The Arbutus Review Vol. 3, No 1 (2012) Scholarly Articles: Church 113 Medicine for the Masses: The Placebo Effect of Early Modern Medical Frontispieces and the Commercialization of Socialized Medicine Ryan Church Abstract: By focusing on a single case study of Girolamo Ruscelli‟s famous Secreti del reverend donno Alessio Piemontese (1555), I argue that the frontispiece contained in this manuscript transformed the knowledge and practices contained within it through the placebo effect, thus helping to generate and mobilize social power through medical self-sufficiency. This tremendous change undercut the economic power of institutional medicine, thus altering the medical landscape toward a utilitarian model in the Early Modern period. Key Terms: Early Modern, Books of Secrets, Placebo Effect, Frontispieces, Socialized Medicine. Introduction Secrets are things, whose reasons are not so clear that they might be known by everyone, but by their very nature are manifested only to a very few; nevertheless they contain certain seeds of discovery, which facilitate finding out the way toward discovering whatever the intellect may desire to know (Eamon, 1994, p. 135) – so wrote the Italian humanist Tommaso Garzoni (1549-1589) in his La piazza universal di tutte le professioni del mondo. Here, we have a definition that fulfills the modern day criteria of secrets as “secretive,” but also one that describes secrets as a type of knowledge that “the intellect might desire to know” (Eamon, 1994, p. 135). To be sure, that meant experimentation. This is an important distinction to make when discussing Early Modern Books of Secreti. Recent studies on Renaissance and Early Modern medical history have used a “ground up” approach, instead of focusing on academia, by looking at “the sick person‟s viewpoint” (Gentilcore, 1998, p. 177), which can be described as a view of the medical world from those in the lower classes. In addition, Books of Secrets – instructional books for the lay-audience – have only recently begun to catch the attention of historians The Arbutus Review Vol. 3, No 1 (2012) Scholarly Articles: Church 114 of science. My discussion, therefore, will be less on academia‟s role and more on how these books transformed the medical landscape through this ground-up approach. These books, used by the literate population, give us a sense of how urban culture viewed medical treatment and what was believed to work – a stark difference from what academia uttered. Figure 1: Frontispiece of Girolamo Ruscelli’s Secreti. 1555. http://honors.nmsu.edu/weamon/sci_secrets.html Although there has been extensive research on the history of popular medicine in Early Modern Europe, the role of visual imagery in healing practices has been largely overlooked. This article redresses this gap by examining the http://honors.nmsu.edu/weamon/sci_secrets.html The Arbutus Review Vol. 3, No 1 (2012) Scholarly Articles: Church 115 healing role of the frontispiece in Books of Secrets. By focusing on a single case study of Girolamo Ruscelli‟s famous Secreti del reverend donno Alessio Piemontese (1555) (Figure 1), I argue that the frontispiece contained in this manuscript helped transform the knowledge and practices contained within it through the placebo effect, thus helping to generate and mobilize social power through medical self- sufficiency. This tremendous change undercut the economic power of institutional medicine, altering the medical landscape toward a utilitarian model that benefited the masses in the Early Modern period. It is important to remember that during this period, imagery held a special place of significance and power (Freedberg, 1989). Due to the lower literacy rates of the period, great attention was placed on visual imagery as a source of knowledge and explanation. Before turning to the frontispiece itself, first, I develop my argument by first examining the medical marketplace; second, I discuss the author Girolamo Ruscelli‟s remarkable story in the production of this book; and third, I examine the placebo effect from the modern perspective and try to transpose what we know today about what may have been happening back then. As I conclude, I draw these topics together while investigating aspects of performance theory to help unlock the power of the frontispiece in transforming the medical landscape. The Medical Marketplace By all accounts, it seems that the climate of exchange for knowledge, ideas and finance was perfect for the introduction of Books of Secrets to Italian society (Gentilcore, 1998). Beginning in the Renaissance, a gradual increase in consumerist attitudes took hold. As Welch explains, “Between 1400 and 1600, the daily business of buying and selling was an act of embedded social behavior” (2005, p. 8). To be sure, by the time the Early Modern period arrived, this flicker of financial flame had been cast into a fiery inferno of economic indulgence. Italians were buying, and how! From silk and spices to majolica, there was not much the Italians were not interested in (Brown, 2004). One of the more specialized areas of indulgence was medicine, for this was also a time rife with pandemics (Boeckl, 2000, p. 72). These two colliding factors, the increase of pandemics paired with an inflated marketplace, provided a powerful force for driving the demand of medicinal books of all kinds. In addition to these