864 Journal ofthe Royal Society ofMedicine Volume 72 November 1979 Spanish in the Golden Age

Robin Price MA ALA Wellcome Institutefor the History ofMedicine, 183 Euston Road, London NWJ 2BP

The extent of the Golden Age of varies according to the criteria used to measure it. In literature it may justly be said to extend from the early 16th century to the end of the reign of Philip IV in 1665; in medicine, from the beginning of the joint reigns. of the Catholic Monarchs, Isabella of Castile and Ferdinand of Aragon, in 1479 to the death of Philip II in 1598. These were tumultuous years for Spain and for the European world in general. For Spain particularly, the conquest ofGranada, the expulsion ofthe , and the discovery ofAmerica in 1492, meant a confirmation of its role as conqueror, now wholly achieved within its own land, and an appetite for renewed conquest wherever else Spanish energies carried its peoples. Conquistadors passed to Mexico and Central America in the traditional sense, but conquistadors existed within Spain in the realm of the arts and architecture, and more particularly in the realms of medicine and surgery. The practice and development of these during this period of released vigour constitute an enormous area of study, the complexities of which are considerable. Any attempt to include all this within the compass of one paper will necessarily be highly selective. Omissions and simplifications, therefore, must be attributed to an attempt to indicate in outline some of the major aspects of the period: medical licensing; education; the place ofreligion in the provision ofinstitutional health care; the practice of dissection, and the teaching of anatomy, surgery, physiology; the practice of representative areas of medicine; the place of classical tradition in medical theory and practice; and the transfer of medical knowledge and skill to the colonies. These categories are, of course, to a great extent interwoven and together form the remarkably rich fabric of Spanish medicine in the 16th century. By definition the official and literate medicine of the Spanish with which this paper deals excludes its opposite, the indigenous or folk medicine which, among the Moors in Valencia, probably among the peasants of the Iberian Peninsula, and certainly among the Indians of New Spain and Peru, enjoyed a high esteem. That of the Aztecs in particular was remarkably complex and undoubtedly efficacious; so much so, that at least one Aztec remedy passed into the European . Licensing and hence the practice of medicine were early regulated by a law of 1477 which first set up the Protomedicato as the medical licensing body. Throughout the 16th century regulations for the education of the practitioner and for his professional life were improved and amplified. Many new universities were created, in addition to the 13th century foundation of ; these were either of royal inspiration (Valencia, 1500), individual inspiration (Alcal'a, 1508), or city inspiration (Osuna, 1548). By 1619 there were no less than 32 universities in Spain, though Salamanca, with 7800 students and 70 professors in 1566, had declined by 1602 to 4000 students. Alcali, founded by the great cardinal Ximenes de Cisneros, Regent of Castile during Charles V's minority and inspirer of the celebrated Complutensian Polyglot text of the Bible, maintained a fairly constant level of 2000 students. By 1566 Alcala had managed to reform itself and its medical faculty satisfactorily. By these reforms, instead of continuing the founder's unworkable arrangement whereby two professors taught the two subjects ofthe Canon ofAvicenna, and and , turn and turn about every two years, the School decided to appoint four professors in the major and minor chairs of Prima I Paper read to Section of the History of Medicine, 5 April 1978. Accepted 28 September 1978 0141-0768/79/110864--11/$01.00/0 ,.', 1979 The Royal Society of Medicine Journal ofthe Royal Society ofMedicine Volume 72 November 1979 865 and Visperas of medicine, a system which became general throughout the hispanic university world. The lectureship in the practice and theory of anatomy which had existed since c. 1563 was confirmed as a chair as a result of the same reforms; and the lectureship in surgery which had existed since c. 1519 became a chair in 1594. By law, the privilege of granting a degree in medicine lay with those universities which at the least possessed chairs of Prima, Visperas, Surgery and Anatomy. The Catholic Monarchs, in laws signed in 1480 and in 1496, had taken care to deny validity to degrees granted by Papal Bull, and these laws were confirmed by Charles V in 1523. In further laws of Philip II of 1563 physicians were obliged first to obtain their degree in Arts. They then took four courses in medicine followed by two years of practice before appearing before the Protomedicato (the licensing and examining body) to obtain licence to practice. In 1588 Philip II further regulated the proofs of competence to be laid before the Protomedicato and again