 It is my great pleasure to welcome colleague and my friend, Walt Shalik, MD, PhD, who's going to talk today about C1, D1, Teach 1, Practice and Errors in Medieval Medicine. Dr. Shalik is a historian of medicine as well as a pediatric rehabilitation physician. After receiving his degree in physics and English literature, he earned both his MD and PhD in the history of medicine from Johns Hopkins, followed by residencies in fellowships at Harvard in pediatrics and physical medicine and rehabilitation. He was a member of the faculty at Washington University in St. Louis before joining the University of Wisconsin in Madison in 2007. At the University of Wisconsin, he has appointments in orthopedics, rehabilitation, pediatrics and the history of science, among others. He is the director of disability studies and now guides research didactics for rehab medicine. He is also the medical director for Central Wisconsin Center, which assists people who have developmental disabilities. He has lectured on four continents and is widely published in areas including modern disability history, medieval pharmacology, disability and medicine, clinical research and ethics. His research has been funded by the National NIH, the NEH, the Robert Wood Johnson Foundation, the German government, among many others. Dr. Shalik has over 31 published articles on a wide variety of topics. To name a few, article he wrote with one of our colleagues, Justin Bar called, Surgeons in the Time of Plague, Guy de Choliak in the 14th century, Communication with Individuals with Intellectual Disabilities and Psychiatric Disabilities, a summary of the literature, Skeleton of the Century, American Journal of Diseases of Children and Rickets in the 1930s, published by the Archives of Pediatrics and Adolescent Medicine. Most importantly, Walt is the kind of guy who can make something like medieval medicine interesting and accessible to a wide audience. His ability to both live in a clinical world and understand how clinicians think and how they process things is really essential to being an effective educator and communicator. So it's my great pleasure to introduce our colleague and friend, Dr. Walt Shalik, who's going to give today's talk. Thank you very much, Mindy. I was saying before and just I have so many lectures open now that I want to give, I want to make sure I give you the right one, that this has been an extraordinary series that the McClean and Mindy have put together. And so I want to thank you all for the invitation to chat today. And the slide is looking good. Elena, thumbs up. Awesome. So it's really been a remarkable series. I think part of what's been intriguing to me is hearing how many of the speakers show us that ethics and history have an enormous amount to talk about. I think that's been true for years, but you guys are just are paying it out in spades. I think it's also a testimony to Mindy's great skill in bringing together such a remarkable group of people accepting myself. And I don't know anybody else who would find two of the very few MD-PhD medieval medical historians in the world and lining them up back to back with Victoria last week. So a huge tip that had to Mindy. I also wanted to say thank you to Mark. I'm not sure if he's on, but when I was the inaugural associate director of the Washu's Ethics Center, Mark was really gracious to come down and give us a talk. And it made all the difference in the world to get us rolling. And so with all that said, first thing I should mention, it looks like my camera has gone out a little bit, so I look plethoric today. But that works out really well because we're going to be talking about medieval humorism. And I think another feature that has come through from all the talks in the series, I feel, is how much the Middle Ages really has to tell us. With the first talk from Keith and opiates, I found there was an enormous amount that I could have been held in dialogue. But certainly as we've gone through the pandemic, this sits over my desk at home, the medieval plague mask, we are seeing the impact of quarantine. I quarantined 52 patients today in response to a series of staff who were positive. And we just see the 14th century keep on giving. So with those thanks, I also want to thank Mindy for asking about medieval leeches. Because if she did this a year and a half, two years ago, and it reminded me as I was trying to pull material together, but there's still a lot about medieval medicine we don't know. And it turns out leeches are a huge part of what we don't know. So there'll be a little bit of that. That all said, there is a remarkable feature of history. It doesn't so much repeat itself, but it definitely rhymes. And this image from 1930 with misinformation and anti-vaccinants, anti-vaccinationists struggling with their own internal prejudices, remind us that what goes around comes around. And I hope that you're going to see some of that today. So that was the reference to in 1930 in the 20s and early 30s, there was a strong movement against vaccines. And misinformation was a huge part of it. And we're seeing an echo of that, of course, today. So the kitchen sink is going to be in this talk. And we'll see what we get through. But part of what I want to try to do is contextualize how medicine entered academia and began to reconfigure it around itself, around the medical marketplace. Something that reverberates with us continually as we're making ethical conversations. And part of the intro I wanted to allude to in January of this year, our rehab medicine Grand Rounds invited Dr. Barry from Michigan who had started her life as an undergrad as a coder. And then when she became unattending, she was interested in figuring out how to alter billing codes so that she could maximize return. But she felt, quote, unethical about it. And she recognized that the value of increasing billing meant that the university was doing better, the hospital was doing better, and therefore they could serve more disenfranchised folk, those with access issues, disabilities, and otherwise. But it still felt icky. And part of what I want to, I'm trying to address in my broader work is to understand where that ethical component around medicine in the marketplace comes from. To try and get us into that topic, I'm going to start with, of course, an ethics case. It's the claim, what else are we going to do? So this story comes out of the 12th century. And it involves twins who are born perfect. Their parents are thrilled. People around them recognize that these are some demonstration of God's goodwill towards the world because they are so flawless. And yet as they're entering their mid-childhood, they become sick. Both of them become ill with the same kind of condition which is unlabeled. But it involves at first an attack on all five of their senses and then progressively shows that as a developmental condition it's leading towards death. The parents are just, just consulate, don't know what to do. So they call for help from physicians. And two physicians respond. And their response is, we don't know what this is. But we can see that the best thing to do is sacrifice one of the children, do an autopsy on them and figure out what the disease is. And learning from that will be able to cure the condition. So the father agrees, remember this is contextualized as the 12th century, father agrees. The autopsy is performed. The condition is determined. They don't label it force in the text. And the other child is saved. Some period of time passes. The mom is absolutely disconsolate about what has happened. And she sues the father and the doctors because of the approach taken. Now the misogyny in the text demonstrates that the mom's perspective is irrational. And the physicians and the dad are extolled as being the rational figures who helped save one of the two children. It's a remarkable text that doesn't end with an answer, which probably is appropriate in