisfaction to nineteenth-century developments that
fundamentally altered medicine, including the advent of hospital medicine,
pathological anatomy, physical examination, the increased use of statistics,
microbiology, and the triumph of the nosological and ontological view of disease.
The patient's words became merely subjective material to be interpreted and
recorded in the objective language of the physician and the hospital chart.
Sometimes lost was a more holistic and humanistic view of medicine that realized
the importance of the non-scientific aspects of medical healing, the complexity
of illness and recovery, and the individuality of each patient. If some within
the medical profession wanted to find the lost patient, some historians began
calling for a history written from the patient's point of view.
But what do we make of practice before the nineteenth century? Of clinical
medicine before the birth of the clinic? Of the evaluation of the patient
before the rise of physical examination? Of pre-"scientific" disease
definition? We still know very little about what actually happened when a
physician of an earlier century encountered a patient. There are good reasons
for this, not the least of which is a source problem. Most interviews between
doctor and patient in Mayerne's day went unrecorded and were lost as the sound
of the words died away. "The physician's part lies hid in domestic privacy,"
wrote Samuel Johnson in his biography of Sir Thomas Browne, "and silent
duties and silent excellencies are soon forgotten." Such records as did
survive are largely the product of learned physicians and are usually rather
unrevealing of more popular styles of practice. Even where sources have extant,
writing about clinical medicine has proven to be one of the more challenging
projects in the history of medicine. The fashion for retrospective diagnosis
has passed, and historians now realize that the conceptual tools of modern
medicine diverge so greatly from those of the past that the investigator must
creatively enter a different world. There, a seemingly unimportant sign turns
out to be the crux of the case, while what appears to be a symptom proves
itself to be a disease. The more serious problem is methodological: how does
one make sense of the vast amount of clinical detail in medical casebooks
from the past? Complex narratives, masses of symptoms, multiple causes, and
pages of prescriptions make casebooks uncharted jungles. And yet the encounter
between physician and patient is central to the medical arts, the very place
where the healer's practice is chiefly made or broken. To overlook it would
be akin to writing legal history without the courtroom or church history without
the pulpit.
Some recent social historians of medicine have examined medical casebooks
from early modern Europe to very good ends. Michael MacDonald has used the
papers of Mayerne's contemporary Richard Napier to study attitudes toward
madness, insanity, and melancholy in seventeenth-century England. Ronald Sawyer
has further examined the casebooks, presenting a well-developed picture of
the social backgrounds of Napier's patients, and a portrait of Napier's eclectic
mix of learned medicine, astrology, spiritual counsel, and magic. In the German
context, Barbara Duden has used the casebooks of Johannes Storch of Eisenbach
to illuminate the history of the body, particularly the way in which Storch's
female patients understood and experienced their own bodies. While I have
profited a good deal from these works, my focus is on the medical consultation
itself and not primarily on another area of the human past such as insanity
or the history of the body.
I am aware that examining the clinical encounter is, methodologically speaking,
a risky business, since I have chosen to inhabit a land between intellectual
history and the social history of medicine. I have tended to work back and
forth between Mayerne's casebooks and several key theoretical works, including
Mayerne's own manuscript treatise on medical practice, his treatise on the
gout, and the writings of others such as Jean Fernel. I have tried not to
favor the textbooks over the casebooks, tried not to merely see in the casebooks
what the theoretical writings of Mayerne or Fernel predict that I should see.
Rather, it has seemed to me that the works of theory often posed certain questions,
all more or less variations of the following: "how would these medical
principles be applied in consultation?" If, for instance, we can ascertain
with reasonable certainty that Mayerne accepted a certain classification of
diseases, how did he then use that classification to identify the diseases
in his practice? On occasion, the reverse has occurred, and some feature of
Mayerne's casebooks inspired curiosity about the sort of theory that might
account for such an entry or practice. These are the sorts of problems that
have fascinated me from the very beginning, and, as a result, this book does
not deal primarily with either abstract theory or with patients. It intends
to show the translation of medical theory to practice within a particular
cultural setting, to make visible those moments when theory and practice did
not exist in Mayerne's mind as binary opposites, but as an integrated medical
outlook that served as the basis for action.