in greater detail in 1593. Similar proofs of competence for surgeons were the subject of regulations in 1528, 1563, 1588, and 1593. Special licences were authorized by Philip II in 1570 and 1578 for practitioners without university education, e.g. barbers, 'poulticers', urological specialists, couchers for cataract, and midwives. In 1559 a Real Provision was issued permitting, for the teaching and study of anatomy at Alcal'a, the dissection of the bodies of executed criminals or of those who died in the hospitals of Alcal'a. The first known dissection for this purpose in Spain had been performed in the late 15th century, with special permission from Rome, in the monastery- hospital of San Juan Bautista at the national shrine of Guadalupe; a shrine which later possessed no less than four hospitals, including one for women. It was at Guadalupe, most appropriately, that St John of God (1495-1550), successively traveller, soldier, shepherd, and merchant, had seen his vision of Our Lady holding out the naked child , and saying: 'Juan, see thou Jesus, so learn thou to clothe the poor'. Following the establishment of his first hospital for the sick poor in 1537 in Granada his movement went from strength to strength, and in 1572 his followers were organized by Pius V into a Congregation under the Augustinian Rule. By 1590 there were said to have been 600 Brothers Hospitaler in , Spain, and the New World, possessing 79 hospitals containing more than 3000 beds. Other orders concerned in medical care were the Hermanos Minimos, usually known as the Obregones, founded in 1568 by Bemardino Obregon (1540-99), which spread to the Low Countries, Lisbon, and the colonies, and which directed the General Hospital of ; and the Brothers of San Hip6lito of Mexico, founded in 1567 by Bernardino Alvarez (1514-84). While in the reformed and Protestant north of Europe hospitals of religious foundation were giving place to lay foundations, in Spain the number of hospitals founded through religious zeal was steadily increasing. On the whole they remained well run and useful until the end of the 18th century. The influence in Spain, during this and successive periods, of the Christian religion on hospitals and on institutional care cannot be over-emphasized. The practice of dissection and the teaching of anatomy, the foundation of medical and the beginning of the new age of enquiry in medicine, was not regularly established in Spain until the creation in 1550 of the first Chair of Anatomy in the University of Valladolid, occupied briefly by Alonso Rodriguez de Guevara (b. 1522), who there taught anatomy and gave public dissections until he moved to Coimbra. His colleague at Valladolid, Juan de Hamusco, studied under Realdo Colombo at Padua and published his Historia de la composicion del cuerpo humano in Rome in 1556 (Figure 1), with its handsome illustrations by Gaspar Becerra. Though his work is based on the Vesalian model and follows the Vesalian division into seven books, even to using cruder and reduced versions, sometimes reversed and altered as to stance, of Vesalius' figures, his personal research corrected errors of detail and filled gaps left by Vesalius. By this text Spanish anatomical terms were now fixed as part ofthe medical language. As a recreation of the Vesalian approach, it is possibly the most distinguished early Spanish textbook ofanatomy; and in its own time it was sufficiently widely regarded throughout Europe to achieve publication in Italian editions (1560, 1586), in a Dutch edition (1568), and in editions (, 1589, 1607), that is, some 50 years of usefulness. 866 Journal ofthe Royal Society ofMedicine Volume 72 November 1979

Figure 1. Title-page ofthe first edition ofJuan Valverde de Hamusco, Historia de la composicion delcuerpo humano, Rome, 1556. (By courtesy of the Wellcome Trustees) The earlier writers such as the polymath Andres Laguna (1499-1560) in his Anatomia methodus seu de sectione humani corporis contemplatio (Paris, 1535), the first work on anatomy written by a Spaniard, adhered to traditional knowledge. Brnardino Montania de Monserrate (c.1480-c.1551), who in old age had himself carried to the lectures of Alonso Rodnrguez de Guevara at Valladolid, enjoys the distinction of having published his Libro de la anothomia del hombre (Valladolid, 1551), the first full anatomical text written in Spanish and the first Spanish anatomical text to include illustrations. It enjoyed European esteem, although it remains true to the Galenic tradition in spite of its appearance 8 years after the Vesalian Defabrica of 1543. In Valencia anatomy was taught by Luis Collado and Pedro Jimeno. The latter, formerly a disciple of Vesalius at Padua, published his version of the new understanding of the human body and the result of his own dissections in Dialogus de re medica (Valencia, 1549). Collado and Jimeno are together said to have published the first description ofthe stapes of the ear. It seems that the presence of Vesalius as surgeon to Charles V and then to Philip II had little direct influence on Spanish anatomy. However, the education of a number of early Spanish anatomists in Italy and France also assisted in bringing new ideas to Spain. In common with general European experience at this time, much practice and some improvement in surgery had been obtained by the second half of the 16th century, partly owing to the wars in Italy and the Netherlands, and partly owing to a renewed outlook and a Journal ofthe Royal Society ofMedicine Volume 72 November 1979 867 revised anatomy. From the last decades of the 15th century the text of Guy de Chauliac (1298?