ethics. We're left with something to imagine. In this case, we don't know how the court rules. But the text itself is used in the 12th century in order to help promulgate a sense of mores of customs. It's offered through the cathedral schools, which we'll talk about in a moment, as a way of conducting the creation of rules, in this case, rhetoric, but also of intellectual conduct, that then help the graduates of the cathedral schools behave in an anticipatable fashion, extolling rationality and proper perspective. The text is associated with one teacher at the cathedral schools in the mid 12th century, Bernard Sylvesteris. And it's based on one of the declamations of the school of Quintillion from the second century. It's a poem and really the intent is to teach rhetorical style, not content, but it's clear that this text does more than that. So I'm showing you this image to remind us for the rest of the session that we know about this stuff because they were hand copied into on usually on parchment or vellum as manuscripts that would come down to us. There was no printing press in the 12th century. There was no printing press in the 13th century as the universities are taking off. And as you come across one copy in another, what medievalists will do is read the text, transliterate them, transcribe them and translate them. And then from having translated them, we'll then look for thematic patterns from which we will then begin to understand what happened. And that last word physicians moved over because this 12th century document is also teaching us about how physicians at the time were beginning to be perceived. I'm going to do a sidebar for the fellows because the disability that's evoked in this text is not going to be a primary focus of what I want to talk about. But in fact, it was critical over the 100 years that follow it because in England, there's a series of law legal texts that are loosely affiliated with a character named Henry Brackton. And these Bractonian texts in the early 13th century, amongst many other features begin to codify English law. And one feature that's codified is around the nature of what who is or is not a human being. And it turns out that infants who are born with disease or disabilities in the early 13th century, were called human beings. They were embraced into the social contract before it existed. So in this Bractonian text, I do not call a child a monster, though nature has given it syndactically or polydactyry, polydactyly too few or too many members. But because this document was copied by hand, text to manuscript to manuscript, one manuscript copyist dropped that word not. And it was critical, because all of a sudden, the grammar says, I do call a child a monster, though it's disabled. And that copy was picked up by subsequent scholars. So by the end of the 13th century in England, Jean Le Breton, who was sort of the Bractonian successor, argues that a child is born a monster if it's disabled. Now, there's a great more to be said about this. But one of the points I want to make coming out about disability in the Middle Ages is that there are transformations of the social interface between children, children with disabilities and eventually all adults with disabilities. And these could be modified by the transcription and copying that's going on. There's also a feature of this about the dangers of being a child. Gee, we better be careful with this warning label. It says, keep away from children. Medieval scholars of medicine began to increasingly argue that children were at risk if they were being treated medically. Henri Neumontville and the late 13th or late 14th century surgeon for kings in France argued that small kids and decrepit old people need smaller doses of medicine and are in grave danger from poisons. I think we're seeing, because of this, even this week, as pharmacies and the FDA CDC are still trying to figure out what to do about COVID vaccines for the smallest children. But I think there's also a reflection of what's happening with disability as we move from the Middle Ages through the early modern period and the Enlightenment, the transfer of proto-professionalization and medicalization of culture that I argue starts in the 12th and 13th centuries and then is eventually lends through governments into bioscience, philosophy, and biopolitics. Much of that will devolve around disabilities and kids with disabilities. Children with disabilities will bring so many other features of social lenses from the nature of medical practice and theory to marketplace dynamics from what is a child and what's their relationship to a family to social institutions. So all of that is a sidebar of the fellows and we can talk about, and it will pull out lots of other themes. But going back to our show, we're still stuck in the 12th century. We have this text that's being deployed to teach rhetoric, but it's also being applied to an audience that's not oblivious that doctors are doing new fangled things. So part of what I think I want to get across today is much of what is interesting today starts in the Middle Ages. Much of it will also, I think, configure for us around specialization and what I'm going to call proto-medicalization, that is the transfer of activities from society from other kinds of agents to physicians. If you look across the landscape of 11th century Europe, medicine is practiced by what a group I'm going to call healers. They're illiterate, they're largely orally and apprentice-based trained, and their practice is far-ranging, but also anomalous. It's not consistent from one individual to the next. What begins to happen is as we move from the 11th into the 12th century, there's a separation, a specialization of activities. Physicians begin to distance themselves from surgeons. They say the manualist of the surgeon is different from I, the textualist, the physician who understands what's happening. And we still see echoes of that today. Columbia University's School of Medicine is the College of Physicians and Surgeons, right? You see it in some organizations both in the UK and in Philadelphia. PNS is because of this separation in the mid-12th century. Now that separation occurs in part because the growth of teaching. Learning, knowledge, textualism in the early medieval period largely resided in monasteries. There was some learning that was transferred from monk to monk, from elder monk to novice. But as the Carolingians began to embrace the notion of wider teaching, because it would help them in their governmental bureaucracy and administration, Charlemagne placed schools into cathedrals. So we see the birth of the cathedral schools in the latter part of the early Middle Ages. And medicine plays out in different ways, in different settings, monasteries to cathedral schools, celeros and epicycle, and then eventually universities in the late 12th and 13th centuries. Universities, in fact, are another huge gift of the Middle Ages to us today. You're sitting in a university, I'm sitting in a university. These are inventions of Western Europe in the 12th and 13th centuries. And the idea was so popular it spread like wildfire from country to country and in part from court to court because it's seen as a prestige factor. Under the aegis of these learning environments, this specialization continued to occur. So apothecaries, pharmacists began to separate themselves off from physicians and surgeons. We still see apprenticed healers hanging on, herbalists and barbers continue to practice kinds of medicine. But by the late 13th century, these figures begin to configure themselves into a social structure, a kind of pyramid of medical practice with, naturally, the alerted physicians sitting at the top of the pyramid and everybody else downstream. Now, the differences of the strength of the specialization and the barriers between the different specialties could have porosity to it at different times and those exceptions