For the Medical Record - Alisha Interview
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Mia Levenson: Hello, and welcome back to another episode of For the Medical Record, a podcast from Johns Hopkins University's Center for the Medical, humanities and Social Medicine. I'm Mia Levenson.

Richard Del Rio: And I'm Richard Del Rio.

Mia Levenson: Our guest today is Alisha Rankin, a professor of history, as well as the chair of the history department from my alma mater, Tufts University. She's also the co-editor for the Bulletin of the History of Medicine. She's here to talk about her paper, the "Skillful Surgeon: Surgical Expertise and Contested Authority in Early Modern Europe," which she presented at the 29th Hideyo Noguchi Lecture here at Hopkins. Alisha, thank you so much for joining us today.

Alisha Rankin: Thank you so much for having me.

Mia Levenson: Let's just start off sort of with the basics. Can you tell us a little bit about the paper you presented?

Alisha Rankin: Yeah, sure. I was highlighting a series of [00:01:00] manuscripts and one printed book by specialist surgeons in 16th and 17th century Germany. So specialist surgeons are surgeons who did some specialized surgical operations, in particular, bladder stone cutting. cataract surgeries and hernia surgeries. So these are all, they all have sort of the same characteristic that you have to actually cut into the body or, or in the case of cataracts, put a needle into the body. So they were a little different than surgeries you might do on the battlefield where you have to repair, um, you know, a laceration, uh, or other responsibilities that a surgeon might have.

So these surgeons were generally considered on the lower end of surgical hierarchies. So these, or these operations in particular because they involve cutting into the body. They were terrifying to people. There is no [00:02:00] anesthesia. There's no antibiotics, there's no antiseptics. So people were really, really, didn't like to have these surgeries and not surprisingly, and, and perhaps like understandably.

So these surgeons were always fighting against a certain reputation of being, you know, attached to the lower classes. And had a bit of a fight for their own medical authority. So these manuscripts that I'm highlighting were actually, I read them as attempts by these specialist surgeons to join a higher level of conversation to raise their status, uh, or to highlight that they were, are actually part of a more elevated and more learned medical conversation. So these sources I was highlighting were all beautifully illustrated, so that's one big characteristic of them. And there's two main authors that I was focusing on, and then two sort of subsidiary authors. So the two main authors were a hernia specialist and eye [00:03:00] doctor named Caspar Stromayr, who was from Bavaria in southern Germany. And then, uh, oculist or cataract surgeon and a bladder stone specialist from Dresden named Georg Bartisch.

So Caspar Stromayr put together a highly illustrated, extremely beautiful manuscript that he never intended for publication. But he made for a friend of his, a surgeon in Zurich, and it's just full of how to do his hernia operations in all kinds of different ways: the proper way to do it, the improper way to do it, how to diagnose hernias, how to treat them both with, surgery and also with non-surgical measures. Georg Bartisch did a similar thing with a manuscript on cutting for stone or lithotomy a operation that involves cutting into the perineum to pull out a bladder stone. So he also had a very, uh, this one has a, not quite as many illustrations, but it's a [00:04:00] very long manuscript explaining how to do the operation, the proper way to do it. Like mistakes that are made trying to really show him as an authority in this measure. And it does include a number of illustrations of the operation itself. And then about six years after he put together that manuscript, he published a book called Care of the Eye, which is on eye, all kinds of eye disease and their treatment, including cataract surgery, but also a wider array of, you know, eye conditions and, and how to treat them. And these involve both surgical and non-surgical measures.

And this book was also heavily illustrated, 88 wood cut illustrations of both eye disease and eye treatments. And also things like amulets and medical vessels. So things that you put medicines into, ways to make medicine and both, um, all three works also include surgical instruments, which is a typical thing to put in surgical works. The other things I was describing are a bit less typical.

So that's the, that's [00:05:00] my, the general focus of the talk were these two men and their manuscripts and their attempts to kind of show their skill, basically show themselves as skilled surgeons and show their professions as professions worthy of respect. And then I also highlighted two manuscripts that were based on Bartisch. One that's now in Copenhagen was probably compiled in Bern in Switzerland, in the early 17th century. And then one that belonged to a Franciscan monastery somewhere in either Southern Germany or Austria in the later 17th century. And these both copy Bartisch, but take the images and make them their own. So it's hard to sort of explain this on a podcast where you can't actually see the images, but these are hand colored, beautifully done images, um, that kind of take the original images in the Bartisch manuscript and turn them into their own with new dress.