-1368) was frequently reprinted in Spain, both in a Catalan version, and in a Castilian version. As we have seen, Philip II had authorized the issue of special licences to non- university-trained practitioners. In his Real Orden of 1593 he charged Luis Mercado with the revision of examination regulations for surgeons (published as Institutiones chirurgicae, Madrid, 1594 (Figure 2), with similar regulations for physicians published in the same year), and with the drawing up of regulations for the examination of algebristas or bonesetters (published as Institutiones que Su Magestad mando hazer. . . para el aprovechamiento y examen de los algebristas, Madrid, 1599) (Figure 3). INS'TIT'VCIONES: >1N$T1TVT?R v QxE SV MAG STAD ~C141VIG1AE iV% Y. MANDO.: HAERALDOTOR: MercadoCu.Meico de Cam aay Proto medicogeneraI:par .- aprouechamien- toy examen de los Algebriflas. Enl,,,#s qr4esbdafi hfmuscw q d ci- yra,eu.dus,0utp.ed.amd. deoocsr.. ud<. Afs|w f,*,cn.emdei d Y vltiimamca:I ...... En .Ca...f:.:^.. .1 ,.:.:j..... ,

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Figure 2. Title-page of Luis Mercado, Insutittiones Figure 3. Title-page of Luis Mercado, Instituciones chirurgicae, Madrid, 1594 (By courtesy of the Well- que Su Magestad mando hazer ... para el aprovecham- come Trustees) iento y examen de los algebristas, Madrid, 1599. (By courtesy of the Wellcome Trustees) The first Spanish surgeon of note and generally regarded as one of the greater surgical authorities of Spain during the 16th and 17th centuries was Juan de Vigo, physician to Pope Julius II (1503-13). His Practica in arte chirurgica copiosa (Rome 1514) was published in the 16th century twice in a French edition, three times in a Spanish edition, three times in an Italian edition (two more followed in the 17th century), and it appeared in at least seven Latin editions; a truly remarkable currency of over 100 years. Francisco de Arceo (1493-?1573), who studied medicine and surgery at Alcala and who was for a while physician attending surgical patients at the monastery-hospital at Guadalupe, was also one of the more distinguished surgeons of the 16th century. His one-time fellow student and continuing close friend the theologian, statesman, and philosopher Benito Arias Montania (1526-1611), who edited Arceo's principal surgical treatise published after his death, recorded in his preface that Arceo continued to perform successful operations into his 80s. He was particularly famed for his empyema operations, and patients came to him from all over Europe, even from France and England. The basic principles set forth in his De recta curandorum vulnerum ratione (Antwerp, 1574) were those of Pare: simplicity, cleanliness, and 868 Journal ofthe Royal Society ofMedicine Volume 72 November 1979

a proper humility on the part ofthe practitioner. He added a detailed dispensatory to his work and developed a balm which was later called after him (bdlsamo de Arceo), and a method of rhinoplasty antedating that of Tagliacozzi. His major work, which was divided into two books, the first dealing with wounds and fractures of the head, and the second with wounds of the rest of the body and (briefly) with ulcers and syphilis, was translated into English as 'A most excellent and compendious method of curing woundes in the head', (trans. J Read, London, 1588), and reached German translations in 1600, 1674 and 1717, and a Dutch translation in 1667. Though his theoretical views were naturally based on Galen and , he was responsible for simplification oftreatment, improvements in dressings and instruments, and for such experiments as the treatment of malaria with sarsaparilla. Both Dionisio Daza Chacon (c.1510-1596) and Bartolome Hildago de Aguero (1530-97) were conservative surgeons in the new style; it is just possible that Daza Chacon (Figure 4), who wrote in old age after a busy career as a military surgeon in the field, was influenced by Pare. His education was orthodox and rational, studying philosophy and thep surgery in his native town of Valladolid, and later surgery at Salamanca. He was army physician in the wars of Charles V, at the court of Philip II, and in the fleet of Don Juan of Austria at Lepanto in 1571, and is supposed there to have treated the wounds of Cervantes himself. Like Pare he rejected the treatment ofwounds and amputations by boiling oil and cautery, and instead used dressings with egg whites, dragon's blood and aloes. A merciful man, he gave his time to victims of the executioner as well as to galley slaves, and for instance, retracted the skin of the hand before execution and sewed it over the wound of the stump, before plunging it into the belly of a live chicken to prevent haemorrhage. His Practica y theorica de cirugia en romance y en latin was published in Valladolid in two parts in 1580-95; both parts were republished in several editions in Spain (Valladolid, 1583, 1584, 1609; Valencia, 1605, 1673; Madrid, 1626, 1678). Eminent in his own day, he was in 1537 appointed director of the military hospitals of