could be intriguing. But for us today, it's largely going to be this kind of a pyramid. And the pyramid is driven up by textualism and it's driven down by competition. So as physicians, as medicine enters the new fangled university, it begins to struggle with its identity within the medical marketplace. And in doing so, some of that ickiness that we saw with Dr. Berry at the beginning begins to enter. Now, another feature of this story I keep mentioning textualism as an MD-PhD historian, I'm actually part of the tradition of academic physicians in the Middle Ages because most of what they did was read old books and transfer the ideas into a more contemporary context, which is exactly what Mindy does. I do and many of the speakers who you've heard this year. That textualism was another critical transition that occurs as we move from, say, the 10th into the 13th century. Because most knowledge in Western Europe, in the early Middle Ages, was conveyed orally. This is an image of the Beowulf text, which probably got its roots in oral formulaic creations. But as we move into the 12th century, as Brian Stock has argued, man began to think of facts not as recorded by text, but as embodied them. And so it became an issue of being able to search through large treasure troves of documents in order to be able to make sense of what was happening. And this became the lifeblood of universities. One figure who was critical in this story is a character named Jean de Saint-Tamol. Somebody had been studying for decades. He was one of the first professors at the University of Paris. And as he would argue in the introduction to one of his texts, he created his written works in order to help the students who would spend sleepless nights searching for information that they could not otherwise find in order to try and quench their thirsty and weary spirits. So his texts began to coordinate and organize that information, a kind of recollection of memory of these texts. His work, the primary work, the recollection of memory, was divided into three parts, kind of a cliff notes or spark notes abbreviation of a series of major textbooks of medicine, largely from Galen and Apocrates. And then he created a concordance. The concordance was in fact, like you think of it, based on the biblical concordance. The biblical concordance was invented in mid-13th century Paris because professors of theology were trying to teach students and they needed to be able to quickly access references in the Bible. And a biblical concordance was the way to do it. Saint-Tamol looked at this biblical concordance in 13th century Paris where he was on faculty and said, hey, this could be good in medicine too. So what he did was transferred this technology wholesale into medical texts. The problem was the Bible was highly organized, but these handwritten copies of Galenic and Hippocratic texts were not. He had to find some way of citation. So he created a very simple but consistent way of saying, I'm going to divide each book or chapter of a book from Galen or Apocrates into a beginning, a middle, and a net. And from that basic citational strategy, I'll be able to in essence footnote where you should go when you're looking up a source. His idea rapidly grabbed hold. Montevil and others began to use this concordancing idea as they themselves were citing other sources. And I would say that the echo for us, the rhyming that we hear going on in 13th century university medicine is a little like the World Wide Web. It's a little like the library. It is gathering together huge troves of data and making it more digestibly useful for students. So Jean was doing all of this. What was he actually writing about? Well, it turns out a fair portion of what he wrote about was pharmacology, which is why I got into medieval pharmacology. Why? Why was this important to him? What I would say is a university professor, he practiced in the context of medieval Paris, and there he would see pharmacists peddling their wares. Almost none of the pharmacists left us documentation to know who they were and what they did. So for a medievalist, what we have to do is find a way to voice the voiceless. One way I've done that is to go through medieval tax rolls looking for evidence of pharmaceutical practitioners. These are boring documents to go through, but they do yield interesting insights. So in going through these documents, I'm able to characterize both numbers of pharmaceutical practitioners, but also the amount of tax they paid. And working off of a simple presupposition that the more tax you paid, the more you've made, which of course is not always true, but is at least a good thumbnail for the time, you begin to characterize the range of pharmaceutical practitioners in 13th century and early 14th century Paris. And it turns out that there was a relative hierarchy of these figures. The apothecaries, the pharmacists surmounted the broader healers and herbalists in both the numbers and amounts of money they were able to generate. So what we'll begin to see is a complexification of this pyramid. Physicians are still on top, but they're competing against a bunch of other kinds of characters, including drug peddlers. One last feature of these tax rolls is that they give you a sense of geography and topography. It turns out that most drug sellers who were not itinerant, who had actual shops, were congregated on both the marketplace on the right bank of 13th century and early 14th century Paris, but also on the little bridge, the petit pont that connected the university with the city, the Ile de la Cité, where Notre-Dame was, and the royal palace. So the petit pont at this time was rather like the Pont de Vecchio is today. It's a short bridge in the middle of a major metropolis, and at this time Paris was the most populous city in western Europe. And the sides of the bridge have buildings on them. So as you walk along the center of the bridge, you are walking past shop after shop, and many of these shops were pharmacies. We have, as I said, very few voices for these characters, but one comes out of a poem in the middle of the 13th century by a famous medieval French poet Ruth Bove. Gentlemen, my lords, everybody here, small and great, young and old, know well, 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 have traveled in quite a few countries. The Lord of Cairo retained me for more than a summer. I can't see all of my the words, so hopefully I get most of it right. I stayed for a long time with it, and I learned a lot. I earned a lot of money. Good people, I am not one of those poor moralizers, nor one of those poor merchants of simple, who come before the churches with their poor unstitched cloaks, tearing boxes and bags, and stretch out a carpet to share their wares. There are some merchants, a peppering of Cuban, without having even as many bags as the others, but know you this, I am not one of them. Rather, I am in the service to a lady named Deng Trot of Salerno. Now this huckster, this barker, if you will, selling his wares, was clearly perceptible, understandable to the audience reading or hearing Ruth's work. What comes out of this language is a couple of things for me. First and foremost, he's obviously being known. He wants money, he wants to sell, and you're seeing echoes of this worry in Dr. Berry's reference in her January grand round. But he's also using reference to the arcane, to the unusual, and to the learned. He talks about Egypt and the Lord of Cairo. He talks about Deng Trotula of Salerno, who was perceived as an elite medical authority, despite being a woman in 12th and 13th century France. And she's a far more complicated story that we're going to go through today. But what we're seeing is this barker is deploying the kinds of elements that medieval elite physicians are using in order to buttress his marketplace dynamic. And the physicians were not unaware of this. One gadfly, Roger Bacon, who was on