So in the earlier [00:06:00] case, it's sort of early 17th century courtly attire. Um, mostly. And then in the other case it's later 17th century Franciscan habits of both monks and nuns. So there are fascinating ways of taking the text of Titian, then using the illustrations to make their own statements.

Richard Del Rio: For those of you listeners out there that are interested, and you want to get a glimpse into the, the weird wild world of early modern medicine, you can look up some of these books, they're really something. and it was a real treat seeing those images displayed in your lecture when you came to visit.

You mentioned that these were people who were trying to accomplish or achieve respect for their profession and. I trying to kind of hold two things at once in my mind. On the one hand, they're trying to achieve respect for the profession, but they're walking around and they're with these books that I imagine are very expensive.

So you could, [00:07:00] can you give us a little bit about the background of the kind of people that are doing this work? That, they, that they have the time to make these books and they're still searching out respect despite the seemingly sizable investment in the production of the books themselves.

Alisha Rankin: Yeah, that's a fantastic question. So I should emphasize that these two men are people who have made it in this, in this hierarchy. So, uh, Stromayr is a city surgeon in the town of Lindo. So he's hired by the city, he has a steady job and he's a little more of a mystery, I would say, why he chose to compile this extremely beautiful and had to be incredibly expensive books.

He didn't do the illustrations himself. He hired at least two different artists to do them, probably three. I mean, it took him at least he started it in 1559 and he died before it finished, he finished it in around [00:08:00] 1567. So it took years and years of his life. It must have taken a lot of money and it appears to be aimed at just a friend of his who lived in Zurich. However, this friend of his was the son-in-law of the Zurich City physician, Jakob Ruf, who had died a couple years before Stromayr started compiling this work. And Ruf had started out as a surgeon but had become city physician. So he had really kind of risen in status. And his son-in-law, Peter Hoffner, who's the dedicatee of this book, followed in his footsteps.

So I think Stromayr might, it might have been a patronage ploy to try to connect himself to, to this status of surgeons in Zurich, which they seem to be able to raise their, raise their status up to the point of being a city physician, which normally you would need a university education for, which, um, Stromayr did not have. So I think that that might have been the motivation for it, but it is because he never finished it, it's unclear exactly what his deal was.

[00:09:00] Bartisch is a little clearer. Bartisch started out as an itinerant surgeon, as many surgeons did, wandering around during his journeyman period through Saxony, Bohemian, Silesia, he went really far. Um, several hundred miles was his radius, and eventually settled in Dresden, a citizen of Dresden. So he must have been well recognized enough that the city wanted to have him stay there. So he has kind of made it in that he's welcomed in Dresden as as a permanent resident. This was not unusual for specialist surgeons to be welcomed into towns, even towns that they weren't born in. Towns valued specialist surgeries. They viewed it as a useful endeavor, even though it didn't have the status of a physician, it was something that was seen as very useful. so he had made it, but he was trying to do one better.

So it, both the manuscript and the printed book are dedicated to Elector August the First of Saxony. So the local [00:10:00] prince, who was one of the most powerful princes in all of Germany, he was one of the seven people allowed to elect the Holy Roman emperor. So the bladder stone manuscript is, was dedicated to August. It's unclear. It's still in the collection today, so clearly August kept it, but he doesn't seem to have gotten paid for it. It sort of just seems to have sat there and not necessarily done any good for Bartisch.

And Bartisch mentioned in that manuscript that he wanted to print it, but he didn't have the funds for to do so, that it would've been too expensive. So he elected just to leave it as a manuscript. So again, a few years later he comes out with his printed book, which appears to be self-funded. So I still have no idea how he got the money for that, but he may have borrowed it, I'm not sure. But he came out with his self-funded printed book that he also dedicated to August, and in this case he did get a payment for the book. Um, something like 20 gulden I think, which is a, a decent payment.