Figure 4. Portrait of Dionisio Daza Chac6n from his Segunda parte de la practica y theorica de cirugia en romancey en latin, Valladolid, 1595. (By courtesy of the Wellcome Trustees) Journal ofthe Royal Society ofMedicine Volume 72 November 1979 869

Madrid, was frequently travelling companion to the Emperor's family, and was surgeon to Don Carlos, the son of Philip II, in 1562. Bartolome Hidalgo de Aguero, born and educated at Seville and Cirujano mayor of the Hospital de la Caridad there, though living a far less peripatetic life than Daza Chacon, perhaps more truly deserves the title of the Spanish Pare, since it appears from his posthumously published work Thesoro de la verdadera cirugia (Seville, 1604) that his treatments were established on a sound theoretical and pragmatic basis. He showed, for instance, that mortality figures ofthe hospital declined as a result ofhis conservative treatment which sought the rapid closure of stab and sword wounds by sutures, which rejected the use of canulas and drains in open wounds of the pleural cavity, which avoided the formation of fistulae, and which above all sought healing by primary intention, by the via particular, his own method of the dry treatment of wounds. His new ideas and his great success in employing them won him the respect ofthe Spanish soldiers who commended themselves to God and to Dr Aguero: 'En Dios me encomiendo, y en los manos de Agiuero'. His description ofthe success ofhis conservative treatment at his hospital in Seville reads: '. . . in the past year, 1573, 436 cases entered the hospital and 20 died, and in 2* months in which head wounds were recorded separately, 57 came in and only 7 died, and during the years in which I and my predecessors have practiced cures in the common way, the number of deaths was less than the number of survivors'. His careful record of mortality in his hospital is sometimes, and perhaps properly, regarded as a forerunner of medical statistics. Medicine in 16th century Spain offers a far more complex picture, which ranges from what is perhaps the first description of the greater circulation, to writings on plague and syphilis, gynaecology and obstetrics, therapeutics and regimen, ophthalmology, paediatrics, diphtheria, deafmutism, urology, social medicine, naval medicine, veterinary medicine and psychology. All these are interesting and important, but only a few of them can rate more than this passing reference. We cannot omit physiology and more particularly the circulation ofthe blood. Juan Valverde de Hamusco, the anatomist whose work has already been touched on, described the lesser circulation; but it was left to the celebrated and unfortunate (1511-53) to suggest for the first time in print the existence of the circulation of the blood, in his last and essentially theological work Christianismi restitutio (Vienne, 1553). Dealing with the theme of the soul, he describes how the divine essence finds its lodging in the blood from air breathed into the lungs whence it diffuses throughout the organism, in a way which apparently refers to the lesser and possibly to the greater circulation. It is likely that Servetus, in a primarily theological argument, was drawing on ideas current at the time, more particularly those in Paris where he had studied medicine shortly after the departure of Vesalius. But on the evidence of his somewhat vague description it is hard to regard Servetus as in any scientific sense the discoverer of the circulation. Epidemics were, ofcourse, a matter of great immediacy and practical importance, and were referred to in all texts of the time dealing with clinical medicine. Many epidemics attacked Spain in the 16th century and many of the best physicians of the time were concerned with their treatment. The Catholic Monarchs signed orders dealing with the treatment of lepers in the late 15th century and Philip II in 1565 ordered the creation of hospitals for the isolation and treatment of the diseased poor and for carriers of contagious diseases. There were, of course, many local outbreaks of epidemic disease, too many to recount here. Those which spread widely throughout Spain were the tabardillo (possibly typhus) epidemics of 1557 and 1570, the smallpox epidemics of 1585 and 1586, and the plague of 1596 and 1599. The last of these gave rise to a pamphlet war on its epidemic character, neatly scotched by Philip III who ordered his Protomedico, Luis Mercado (1520-1606), to give