physical forces, there was also a moral force pushing a particular type of medicinal book, the “how-to” Book of Secrets, written in Italian. Indeed, the sixteenth-century Protestant Reformation preached ideas of self-help; in certain aspects, this also meant the ability to heal oneself, and these books were the tools to do it. The Arbutus Review Vol. 3, No 1 (2012) Scholarly Articles: Church 116 Books of Secrets provided the best option available for gaining utilitarian medical knowledge. During the Reformation and counter-Reformation, the Catholic Church stood vehemently in the way of these books; the Spanish Inquisition‟s prosecution of research leading to the publication of Secreti is evidence of this stance. Likewise, academia was also against the free movement of medical “know- how.” From about the 12 th to the 15 th centuries, physicians were seen as the heirs of ancient texts from revered sources (Siraisi, 2007, p. 64). Many of these ancient texts are attributed to Hippocrates, who was viewed as a divinely appointed discoverer of medical knowledge (Siraisi, 2007, p. 79). These beliefs also reflected the common attitude of the college of physicians that people outside the profession were not supposed to know the contents of these revered books – an idea delivered in the 10 th and 11 th centuries from Islamist Sages and their medical cryptograms (Eamon, 1994, p. 40). There was, it seems, a Faustian mentality of overstepping your bounds when it came to seeking excessive knowledge in treacherous subjects (Eamon, 1994, p. 62). Along with this secrecy came the belief from the college of physicians that their form of medicine was supreme, which led them to “enforce the superiority of university medicine” (Gentilcore, 1998, p. 159). But what was “university medicine,” and how did it differ from lay medicine practiced by charlatans, peddlers and, eventually, the philanthropist authors of Books of Secrets? Here, it should be noted that in this medical landscape there were two different streams of thought flowing through both sectors of medicine. In the university curriculum, reason was seen as a more trustworthy and higher form of knowledge, while empirical experimentation was left to peddlers (Eamon, 1994, p. 56; Gentilcore, 2004, pp. 151-66). Thus, experimentation was seen as a fringe science practiced by those who were set, as we will see, to change the medical landscape. Some doctors actually practiced both forms of medicine, reason in the classroom and experimentation at home (McVaugh, 1971, p. 111). From the perspective of modern medicine, we can now understand that medications brought about through experimentation would almost certainly outperform those brought about through reason alone. The increased cure rate among those medications created through empirical study would have fostered their own success. Alessio Peimontese’s Secreti It is with these scientific thoughts that self-styled philanthropist and humanist Ruscelli set forth in creating his famous Secreti. Disguising himself by using the pseudonym Alessio Piemontese for at least the first twelve years of publication, (Eamon, 1994, p. 147), Ruscelli formed the first Italian medical academy in 1541 The Arbutus Review Vol. 3, No 1 (2012) Scholarly Articles: Church 117 dedicated strictly to the scientific pursuit of experimentation, the Academia Segreta (Eamon & Peheau, 1984, p. 329). Within a compound built by a “generous duke” in a “famous city in Naples” (Eamon & Peheau, 1984, p. 329), Ruscelli and 27 members (Eamon, 1994, p. 148) set forth in proving all the secrets of nature they could find (Eamon & Peheau, 1984, p. 333; Findlen, 1994, p. 159). For a secret to be valid, it must be successful three times (Findlin, 1994, p. 159) – thus forming the very beginning of the experimental method. Within the Secreti, we find 108 out of the 350 recipes to be medicinal in nature (Eamon, 1994, p. 144; Bell, 1999), with another third covering domestic recipes. These recipes are introduced to the reader through the preface that reads: “Truly, I would not sette my selfe to write fables and lies, … there is nothing in this boke but what is true and experimented” (Eamon, 1994, p. 139). The preface continues to tell about Alessio Piemontese‟s life, his collection of all the secrets of nature he could find, and the circumstances that arose whereby he relinquished these secrets because of his guilt and remorse for refusing treatment, which ultimately led to a patient‟s death. Ruscelli almost certainly wrote this story, but it fits nicely with the paradigm of amassing Faustian levels of knowledge and then needing a moralizing tale to release them. After all, it is out of kindness that he published this data, perhaps to clear his conscience. Humanists such as Ruscelli also believed that they were doing another service in divulging secrets jealously and selfishly guarded by practitioners (Eamon, 1994, p. 139). He warns his readers that physicians “moved with a certaine rustick and evyll grounded envie, with a passion of jalousey, are wont to blame and contempne thinges that come not of themselves (Eamon, 1994, p. 144). This then, sets up a showdown in the medical arena. As print culture expanded during the 16 th century – to be sure, some 15000-17000 books were printed in Venice alone (Eamon, 1994, p. 127) – physicians grew nervous. If you were sick, where would