The results allow us to begin placing Mayerne's achievement in historical context. I argue that Mayerne was a moderate chemical physician who went out of his way to show that chemical medicine was compatible with the teachings of Galen and Hippocrates. He saw himself not so much as rejecting things from the classical past, but as adding things to it: he added chemical principles to a humoral understanding of the body, a greater empiricism to an essentially rationalist approach to medicine, an interventionist therapeutics to an older and more cautious view of therapy. Mayerne's Calvinism seems to have encouraged his aggressively empirical approach to medicine, as well as his belief in the government's responsibility to act decisively to protect the health of the public. The attempt to implement these ideas into an older medicine produced a tension-ridden and eclectic synthesis, bulging at the seams and baroque in its complexity. Mayerne conceived his casebooks from the very beginning as a tool to help him administer and defend this medicine in the potentially hazardous world of the court physician. He brilliantly adapted certain aspects of his theory to court practice, placing great emphasis on the unique characteristics of each patient and each disease. This allowed for the creation of a medical portrait that could be individually tailored for Mayerne's aristocratic patients. These portraits, the final product of Mayerne's encounter with his clients and the basis for his therapeutics, arose directly from his particular brand of chemical Galenism forged in Montpellier and Paris, and articulated at court.
The layout of the book is relatively simple. After a brief biographical chapter
introducing the broad outlines of Mayerne's life, I turn to an evaluation
of the casebooks themselves in which I describe the manuscripts, their history,
and then place them in the context of late-Renaissance medical writing. Then,
in six chapters located in the center- physically and conceptually- of the
book, I break down Mayerne's clinical encounters into the three chronological
increments of past, present, and future. Chapters Three and Four examine the
past. When Mayerne faced a suffering patient, he already lagged behind the
disease, and needed to bring himself up to date on the patient and the condition.
Chapter Three shows how Mayerne's medical theory shaped the evaluation of
his aristocratic patients, while Chapter Four will consider how he made a
key clinical judgment: the determination of the patient's temperament. Having
completed his initial evaluation of the patient, Mayerne then entered the
present and diagnosed the patient's illness. Chapter Five raises a perennial
question in the history of medicine: what is a disease? It places Mayerne's
definition and classification of disease within a broad historical context
by distinguishing his primarily physiological view of illness from later ontological
ones, and also shows how Mayerne's chemical principles affected his understanding
of disease. Chapter Six is a statistical examination of Mayerne's diagnoses
that gives a broad overview of the illness patterns recorded in the Ephemerides.
The next two chapters consider Mayerne's concern with the future. Chapter
Seven examines his administration of prognoses, with particular attention
to the ethical issues surrounding the deliverance of a fatal prognosis. Chapter
Eight surveys the principles that governed his therapeutics, focusing in particular
on Mayerne's treatment of arthritis and stones, and is a particularly good
example of how Mayerne understood and applied his chemical medicine. Another
way to get at the clinical encounter is to focus on a single case in great
detail, a method employed by Duden and others, and this is the plan adopted
in Chapter Nine, which leaves the clinical encounter as such and examines
the great controversy that erupted after the unexpected death of Prince Henry
in 1612. This chapter is offered as something of a dessert after the main
course, and shows how Mayerne functioned with a team of other healers in a
highly public case. In the last chapter I review the various constituents
of Mayerne's medical portraiture and point out certain structural similarities
between his medical ideas and baroque art and culture
In resurrecting a medical practice that has lain dead in the manuscripts for
nearly four hundred years, this book aspires to bring the medical consultation
to a more central position in the history of medicine, and to encourage patients,
healers, scholars, and the curious to think about how medical perception has
changed over the centuries.
Notes