his judgment on the matter - a man peculiarly fitted to the task following the publication ofhis Defebrium essentia, differentiis, causis (Valladolid, 1586). The same author made his contribution to knowledge of tabardillo in his De essentia, causis, signis et curatione febris malignae (Valladolid, 1574), which he republished in later treatises. In one of his Consultas published in his posthumous collection 870 Journal ofthe Royal Society ofMedicine Volume 72 November 1979 of 1614 he was the first to describe garrotillo (diphtheria), for which he recommended the use of alum. Many other works on fevers were published, most importantly perhaps by the Jewish philosopher and Medico de ca'mara to Philip II, Antonio Gomez Pereira, graduate of Salamanca and highly regarded by his contemporaries, who believed that fever was only an augmentation of natural heat which represented the effort of nature to re-establish the state of health disrupted by the causa morbi, thus anticipating Sydenham over a century later. The same author avoided bloodletting and drastic medicaments, and recommended mild laxatives, emetics, diuretics, and diaphoretics. His was a reasoned approach to traditionalism: he believed in the direct observation of nature and the light of experience. Among the many works which describe particular epidemics are those of Juan Tomtas Porcell, native of Sardinia, who had studied medicine at Salamanca and taught at Zaragoza, and who described in his Informacion y curacion de la peste de (7aragoVa y preservacion contra la peste en general (Zaragoza, 1565) how he had carried out detailed post-mortems on five of the 10 000 victims of bubonic plague in the Zaragoza outbreak of 1564. His study examined the cause of the outbreak and its diffusion, its clinical appearance and its treatment, and the preventive measures which should not be omitted during an outbreak. He was the first to carry out systematic post-mortems on plague victims (he performed 50 in all) in an attempt to discover the nature of the plague process and to explore further possible remedies. Syphilis as a particular, virulent, and apparently hitherto unknown epidemic, aroused special medical and surgical concern in Spain, as indeed elsewhere at this time. Among the earlier descriptions of the morbo gatlico was that of Francisco L6pez de Villalobos (b.c. 1460) who described it as una pestilencia no vista jama's, and included his rhymed description as appendix to El sumario de la medicina con un tratado sobre las pestiferas bubas (Salamanca, 1498). One work by the famous Ruy Diaz de Isla (1462-1542?), published in Seville in 1539 but written some twenty years before that date, put forward the theory of the American origin of syphilis, relating it to the mal serpentino brought from San Domingo (or Hispaniola) by Columbus' ships, which he supposed gave rise to the first cases in Barcelona in 1493 whither Columbus had travelled to give the news of his discoveries to the Catholic Monarchs. The use of guiaiacum in the treatment of syphilis was described by many, such as the priest Francisco Delicado writing in Italian in Venice in 1529; by Nicolas Pol (c. 1470-1532), Medico de caimara to Charles V, who also published his treatise on the subject in Venice in 1535; and by the great Nicolas Monardes who in his Prima, segunda, tercera partes de la historia medicinal (Seville, 1574) describes the different ways of treating lues, and the method of use and properties of guiaiacum, china root, and sarsaparilla. In therapeutics, a distinct movement towards a critical understanding of traditional remedies is apparent during the period. Most physicians and surgeons treat the subject in detail, particularly the use of phlebotomy and the indications for purging. Servetus himself dealt with the topic of syrups in his Syruporum universa ratio (Paris, 1537), which dealt, inter alia, with the practical problem of their exact use, their proper preparation, and their therapeutic action. Many investigations such as those of Francisco Hernandez in New Spain were made to identify the use of the aboriginal materia medica of newly discovered lands. Other investigations were made by Nicol'as Monardes in Seville to determine the action of drugs imported from the Americas, and yet others by Crist6bal de Acosta, author of Tratado de las drogas y medicinas de las Indias orientales (Burgos, 1578); both these were translated and republished outside Spain. Of the surgeons, Juan Fragoso (d. 1597) was the most interested in drugs, describing them in Catalogus simpliciorum medicamentorum (Alcala, 1566) and in his De succedaneis medicamentis (Madrid, 1575). Others pursued their own lines of enquiry, such as Lorenzo Perez in his Libro de theriaca (Toledo, 1575) which pointed out many errors in past and present writers on , endeavoured to point out the true constituents, and proposed new succedanea. Bloodletting, of course, had its advocates, among them Fernando de Valdes in his Tratado de la utilidad de la sangria en las viruelas y otras enfermedades de los muchachos (Seville, 1582). Journal ofthe Royal Society ofMedicine Volume 72 November 1979 871