faculty in Paris, argued, the ordinary doctor knows nothing about simple drugs, but entrust 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 the drugs. This kind of sense, this topos of huckstering, and actually being perceived as huckstering, begins to help us understand that the Parisian medical marketplace was one of contentious dyads, theory versus practice, elite versus lay, literate versus oral. Into this step, the university faculty who begin to, I think, pull out some of the mores of the cathedral schools, some of the regulate, the regulations, and begin to argue that the marketplace needs to be controlled. And they turn to the royal court. Part of the work I've done looks at the evolution of the royal physician across time in the French and English court. And in fact, there's a growing number of university faculty who become the royal physician. Likewise, royal surgeons, as they try and move up that pyramid of medical practice, also put themselves into positions of elite status. And they use their position at the royal court to begin to argue for regulation. Excellent, sir. Now, can you tell me which is Sonicola and which is the laxative? This kind of hucksterism needs to be controlled because, in fact, there are cases that we see in manuscripts, but we know there are many more in which laxatives led to death. And we think today of laxatives and perhaps laxative abuse as more of a nuisance or a basic over-the-counter activity. But in the Middle Ages, where no regulation of production was assured, you had no idea what dose you were getting. And so death was possible. As a consequence, the medieval university medical professor standing up before his trainees begins to say, look, I'm walking that teep hole every day as I go to the royal court, as I go to Notre Dame, and I hear these hucksters selling their wares. There's a problem here. They take their ideas to the king, and we see a sequence of royal ordinances begin to be promulgated in the beginning of the 14th century, regulating both the nature of apothecaries and their practice. Some of this is built to an apotheosis in the middle of the 14th century, where we are seeing that the court is willing to back the master or licensure in medicine to be the sole dispenser or at least the sole orderer of drugs that are dangerous. I would argue that this is one of the first instances we see of the medical order of the prescription. In fact, there'll begin to be a separation of what we would call over-the-counter drugs and drugs that require prescription all based on this notion of danger to the community. Well, in fact, the notion of danger is enhanced for medical authors by looking at listings of drugs. And in fact, Jean will be one of the first to emphasize side effects. Side effects become the bedroir for the elite ordering physician. You don't use this drug, but you've got to be careful because that may happen. And that may happen, and most people don't know it. Only I, a university professor, will know this. The regulation of drug sellers and spice sellers, in fact, increasingly focuses in on opiates and laxatives. In the Middle Ages, these were contrastive medicines. An opiate tend to bind you up. A laxative tended to loosen you up. And they could be balanced, but they could also be used individually. Eventually, masters of medicine are expected to examine all laxatives and opiates, which are stored for any period of time before they can be compounded to be sure they are good and fresh. So imagine the dean at the University of Chicago is expected to go around and assess the wares at every pharmacy in Chicago. Crazy, but that's what's happening at the University of Paris in the middle of the 14th century. It's just a correction. The fundamentals are still good. In fact, texts become the basis of this kind of evaluation. Jean de Saint-Tamol, one of his premier texts, is a corrective text, an expository text on a primary document, the antidotary of Nicholas, which was used by many pharmacies as a dispensing document. So Jean's corrections of the pharmacist Pharmacopeia becomes the basis for both the Guild of Apothecaries and the medical deans at the University of Paris to be able to correct the wares that are being used and dispensed by pharmacists. What we see is a further instantiation of that vertical pyramid with the literary textualists surmounting everybody else. We see in this also some of the echoes of the opiate challenges we faced over the last several decades of the United States. Now there are other kinds of practices that we could examine. This is my tip of the hat to Mindy. When she reached out to me about the leeches, we go to Canada every year and I remember seeing this story that a drug significant Beagle helped bust a man who was importing 5,000 leeches in and he was caught at the Toronto airport. Leech importation, actually John Harley Warner has a beautiful description of 19th century lechery, if you will, importations in France and Paris, which I think the highest number I remember is something like 3 million leeches are imported into Paris in early 19th century France. Well, obviously the Canadians are trying to catch up a little while later. Leech therapy, of course, has made a comeback. The NHS at the Oxford hospitals has patient information about when you're going to use leeches. In fact, there is an alternative health focus on leech therapy, which I would love to talk more about. But when Mindy asked her question, I realized we actually, medical historians don't talk about it much. A colleague Claire Pillsworth has a wonderful book on early medieval Northern Italian medicine, more to life than leeches, but she herself in a number of points says, you know, actually there wasn't a lot of leeching going on that she can see in early medieval Italian medicine. So you have to scratch deeper. So this will eventually be another side project with which Mindy is going to get this huge introductory footnote on. But one of the intriguing sets of stories to come out of investigating leeches, Alexander Neckum, who was teaching in Paris in the 12th century, in fact, near the Petit Pont, describes a plague of leeches that descends upon naples. And the people go nuts, rather like the mother and father in the story we talked about in the beginning. They bring in a medieval necromancer, Virgil, and it, yes, is that Virgil in his mythical status. He recommends making a golden statue of a leech and putting it into a well. And this apparently drives the leeches crazy and they all leave. The greed of the citizens is such that they then take the golden statue back out. What happens? The leeches return. What we see here is leeches are at the middle of practice, knowledge, and greed, which of course makes sense because the idea of a blood-sucking leech is just like the idea of a blood-sucking lecherous doctor or lawyer. It's an image that in fact begins to grow at this time. What's also interesting is I was digging through more material to try and share back to Mindy eventually. There's a galenic text, probably not by Galen, that it survives in three or four manuscripts that talks about phlebotomy and leeches. Now it doesn't appear to me that Galen was actually interested in leeches, but the fact that medieval textualists felt that he was is going to be worth more investigation. Leeches were associated with water. And in fact, for medical authors, images like this from Alde Brondino of Siena, and there are about eight of these variant images, you stick your legs into water and leeches swim up to you on glob hold began to provoke the notion that maybe they could be used in different ways, of course, but it looks to me like very few times was phlebotomy done with leeches. Leeches could be used for other things, though. There's a brilliant image from the late 14th century of ground up leeches being applied with pork fat and ash to collice and bugs and other body vermin that could be problematic. And