you turn? It seems a great deal turned to Books of Secrets. This new utilitarian medical landscape was made possible by the printing press (Eisentein, 1979; Eamon, 1984), an agent of social change that enlivened and reinvented print culture in Italy during the Early Renaissance. By the Early Modern period, books of all sorts flooded the marketplace. One of the best sellers was Ruscelli‟s Secreti, which went through 70 editions and translations between 1555 and 1600 (Eamon, 1994, p. 140; Findlin, 1994, p. 229). The rise in popularity of Books of Secrets during the latter half of the 16 th century can be traced as far back as the Black Plague of 1348 and the Great Western Schism. These events ultimately undermined the Catholic Church and helped foster the Reformation some centuries later. William Eamon, a noted and respected (Barnett, 1996; Dear, 1995) scholar in The Arbutus Review Vol. 3, No 1 (2012) Scholarly Articles: Church 118 Renaissance and Early Modern Books of Secrets and Italian cultural history, has noted “the role of the Protestant Reformation in stimulating self-improvement” (Eamon, 1994, p. 126). This role was obviously noted by Ruscelli, who chose as his pseudonym, Alessio Piemontese (Alessio of Piedmont) – an area in northern Italy known as a center for Protestantism, and one geographically close to the publishing houses of Venice, the location of its production. To this end, it should also be noted that in 1548, the Spanish Inquisition arrived in southern Italy, an area not as tolerant as Piedmont to ideas of utilitarian medical knowledge. This caused Ruscelli to flee to Venice to avoid persecution. His ideas on experimental knowledge were dangerous to the Catholic Church, since they wanted the monopoly on salvation through their institution. The Frontispiece: A Powerful Vehicle for the Placebo Effect In modern science, the placebo effect is well known (Nuhn, et al., 2010; Beedie & Foad, 2009). As John Welch states,“The power of placebo relies on ritual, the interaction with the patient [and] the space in which it‟s performed” (2003, p. 21). The placebo effect also gives power and authority (McTavish, 2005) through display and ritual to an object that may otherwise not have such power. Put scientifically, the “effect a drug has upon an individual [is also] due to the meaning of symbolic importance attached to its use, rather than to its pharmacologic or physiologic properties alone” (Brody, 1998).These aspects of the placebo effect can be seen in Secreti. In the frontispiece, we can see that Alessio Piemontese is displayed prominently at the top. This would be a powerful indicator of the possibilities of self-improvement lying within the book, since it is implied that Alessio of Piedmont wrote this book with the intention that you would be able to cure yourself, as is stated in Protestantism. This is an example of the placebo effect of words. Every word has meaning, and Piemontese would conjure up these notions of self- improvement in the literate public. It is important to stress that the popularity of these books also strongly correlates with literacy rates during the period (Eamon, 1985), which relates back to the rise in print culture due to the invention of the printing press. This circular dichotomy rotated the economic engine of the medical economy, continually fostering greater involvement in learning and self-medication. The significance of this cannot be overstated, as this is the main economic driving force behind the success of these books. Moving down the frontispiece, we see the main emblem, the symbol of a winged lion of St. Mark, “the oldest and most universal symbol of the [Venetian] republic” (Brown, 1997, p. 80). He stands atop The Arbutus Review Vol. 3, No 1 (2012) Scholarly Articles: Church 119 the globe displaying Venice prominently with a sword and an open book in his hands bearing the inscription: PAX TIBI MARCE EVANGELISTA MEVS (Peace unto you, Mark my evangelist) (Brown, 1997, p. 81). St. Mark was seen as the protector of Venice – in times of medical pandemics, this symbol seems appropriate (Freedberg, 1989). Performance aspects of the Secreti As Cavallo and Gentilcore note, not much attention has been placed on the domestic space as a setting for medicine (Cavallo & Gentilcore, 2007, p. 474). However, the location of these books within the Italian Studiolo is central to the performance aspect of these books and the role ritual played in harnessing their power through the eyes of those who used them. The Studiolo was a place of learning and quiet contemplation. It was also a place of invitation and transmission of knowledge (Brown, 1997, p. 221). The fact that these books were housed in this space gave them added power; where they were read determined how they were read (Livingston, 2005). The underlying rationale is that if you are inclined to believe something will work, you stand a better chance of being made a believer, and the location of this inclination matters. If we look further at the use of these books, we will see an interesting power dynamic. Those reading from this book can be thought of as holders of knowledge and power – not unlike our modern day “physician.” Those receiving this knowledge can be thought of as “patients.” Therefore, we have an example of the modern day physician-patient relationship, which places the physician as the holder