But then he also a couple years later, not only got a payment but also got appointed as [00:11:00] court oculist. So he was the official court oculist to August of Saxony. He got a yearly payment from the electors' finances. And so he had a steady job and he was still allowed to go out on his tours occasionally. So he would still travel through the countryside to take care of patients in the countryside. But he also was, had quite a strong reputation at court. Sometimes August of Saxony would lend him out to other noble people to help them. So he was, I mean his, his position is really clear. He was trying to raise his status and he was successful at it. He did it.

Richard Del Rio: Can, can we talk a little bit about. The other side of this transaction, the people who generally are the clientele for this kind of procedure. Um, whether I, you know, I just as a time just imagine myself as a time traveler, whether I was wealthy or poor. I couldn't imagine myself, uh, making my eye available [00:12:00] to anyone under these circumstances of being awake, tied to the table.

You know, there's a needle there. There's a guy just jamming his hands around my head, holding me still. Who were the typical clientele for these things? I mean, clearly the successful men you've already mentioned are nobles. But how about the less successful surgeons? Any insight to that? You know, the itinerant, the guys who were doing stuff out of their market stalls, and, and how were they paying you?

Were they, did, did you pay 'em an eggs? Did you pay? How, what did you do?

Alisha Rankin: Yeah, that's, that's a great question. Yeah. So there is a range of, of venues for this kind of surgery. There a range of talent of surgeons who actually perform these surgeries. So I'm gonna start with Stromayr and Bartisch and then I'll go down to some of the other itinerant practitioners. So Stromayr and Bartisch in their manuscripts, both try to make a really clear point, which is, everyone has this kind of surgery. So uh Stromayr has images of people of all kinds of walks of life. There's a monk, there's a farmer, there's, you know, [00:13:00] people dressed in courtly attire. There's people dressed in sort of regular citizen attire. So the message, the sort of unspoken message, the visual message that he's conveying is that everyone needs surgery and everyone gets surgery.

Bartisch, same thing. He's got, oh, and his, his images are a little bit more cookie cutter and a little bit more focused on courtly attire. A couple of the manuscripts based on him have a much wider range of clothing and, and types. So several of these. visual images are trying to get to the point across that it's important for everyone to have surgery.

But Bartisch and Stromayr both make a very clear point that a place not to do the surgery is in the marketplace. That there are a lot of unqualified people doing it. This is one of the, their big points, trying to separate themselves out from what they view as unqualified empirical practitioners who don't have the proper training to do it. So you can kind of read into what the situation might have [00:14:00] been, of course it's probably some hyperbole, so you don't, you have to take it with a grain of salt. But Bartisch describes these itinerant empirics coming in in really fancy dress. They make themselves look like they're very rich. They're wearing lots of gold bands and bracelets and rings, and they come in with a coach and horses to show their skill. They set up a stall in the marketplace, and then they sort of poke a, you know, poke the eyes of every patient who comes through. And, and the way Bartisch describes

Richard Del Rio: Oof.

Alisha Rankin: it as like a pig to slaughter is the specific term he uses. So, you know, we can read into that, that, you know, maybe it wasn't quite as bad as Bartisch is saying maybe some of these people were, were qualified. I mean, Bartisch himself did this. He did, he did go from town to town doing this. but all of the images in both of their books, are inside in solid four walls, so they're like making the statement that they are not doing it in the marketplace. They're doing it properly. In a room, the room [00:15:00] often has a bed in it so you can lead the patient to bed afterwards. That was something that was recommended.

So in terms of payment, that was your other question. Again, all we can do is read into what Bartisch is saying, but it seems that there is both payment in coin and in kind, so they do often pay it it sounds like it, it is a fairly cheap operation for some of these empirics. A a, a few groschen, which are, you know, kind of like pennies, is how they describe it, but also bartered goods, eggs, bread, sometimes meat that would be quite expensive.

So, but, but we don't really have, um. I have not yet dug into the city archives to see if I can find out more about how exactly these marketplace transactions would take place.

In many cases, the empiric would actually pay a tax to the city to be allowed to practice there. So that was one complaint that Stromayr had that greedy aristocrats and town authorities were just taking their money and [00:16:00] not really controlling whether they were qualified or not. But that I think would need some verification from looking at archival records. That's something I'd still like to do with this project.