it's such vermin were also considered worms as was the leech. So it's using one worm to go after another. The metaphorical power of leeches also was tightly associated with sin. So Peter Damian, writing to Cunebert argues that there's this downward spiral. You start with leeches and monsters, and eventually you wind up in hell, which is a contrastive concern for professional practitioners. I can talk about this at another time. It's going to be interesting for money, but I'm just going to stick to the courts, both of England and France, got increasingly interested in blood and removal of blood, not the least because when Henry III in England in the middle of the 13th century received a gift from the Levant supposedly containing the blood of Christ, there was an rising interest in the products of bodies, the separations of bodies and the meaning of blood on a daily basis so that healers and phlebotomists at the courts, both of France and of England, began to take a more important role. These interests began to occur simultaneous with the rebirth of dissection, which had largely been, let's say, outlawed since late antiquity. And that occurred simultaneous with an increasing interest in reliquary dismemberment. Saints' bodies would be separated out and deposited a finger bone of a saint here, the jaw bone of a saint there, the blood of Christ here, in order to drive in miraculous penitence. And this interest in separating bodies and body parts helps provoke different in northern rather than southern Europe and interest in separating the body, which is an echo of what we heard with Bernard of Sylvesterus and the twins. I think I'm going to jump through this section very quickly. Along with leachcraft, which I think begins to go through transitions at this point, newfangled medicines are also invented. Distillation is imported from the Arabic world into the Latinate world in the form of the water of life, aquavidae. Jean de Saint-Tamol writes about the water of life, and he does so at a time when chemical medicine, as Michael McVaw has argued, is beginning to specialize in how you produce items, drugs, chemicals, pharmaceuticals, and foodstuffs. Physicians begin to grab hold of it earlier than surgeons do, but both begin to see it's a tool for the medical marketplace. And in fact, you see a geometric growth and transmission of ideas around the water of life in the 13th into the 16th centuries. Not only are the number of documents written about the water of life accelerating, but so too are the kinds of diseases that are healed by it. Rather like what we saw in the middle of the 20th century with the invention of steroids and doctors applied steroids to everything, clearly distilled alcohol was going to be a tool, a newfangled tool for marketplace physicians. And I think there was good reason for the implantation of the newfangled. As John of Mirfield argued in the middle of the late part of the 14th and early 15th century, patients were impatient. They wanted to be cured right away. Many sick people nowadays are exceedingly impatient. They can't wait around until the 4th or 5th day to see if they are going to get better for the packet matter to be digested and expelled the way they used to do in the old days. Indeed, unless they get an improvement right away the first day, they're distrustful of you. This is a problem. So looking for transformative medications became an inspiration for innovation in the medieval marketplace. So much so that non-medical practitioners like Dominican friars were beginning to use distillation techniques and had to be told stop doing that. I think it's an echo of what we were seeing with Roger Bacon before. You really had to have a literate knowledge to be able to apply this innovation in the appropriate way. Because in fact, there were month banks out there peddling aquavite that was false or using it in ways that patients died from. So again, even with new drugs and probably even with leachcraft, regulation was necessary. One other echo from the Cathedral School image of the twins is another kind of practitioner. So in going through the tax rolls from 13th and 14th century France, I found a surprising number of women who were listed as apothecaries or drug sellers. And in two years, the most tax was paid by a woman, D'Amparonelle. She was active in a number of sites in France, but clearly she was a representation for medical practitioners of university practitioners of another source of competition, women. So when the medical faculty in 1271 makes their own statement of restriction of practice in Paris, they don't just say any surgeon or apothecary. They are explicit in saying male or female, because they know they need to regulate women. And there's an entire another talk I could do about the dichotomy that begins to emerge, a female practice in the Middle Ages. But in fact, they go so far as to prosecute female practitioners, the most famous of whom Jacqueline Fedeci is holed up in front of a tribunal. And the medical faculty say, look, it's wrong because we said so in 1271. We said so 200 years ago, which is a fabrication, because they didn't exist in 1071. We have royal practitioners who are against it. She's ignorant. She's unlettered. She only knows oral knowledge. She hasn't been approved as competent. She isn't licensed. When women can't practice law, why should they practice medicine and think about what would happen if she kills somebody? That would be bad. She is not a licensed practitioner. Her defense was, look, the doctors tried treating the patients I've treated, and they didn't get anywhere. I was called in to help after the fact. If they weren't doing any better with your help and I'm able to cure them, how come I shouldn't be able to practice? Her reputation was sufficient that people came to her. She didn't ask for money up front. Other people are doing it. And you know what? No taxation without representation. I didn't vote for this rule. How come I'm governed by this rule too? And in the end, if you have to limit my practice, maybe it's better that women should treat women. She lost the case just as women in Valencia would lose and in parts of Italy, but what we begin to see is not so much the individual case as frustrating as it is, but the fact that the medical faculty felt they needed to protect themselves in a competitive marketplace. Regulation becomes a tool, an interface between medical knowledge, elite status, and the control of the mores, I think, coming out of cathedral schools. As I said, there are many other kinds of women practicing and more stories to be told here. So part of this extra epicycle in this story is that another set of dyads are created. The static nature of increasingly masculine medicine and the itinerant nature of more feminine medicine become crucial. The word of mouth and women going from person to person to learn what best to do. All of this create a very complex marketplace, which leads me to my final points about medical errors. What's Scandinavian about cardboard? It's from Ikea. I love this cartoon because of the story of the Swedish ship Vasa. It was at the time the most advanced warship anywhere in Europe. This was a story about the ship that was extremely expensive. It goes on its maiden voyage and as it sets sail, it begins to sink. Now, I first came across this story because my mother, who worked for Joseph Gerand and was the editor of his quality control handbook, he was one of the inventors of quality control in the United States, commissioned an image of the sinking of the Vasa for one of their manuals in order to highlight that quality control is crucial even in the 17th century. On a daily basis, we as educators and physicians are daily looking for errors to root out errors, grading students, preventing our own errors in our scholarship, and of course identifying errors in our colleagues. Medical errors, and I've been privileged to study with several of the