of knowledge and the patient as the receiver. This gives the owners of these books a special place within the community, and no doubt led to the commercial success of these books. In addition to the importance of where Books of Secrets were consulted, scholars have also noted that ritual images, such as those found on the Ruscelli frontispiece, display power and connect “society and culture by creating experiences that affirm and thereby make authoritative a society‟s world views and ethos” (Alexander, 1994). Such a ritual role can be seen in the depiction of the winged lion of St. Mark, symbol of Venice. The image of St. Mark displayed the ethos of Venetian society. The inclusion on the frontispiece of Secreti displays a complex layering of meaning, power and knowledge that is transferred to the secrets kept inside. The ritual role of the image of St. Mark is supported by emblem theory, which decodes an emblem in three parts: inscriptio, picturio and subscription (Daly, 1998, p. 7). The most important of the three parts for understanding the ritual role of the image of St. Mark is picturio. Literate and non-literate alike can understand this The Arbutus Review Vol. 3, No 1 (2012) Scholarly Articles: Church 120 part, so it has the ability to communicate to and help transform the largest segment of society. With respect to the imagery of St. Mark, as an emblem that relates to the identity of the city, this emblem would have been visible as a series of mosaics in the Church of San Marco. Of the many stories of St. Mark, one, during his time in Alexandria, stands out. Here, he is said to have miraculously cured Anianus, a cobbler who mangled his hand with an awl (Hall, 1974, p. 199). Many Venetians and Italians would have been familiar with these stories, along with the symbolic association of miraculous cures. This emblem was intended primarily for an Italian audience. The constraints of production of this book define its meaning and audience (Chartier, 1995). Given the power and knowledge contained in these books as represented in the frontispiece, they altered the social and medical landscape. Before 1555, if an individual wanted treatment and was not wealthy, one had no choice but to consult with a charlatan and pay the current rate. These books altered that pattern and did away with social stratification in the medical sphere. It is a small step from buying drugs from the pharmacist to making them at home (Eamon, 1994, p. 138). Pharmacists had to adapt and bring in ingredients that could fill the demand of the recipes in these books. However, owners and users of Ruscelli‟s Secreti would probably be part of a privileged group in any community. Literacy and wealth often come together, and both were needed for this “how to” book. The ingredients list is extensive and would require some wealth to prepare. This is another feature of the textual placebo effect described earlier: the longer the ingredients list, the better you presume it will work. In addition, the sheer length of these recipes places the owner in a unique position as a community healer – a person to be respected and revered. As competition for medical services grew, services switched to drugs that could cure specific illnesses (Eamon, 1994, p. 138). Physicians were now treating as the books treated. This radically shifted the medical landscape to a more utilitarian model. Economically, these practices shifted the sum total of wealth circulating in the medical field to a larger proportion of the population. Conclusion The appearance of Girolamo Ruscelli‟s Secreti del reverend donno Alessio Piemontese in 1555 was a landmark achievement in the history of science. It helped radically alter the medical landscape toward a utilitarian model and opened a new avenue of thought previously concealed and declared treacherous. Using a “ground up” approach, I have surveyed the various avenues of medical treatment available to patients during this period, along with the economic ramifications they faced in both streams of the medical economy. Due to the introduction of these books, academia The Arbutus Review Vol. 3, No 1 (2012) Scholarly Articles: Church 121 and institutionalized medicine was forced to react, sometimes violently. This article elucidates the impact of Protestantism and the ideal of self-empowerment on the medical landscape. As well, the placebo effects of the frontispiece had a resounding impact, transplanting knowledge and power from the college of physicians to the recipes listed within Ruscelli‟s Secreti. The urging of an increasingly literate public hungry for new ideas, along with a ravenous consumerist climate, catalyzed this commercialization of social medicine. References Alexander, B.C. (1994). An afterward on ritual and biblical studies. Sennia, 67, 209-25. Barnett, M. (1996). 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Contact Information Ryan Church, from the Department of History in Art, can be reached at newton.davinci@gmail.com. mailto:newton.davinci@gmail.com The Arbutus Review Vol. 3, No 1 (2012) Scholarly Articles: Church 123 Acknowledgements Thanks to: Dr. Erin Campbell, Associate Professor, Department of History in Art, University of Victoria; Jamie Kemp, Doctoral Candidate, Department of History in Art, University of Victoria; The Learning and Teaching Centre, University of Victoria, JCURA Award funder.