Mia Levenson: I love the, the itinerant in the marketplace. It's, it's just such a, a fascinating sort of combination of like medicine and performance. Something that you that you mentioned in your talk were these references to the Christian Bible in some of these manuscripts. And then you also have the one manuscript that comes out of the monastery that features Franciscan monks and, and nuns. As a, as a historian of early modern medicine, I'm curious about this relationship between religion and surgical procedures that's happening during this time period.

Alisha Rankin: Yeah, well there's, there's multiple relationships between religion and these surgical procedures. The most basic one is that everyone knew these surgeries were dangerous. Both of these authors make no bones about [00:17:00] it. This is dangerous. It doesn't not, it doesn't go well for everyone. It has the best chances of going well if you, you know, do it with a very qualified surgeon. But no matter, like if you are the most qualified surgeon or the least, you still have to pray to God for like, it's really important. Prayer is described as a really important part of the surgical procedure. Like, that's like before you do the surgery, everyone has to pray and ask God for, you know, help during, during it and also make sure, that the patient is in the right way with God, so that if things go wrong and he dies, that he will at least go to heaven.

And both authors mention that. And they both mentioned the real danger of surgery and the fear that patients have of doing surgery. And Bartisch even mentions his own fear of doing the surgery. He says the cataract surgery isn't as painful, so that one is not as bad, but the bladder stone surgery is, is a really difficult procedure that causes pain and that he would rather be anywhere else but than [00:18:00] doing it. But that it's an important thing to do. So that's one thing with, with religion.

The other thing, um, with Bartisch is Lutheran and both Stromayr and the author of the manuscript that was based on Bartisch. One of them was probably Calvinist or Swiss Reformed . And then the other one was probably, well it's obviously Catholic 'cause it was in a Catholic monastery and Franciscan monastery. So there is like different entries into how religion works with all three of those. Bartisch in his book on eyecare is really emphasizing how bad it is to be blind, so he's trying to make clear how important it is to have good eye care, and therefore he takes all of these quotations from the Bible about the how really bad it is to be blind. So it's interesting from a disability history perspective, just the way that blindness is described as like one of the worst things that could happen to you.

Of course, he's trying to do that in order to [00:19:00] make it clear how good his medicine is and how important his medicine is. So there's a method to his doing this, but he is drawing on Bible quotes because he is Lutheran in, you know, reformation Europe it was important to, to read the Bible in the reformed parts of Europe. We don't know exactly who compiled one of the manuscripts based on him, the one in, in early 17th century. But I think it was attached to the surgeon who was a city surgeon in Bern named Wilhelm Fabry von Hilden, a very, very famous surgeon. He was not a specialist, he was a general surgeon. But he was Swiss Reformed and there is an image in that manuscript of a Swiss reformed preacher. So that's, again, emphasizing not only that, everyone gets eye disease, including reformed preachers. So the, the preacher in that case had cataracts. But also that prayer is really important in medical care.

For the two Catholics, it's really focusing on, you know, the [00:20:00] importance of prayer. But they don't have the emphasis on the Bible quotes in the same way because Catholics aren't as, interested in that. And you don't actually see religion, even though in the, the manuscript based in the monastery, everyone's in, you know, the habit of monks. There is no particular emphasis on religion in that. It's just kind of, it's not copying does not copy the parts of Bartisch that have all the Bible quotes. Um, except for there's one big red letters on one page that says, "A blind man is a poor man." That's the only thing.

Richard Del Rio: This, this kind of spurs a thought about the preparation education of surgeons. Bartisch made an emphasis of art being, art and art education as being fundamental to the education of a surgeon or a physician.

How, how widespread of an idea was that? I mean, because it seems time has proven to show that most people agree with the idea. I mean, here at Hopkins we have, Art as [00:21:00] Applied to Medicine Department. So if you could speak to this idea of art as part of a surgeon's education.

Um, how widespread with this idea and then also a, a kind of alleyoop question or rather a side, a side question would be, what did it mean to learn behind the oven? 'cause I remember Bartisch was particularly critical of, since we're speaking about education, people who, um, learned behind the oven. He kind of looked down on, could you, could you speak to both of these things?