founders of healthcare quality improvement and Dave Gustafson Sr., a colleague on the lower left, continue to remind us that we are awash in systems errors in medical management. The IOM, now the NAM, came out to errors human and remind us that untold deaths continue to be associated with medical errors. For many of us thus, errors are a critical point to deal with on a daily basis, but they're also a nightmare. I think the history of medical errors is much older. You can Google Ngram medical errors and obviously there's a history to the use of the term errors. The IOM didn't appeal to it except a brief reference to Hippocrates, they needed more medical historians. What I'm going to share in the next couple of minutes is just a Latinate history. There is in fact a deeper root to the etymology of errors. Most of its intrinsic meaning comes from meandering. It can be meandering actually, it can be meandering mentally, it can relate to meandering that's so bad that it becomes a total derangement of intellectual capacity, but as we move from antiquity into the late, into the early Middle Ages and beyond, there's an increasing core meaning of for error, of a departure from the truth. Isidore of Seville, his etymology is a touchstone for medievalist. He was not a scientific etymologist so you can't trust anything he says, but it's always interesting when you read it. He affirms that the cessation of errors is really important in conjunction with confession. And in fact, we begin to see this linkage of errors and moralism. Remember again, Professor Berry talking about her ickiness sense of being unethical. There is a crescendoing interest in rooting out errors of all intellectual capacity. A German cleric who was trained in Paris and one medieval manuscript creates a neologism, the Orophilus, somebody who loves errors and that Orophilus needs to be constrained. So much so that St. Bernard will write to Pope Innocent II to attack the errors of Peter Abelard and it will be a rising feature as the hunts for heresy go on in the 13th and 14th century. But medicine, it doesn't appear in these early texts to be linked to medical errors. Until we get to the cathedral schools in the 13th century. And here, no less a figure than John of Salisbury and his polycraticus will argue that physiology, which is one term for physicians at this time, need to be cautious around errors, understanding the meaning of assignment of etiology and causation. This is an allusion to my dissertation advisor, Jerry Beilbel, who was a faculty at the University of Chicago. And he looked at the separation of the word medicus from physicals, both of which could be applied to referring to a doctor at different times. In English, we refer to a doctor as a physician, from Physique. But in French, it's a medzah from medicus. And it depends on where the specialization breaks off in time. And so John of Salisbury and the polycraticus is probably applying to both a natural scientist and a physician. Moralism becomes important. But it becomes important, especially in the universities. As as high scholastics will begin to argue, the way to avoid errors is to study. And if you haven't studied, it's hard to avoid those errors. And you make yourself available to heresies. So much so, that professors themselves, if they aren't studying the right stuff, and here, he's referring to you should be studying theology, not philosophers, like Elena's backdrop, that that can lead you into error. But it will increasingly become important for the specialization of medicine. So as Saint Bonaventure will argue, I would call myself a fool if I wish to, fortunately, the images of folks in the background is covering this. But if I wish to read a pulse, I would have been in error because I would have not read medicine. Others will begin to say the same thing. Physicians utter that which is medical Smith's handle tools, you have to study and train to become specialized appropriately. I think theology affected medicine in profound ways at this time, because both were in the Newfangled University. And I think medicine adopts errors. I'll just zoom through this. Some of the big three authors at the time, Jean de Saint-Mont, as well as Arnoldo Villanova, and in Bologna today, Walter Roddy, will become critical to absorbing Galen, galactic translations from Greek into Latin eventually, by way of Arabic, and begin to make sense of them. They do so and they begin to root out errors. Errors can occur in interpretation. Errors can occur in production of new knowledge. And errors can occur in practice. Arnoldo Villanova will argue so. Alderotti will argue so and say that dangers, especially around drugs, are important. And Jean will certainly do so. And each of them are talking about errors. I think this becomes part of the language of Roger Bacon. When he sees the ignorant apothecary and the ordinary doctor who is ignorant as well, it's because they're easily coaxed into error just as a heretic would be. And so as Arnoldo Villanova will argue, it's important for the learned physician to correct his assistance, the apothecaries, and others in his instructions. I think there's an echo of Jean's concern about side effects. And all of this comes back to specifics. Here, Walter Eagle, Walter Aguilon, is concerned about narcotics, causing great errors in prescription. And that's part of the reason that opiates are regulated. Jean is concerned that doctors get the names wrong. And in fact, that's why correcting with his text is so important. Other authors will write as well. In the end, though, as Villanova is pointing out, the doctor should always command the patient to follow his instructions. And that's a final change at this time. It's the birth of what I would say is the modern notion of the patient. Actually, there's nothing wrong with you, but by the time I see the doctor, they're probably wrong. Patients actually are designed to be long suffering and patient. If you look at the etymology, it's in the very root of the word to suffer and to endure. It's well-attested in classical Latin, but not medically. And yet, the word patient is widely dispersed etymologically in romance languages in Western Europe. I would argue that this is a longer talk, that it's because of the changing notion of suffering in the high Middle Ages. As you move from the 11th to 12th centuries into the 13th and 14th centuries, the image of Jesus on the cross is shifted from a triumphalist Christ into a suffering Christ. And the emulation of Jesus in that fashion becomes something that is widely desired. That's where the flagellants come from, people who whip themselves. There is a changing notion then of what pain means at this time, such that elsewhere I've argued that a growth of understanding of nerves as explanatory models and the interface with touch and pain begin to shift the power of pain in the medical context. And we begin to think of different ways of understanding our patient's pain, such that we begin to deploy new kinds of ideologies and treatments around each of these kinds of new neuralistic conditions, echoing back to what Keith Whaley was saying in the first session of the seminars. Jean and his congener will begin to use this newfangled way of describing the patients, the patiens. No longer are they the sickie of the Princess Bride and the grandfather, now they are the suffering person who needs to be treated and demoted, put at the beck and call of the physician who is going to prescribe. And the patients ought to obey surgeons and physicians in all things pertaining to the care of their diseases. There's a reason that the word patient is so widespread in its etymology in modern languages. So if we turn back to Dr. Berry, why was she feeling icky about this? It's because she's dealing with 800 years of history that all invoke ethical concerns and separations in the marketplace between good morays and bad customs, doing the right thing and following the wrong rule. I think we also see that in the cathedral schools. We don't need to read this, but one of the points I'm making here, and this is from another one of my Dr. Vater, John Baldwin, who looked at the birth of the concept of the just price in 12th and 13th century Europe and focusing on France. We see a moralizing of the marketplace concepts and a pretensity to finding failings and errors in medicine as it transitions from a non-university into a university discipline. I would and join us all to remember that the ethics that we're dealing with so often are coming out of these morays. The proto professionalization that is medicine are interfaced with theology and the other higher arts, as well as how we deal with conflict, conflict in the marketplace, regulations, laws, lawsuits, and the object of our cares, the patient who has been demoted. All of this comes through from the stories I've tried to share today. I was going to, Mindy was asking how I, if I could share where I, where some of my ideas out my career is unfolded, I'll save that for the fellows. I'd like to thank a variety of funders over the years and certainly thank you for your patience, your long suffering today, and I'll end there. Well, thank you, Walt. That was obviously unlike any lecture we've had so far this and it's also reminds us, you know, I know that medievalists like to tell us this, but really so much of modern medicine really has its roots deep in the Middle Ages. And, you know, between the university and, you know, the separations of, I mean, people are always amazed to learn the difference, the whole physician, surgeon, apothecary, triad and how that morphs into different things. So I just thought that was absolutely fascinating. And, you know, it is interesting that I like the idea that you said they took on errors. And if you think about it, we have a figure to make the institution kind of absorb the blame or absorb changes so that we not be personally responsible, you know, we're always trying to look for systemic fixes to things that we've personally experienced. So I think this was really absolutely fascinating. And anybody who thinks the Middle Ages was a boring static time to hear a talk from you. So I'm going to end up to questions, you know, because several people in the chat were interested. So one of our colleagues, Peggy Mason, said there's an interesting book that she read. It wasn't a terrific book, but it was just, well, it wasn't terrific because it wasn't well written, but it's called Index, A History of... Oh, yes. Yeah. And she said, and I think the title was, let me get that because I thought it had a really catchy concept. It is a bookish adventure from medieval manuscripts to the digital age by a man named Dennis Duncan. She thought that was actually an interesting link to what you were talking about. But I'm going to agree with both sides of her comment, both that it's great and fun and definitely linked to what we're talking about. And it's not as good as it could be, but it's still a very entertaining read. And the index of that book, the index of the index is kind of interesting. Great. Well, I'm going to first call on Jay Carlson and then Dr. Ekmat. So... Hi, thanks. Thanks for this really interesting talk. I'm a philosopher by trade, but I'm always impressed by the details, how the historical details still remain highly, highly relevant. Your talk actually brought to mind sort of what I think last year I read Paul Star's Social Transformation of American Medicine. And one of the sort of things that stuck out to me in his story is the sort of 19th century, the role of sort of advertising that physicians used as a way of consolidating their sort of guild, as it were, but also as a way of sort of leveraging advertising regulations to stamp out quacks, the people who pleased their customers, but not their colleagues. And so I'm curious, I mean, obviously we're dealing, we deal with lots of ethical issues involving advertising and medicine with us now. I'm curious in the period that you've done research, obviously you have the story of this carnival, you call it a carnival barker. Yep. Step right up for this. But I'm curious if there are other areas of advertising or the relevant, the analogical equivalent is taking place here in that period? So brilliant. I'm both, because I love that you're reading Paul Star. I remember when I started grad school, having started my first years of medical school and then transitioning into history of medicine, I found thing after thing echo after echo in Star's book, both for what I was experiencing as a medical student and as a contemporary in our culture, but also for the Middle Ages. I think there's a recapitulation of Western European medicalization over 800 years into the 250, 300 years that they're embraced in Star's book and do a degree in Ken Ludmer's work too. That all said, getting to the advertisement. You've said it right. There is no advertisement like we think of it, but there was definitely transmission of idea within the marketplace to try and both educate, but also bring in business. And that's the complex dualism around pharmaceutical advertisement, right? You're educating patients, which is a big change in the United States over the last 30 years, and Nancy Tom's book is a perfect example of that, but also educating practitioners, the latest drug. It's been a while since I was in a pharmacology class. I need to learn about the latest thing, and that's where the pharmaceutical companies were coming. I think there were echoes of that back then too. So we're stuck. We need the manuscripts to show us, but it appears to me that both the physicians and to a lesser extent the others were doing exactly that. Hey, ma'am, come up here. Let me tell you what I'm doing. Let me explain. Here's a free sample, and then you need to come back, and then go tell your friends, and so on and so on and so forth. I think it's the same story. It's just the differences, the media, the technology that allows it to occur so that the megaphone was the individual, and you spread out your blanket, you put your drugs there, and you have a few people that you call in. It's the distance of your voice, with the exception of those who could write. Those who could write could, in essence, spread their fame and their ideas more widely, and that's why it looks like the faculty, the professors, do better at it, but it's clear from the lawsuits that they don't. I think word of mouth on the ground wins. I think the reality is the unlicensed practitioner, drug seller, is dominating the market, and the physicians are really fighting rearguard actions, and I think part of the point I wanted to go for, for Mindy, the reason many of our problems are so intractable is not because it's because they're 800 years old. We created these structures and systems, and we're still struggling with them. The moralism around errors, Mindy, it starts in the 12th century, so what Professor Berry was worried about, she's dealing with an 800-year-old moralism, and to try and unpack that and feel better about it is difficult, and that's why we need philosophers and ethicists and historians to work together to be able to see that. I'm trying to answer your question in the paucity of data we have, but I think what you're really getting at is the echoes, the roots, which are just brilliant. Thank you. Dr. Heckmack, you want to unmute yourself? We'd love to hear. You're still muted. Unmute, yeah. A large amount of information is distributed through the news and political parties. This COVID shows us how much of information was misinformation, right information, wrong information. It is hard to convince our patients to even get vaccination. We still do not know whether it is effective to wear masks or not. What do you think of the moral responsibility and ethical responsibility that we all relate to the physician toward the news agencies? Hardly ever