Alisha Rankin: Yeah. Yeah. Those are both great questions. So the art historian, Susanna Berger has a really interesting paper in Early Science and Medicine about exactly this question, Bartisch and his emphasis on art for educational purposes.

He said that he had no small skill in drawing and painting. And he said it was really important for a surgeon in order for them because that helped hone their both mental and physical skill. For one thing. It was also really important in order to sketch out the instruments [00:22:00] that you would have instrument makers make.

So most surgeons kind of develop their own instruments and they liked to invent their own instruments. So in, or he said it was much easier to be able to sketch it out well, so exactly what you want to show an instrument maker so they could make it accurately. It was much harder to describe it. So both a practical and also a, a, just a, you know, fine what we might now call fine motor training, um, perspective. Now that is not something I've seen widely, so this is, but um, so that's not something I've seen widely as a requisite for surgical training. However, Berger makes a point in her article that there was a much broader emphasis and artistic skill in early modern Germany. So early modern Germany was really a center point for art and, and art theory.

So, the German artist, Albrecht Dürer really had a lot of theories of how art was important in various ways. And then a variety of artisans actually read Dürer and drew on him. So this is not my own [00:23:00] research, this is coming from her article, but it's not unthinkable that a surgeon would make this connection because there was just a lot of interest, among artisan classes in like artistic skill.

And the art historian Stephanie Leitch has recently published a book, I think just last year about what she calls The Literate Eye. And she argues that viewers in early modern Germany, like were quite literate in reading images. So this really makes sense in terms of looking at Bartisch and Stromayr that they had high expectations of their viewers because viewers and readers in early modern Germany were used to taking images and reading a lot out of them. So I think, I think those are, that's kind of both of reasons, , why he was focusing on that. But it, it really wasn't something that you saw widely.

In terms of learning behind the oven. So this is one of the things that Bartisch, he criticizes when he's talking about the marketplace surgeons, and he like has a long string of things that he [00:24:00] is criticizing. And one of them is this phrase that you mentioned, learning behind the oven. I am not a hundred percent sure what he means, but I think he's probably talking about learning in the kitchen from women.

He's pretty misogynistic in his text

Richard Del Rio: Wow.

Alisha Rankin: Um, like he, he specifically says that women should not be present in the surgical room. Like they shouldn't even be pre-, they should absolutely not be doing surgery, but they should not be present in the surgical room because they're, um, know, they're, they corrupt everything and, and they, they're absolutely inappropriate, uh, people to have around during a surgery, uh, unless they are the, unless they're the patients themselves. And a lot of as I have, uh, discussed in some of my previous research, women were very much connected with the kitchen, but also with domestic healing. Domestic healing was a really important part of healing in early modern Germany. So he doesn't, I mean, he [00:25:00] criticizes old women in this kind of string of things, but also this learning behind the oven I think might be connected to the kitchen and that you shouldn't learn something at home in the kitchen.

You should be going out in the world and learning it by apprenticeship, working with surgeons like the normal practice would be. That's my interpretation. I'm not entirely sure I'm correct, but um, just knowing what I know of how German medicine worked, that's my guess.

Richard Del Rio: Interesting.

Mia Levenson: That's amazing 'cause you also showed like one of the manuscripts that had a woman as a, a surgical assistant.

Alisha Rankin: Yes, exactly. And, and this is what I mean by the manuscripts that were based on Bartisch taking it and making their own. So this is a wonderful story. The, yeah, this exact passage in Bartisch that says "A woman should not be present during eye surgery." takes place during the chapter in which he describes cataract surgery.

So in this early 17th century manuscript, this scene that's depicted is, so I, I should probably [00:26:00] describe this image in the original Bartisch. It is a patient getting cataract surgery there in it, sitting in this room that the cozy looking room, the surgeon is sitting there facing the patient. The patient's head is being held by a male attendant. And the surgeon has his needle out about to stab him in the eye or in the process of stabbing him in the eye. And then the other eye is already clear. So you, you can tell that he's already, he's already taking care of the other eye and he's doing this. So this, this, um, image in this 17th century manuscript is a double page image.