one criticizes them or bring them to some kind of level that one approaches the physician with. Interesting. I assume you're asking this in a modern context rather than medieval. Today I am talking about so much information is given by journalists and some of them based on the political views. There are so many ways I could respond to this and what I'm trying to do is think of the one that's going to be most useful. I think the way I'll respond to it is reflect back on a point I was raising. The story I told you is one of society transferring social authority and power to one group. That's in this case to doctors. That's a process of medicalization. To a degree it's a bit of Paul Starr's argument. What I think we've been seeing is an erosion over the last 20-30 years of the social valuation of experts. That erosion has been variously studied. What I think you're highlighting is the interface of journalistic expertise and medical expertise or even scientific expertise. Those at times finding the journalistic stories perhaps undercutting the authority of the physician. In some ways that story is not new. The 1930 image I started with certainly the doctors in the 13th and 14th centuries were trying to assert their superiority and constantly be undercut. But I think the epicycle that we're going through in the United States in particular is so different than it is in Western parts of Central Europe where Germany, for example, where physicians are still held in the highest regard as experts. The internet is part of it. The divisiveness of politics doesn't help us versus them. Where journalists then become part of that story, you find scapegoats. You begin to undercut the respectability of the other side. And that as it applies to doctors, whether it be lawsuits and deaths, whether it be the deployment of science and trying to get people to understand it, all of that clusters together into what you're highlighting. In some ways it's not new. In some ways for us it's particularly acute. The diffusion of knowledge much like the creation of the printing press is part of it. But I think we are going through a cycle of culture in which it's us versus them, which is incredibly exhausting. And when we deal with our patients and we're seen as the other, it's hard to create that therapeutic bridge, that therapeutic relationship. And then we as ethicists have to find ways of adjudicating, but doing so in a way that it's absorbed. And it's tremendously complex right now. It was hard enough to do the ideas. Now we have to deal with the social stuff even more. You've got your finger on a very aberrant pulse that's so scary. Thank you. Peggy, you want to take it from me? I'm kind of interested in this. The way you put it, these physicians are sort of resting autonomy from the sick people because they're taking over. That's the beginning of, this is what you need to do. You have to do this. A friend of mine says, well, I have to do radiation, but not chemo. And I'm thinking, you don't have to do anything, but whatever. But I'm kind of curious where these other, in your pyramid, the grabbing for autonomy, is that also pyramidal or is that throughout? So you guys are all asking brilliant and perceptive questions, which is not a surprise to me. And I'm pandering you because I love the question, right? I'm pandering to all of you this way. So it's actually really complicated. It's why it's not in a simple diagram. So as much as I think the birth of the patient concept and the word, as it's deployed, occurs at that time. On the ground, doctors didn't have that kind of authority. They especially didn't have that authority in patients who could really pay. Dr. Kings, Prince's dukes, anybody with a lot of money, we were tugging our forelock. We were genuflecting. We could get fired at the drop of a hat. We came running to them. It wasn't the other way around. Charlemagne actually at one point basically thumbs his nose at his doctors because he's being told he's not supposed to eat the certain kind of food. He says, the heck with you, I'm going to do what I want to do. On the ground, that is not in the elite world, it's probably happening that way too, but less so. And there I think we see a diversification. Rather like your friend whom you were mentioning, the sicker you were, the more you felt like the mother and father at the beginning of the story, the more you felt like you needed to listen to somebody. If you had no other choice, your last hope was X, right? I think it's Loeb's fourth law of medicine, at least when I was in training, never let the surgeon get your patient, right? Because that means it's reaching the end of the story. And I apologize to surgeons in the crowd. But the notion in the Middle Ages, I think is if you have to go to the doctor, you're kind of stuck. And so there is some of that have to do this coming from that story. That said, I think there was more patient autonomy perhaps than there is now because the structures social regulatory and otherwise were still in co-aid. Now we have all this baggage. You can't leave the hospital AMA, or else you're going to get stuck with the bill, right? That didn't exist back then. In fact, if anything, you were paid to be a patient in the hospital to the extent the hospitals look like they do now. What I'm trying to do is give you some of the nuanced context to say it doesn't fit into an easy pyramid because it wasn't easy. But I think we see the roots of what becomes our story today, which is why Paul Starr and Ken Ludmer and others is so important. Because how did we get there 500 years, 600 years later? There were other structures that began to pile on top. The specialization that the wildfire specialization in medicine that takes roots in the mid-19th century around ophthalmology and extrapolates from there is grabbing hold of this 800-year-old idea. And it increasingly pushes the patient down on that pyramid until we get to the 1960s and 70s when we see the patient advocacy movement. Right? And so we're seeing an inversion just like we were talking a moment ago about questioning the authority again, right? The demotion of the specialist, of the expert, in favor of the person who's living the experience. I think we're horse trading now. And so it's exciting to watch as a social scientist. Sometimes crummy to be a doctor, and it's certainly crummy to be a patient. Is that helping at all? But it's brilliant. Absolutely brilliant. Anyway, I just want to leave you with one thought as you take a few minutes of break before you go into the session with the fellows. In some ways, one of my colleagues texted that your pyramid now has surgeons on the top. And part of it is financial pressures that have pushed the system up where, just apropos to what you were saying, patients as consumers, the whole patient experience as opposed to malpractice. The other interesting piece is the fact that hospitals during COVID wanted to open up as quickly as possible because of the financial benefit of getting started back with surgeries, which are well reimbursed. I'm going to leave that because you're going to have some great time talking to the fellows, including, and we have many surgical colleagues watching this thing. So it's just fascinating to see the constant evolution of not only the medical hierarchy, but the medical marketplace. So I just want to thank you on behalf of the McLean Center. You still remain one of the most interesting lecturers in history of medicine because nobody else makes medieval medicine as accessible or interesting as you do. And it's clear, you know, it's hard to me to be, imagine you as a clinician, but as a scholar, I mean, just the fact that you can pull these things from all different aspects of medieval history and can read Latin in that degree is just I'm in awe. So I want to thank you on behalf of us. And thank you for giving me a little time before 1.30 before we come back for the afternoon session.