So there's, there's that, you know, sort of the, the surgeon doing the male patient, but there's also a mirror image of a surgeon doing a female patient. In both cases, both for the male and the female patient, the person holding the head is a woman. It's not a man. So this is directly after the, the text is copied faithfully from Bartisch.

So this part that says, under no circumstances should a woman be present in the operating room is this [00:27:00] double image of a woman holding the head, which is amazing. And the reason, one reason why I think it's attached to Fabry von Hilden is that his wife, Marie Colinet. Was well known for assisting him in surgery.

Um, so I, I think it's a depiction of the, them doing the surgeries. The surgeon in one of those images is also leaning his hand on a stabilizing tool that Fabry invented and has an, an image of in his printed book. So that's another connection to him. But yes, the, there is this kind of, I don't know if it's intentional shade being thrown or if the images and the texts are just totally disconnected, but there is this wonderful contrast of saying women can't be present and then this woman on two different pages is present in the operating room. So I really just love that.

Mia Levenson: I love the idea of shade being thrown through medical manuscripts of, and

Alisha Rankin: I hope, I hope that, I don't know if that's really what they're doing, but I like to like tell myself that's exactly what's happening.

Mia Levenson: So this, this lecture that you gave was [00:28:00] part, will be part of a larger book project, um, that's in the works. And I was curious if you can give us just a bit of a preview of what you're, you're sort of looking for forward to in the future. What is the sort of larger argument that you're thinking of making with these manuscripts?

Alisha Rankin: Yeah, I have really two. I mean, I think these are kind of two different projects and I'm not sure they'll both be book projects. There is a book project on itinerant healers and the status of itinerant healers, more broadly and not just surgeons. So that is something that I definitely will want to do and, and I don't think I'm far enough along on my research to give an argument for that. It's more I find, there, there are lots of sources that really haven't been looked into to examine itinerary healers through, and I, I think I'm going to be probing that more.

I am farther along on the project of the visual images. I'm not sure yet if this will be a book or if this will just be a series of a couple of, of articles, but I really want to show how this [00:29:00] combination of art and medicine and how the images are making arguments. So that was one of the big points of my talk, that the images themselves are doing some of the work for the authors. It's not just the text. And in, you see this in particular in the two manuscripts for the images are quite different than the original images.

Um, so you can read into it. Arguments not just about status, but about innovation. So you see new things in, in both of those. And so connecting these later surgeons with innovation, particularly in the realm of surgical tools. So that's something that I'd really like to focus on with, with these because there's, the images are so important. I'll, I'll have to see whether this can be a book, because it would be really expensive to do a book with all these images. Um, so it, it, it may be a book, it might just be two different articles.

Richard Del Rio: The topics of itinerant healers is such a fascinating one because as, as medical profession become established, people try to put limits [00:30:00] on the mobility of practitioners. And in, in one sense, they succeed, but another since they fail and that itinerant healer still exists today.

I am just, I've, I've really had fun with this conversation. I really enjoyed talking about this. And I just have to ask, when you're doing this kind of work, who is your ideal audience?

Alisha Rankin: I love that question. Um, I mean, I'm writing, I'm definitely writing for other scholars. Of course. I think we all are, but I'm also writing for students, so I love weird stories. That's my favorite. I mean, I, that I feel like that's been a kind of through, through line for a lot of my historical work. Stories that haven't been told. Stories about people that haven't been told before.

I try to think about my undergraduates. At Tufts I mostly teach undergraduates we don't have a big PhD program, not in my area. Uh, we have a small master's program, so the students I interact with on a regular basis are [00:31:00] undergraduate students.

So really I try to have them in mind. And I sometimes try out some of my work. I sometimes give my undergraduates a article in progress to see what they think. so that's, that's partially my audience I have thought about. Speaking to an even broader audience, doing a book that would be more of a trade book and it, that might be a possibility with one of these two projects.

Uh, I'm not sure. I'm still thinking about it, talking to publishers. So more to come on that

Mia Levenson: Alisha, thank you so much for being here. This was such a, a fantastic conversation. I really don't know how I'm gonna edit this down. Thank you so much for, for sharing your time with us.

Alisha Rankin: It was really great. Thanks so much for having me. I had a blast.

Richard Del Rio: Thank you so much