It must be made clear that the theory and practice of the physicians were based on a traditional education, and on a traditional set of concepts. There were, for example, no less than thirty translations of the Aphorisms, Prognostics and Acute diseases of the Hippocratic corpus by twenty-three translators and commentators, published in Spain in the 16th century; twenty-six of these translations carry commentaries, primarily for teaching purposes. In assessing their contemporary importance it is useful to note that fifteen of the twenty-three translators were catedraticos (or full professors), three were surgeons, two were interested for non-medical reasons, and three were practising physicians. It is interesting to know that at least six of the authors were judaizers, or had Jewish ancestry. The two most important translators, Francisco Valles (1524-92) and Juan Fragoso (d. 1597) were also physicians and academics of considerable fame. Valles indeed, 'el Divino' and 'the Spanish Galen', was the most famous practitioner of his time and may stand as the perfect type of practitioner so beguilingly outlined in all his perfect attributes (the chief of which is moderation) by Enrique Jorge Enriquez in his Retrato delperfecto medico (SalamanIca, 1595). Typical of his time, Valles read medicine and took his doctorate at Alcala, where he continued to teach, becoming Catedratico de prima de medicina (1557-72), which he resigned on his appointment as Medico de catmara to Philip II and as Protomedico. He took a major part in the reforms of his university in the 1560s, and besides standardizing medical degrees and licences and weights and measures, he published many versions of and commentaries on Hippocrates, , and Galen. Speaking of Valles' commentaries on Hippocrates, Boerhaave said that 'ifone believed in the transmigration of souls, then Valles was the reincarnation ofHippocrates himself'. He was sufficiently flexible in his ideas and Hippocratic in spirit to advise methods of trial and error; and he was sufficiently practical and wise to mitigate Philip II's torment of gout with tepid milk footbaths and emollient cataplasms. At court he enjoyed high prestige as physician, humanist, and thinker, and was employed on such extra-medical activities as the setting up of the Escorial Library. Before passing to New Spain it is appropriate here to record that Naval Orders had been issued in 1587, 1606, 1608, 1613, and 1618. These were consolidated in the Ordenanzas of 1633, whose paragraphs 213-230 laid down in precise terms the requirements for the administration ofnaval hospitals, their service by the chaplains of the fleet, the examination of naval surgeons and naval barber-surgeons by the Protomedico of the Armada, the provision of drugs and (surprisingly delicate) special foods for the sick, as well as cupping-glasses and bandages 'so that those who serve me [i.e. Philip IV] suffer no want in things so necessary'; and, true to the Spanish tradition, provision is also made for officially appointed keyholders in each ship to the cupboard for the special articles of diet and to the medicine chest. Since the transfer of medical knowledge and skill to the Americas was subject to some natural delay it is appropriate to extend the period under survey to 1620 for New Spain, that vast entity conquered in stages from 1521, which was in the north to extend to the area now occupied by the southwestern and southeastern states of the USA and in the south as far as Panamia. By 1620, here too the original genius of Empire had been extinguished. Medical expertise was early transferred to the New World. The second expedition of Columbus of 1493 took with it as official physician Diego Alvarez Chanca, who later became physician to the colonies. Besides treating Columbus himself, who twice fell dangerously ill with possible typhus and malaria, Alvarez Chanca recorded his remarkable and vivid observations and experiences in a celebrated letter to the Cabildo of his native Seville, including the cannibalistic customs of the Caribbees, the poisonous effects of the manchineel tree, the discovery of Sea Island cotton, of the wax palm, and of tar or mineral pitch. Among the earlier official American practitioners we find the elder Pedro L6pez, formerly physician to , whose Crown appointment enabled him to take his place as Protomedico to the City of Mexico in succession to the licentiate Barreda in 1527, only six years after the conquest of Mexico. Following similar individual appointments to townships in metropolitan Spain, it was his duty to ensure that the few local physicians fulfilled their duties on pain of heavy fines. But the flow of qualified practitioners to the colonies was at first only a trickle. As the title- 872 Journal ofthe Royal Society ofMedicine Volume 72 November 1979 pages of the 16th century publications in New Spain make clear, colonial textbooks were frequently published for the benefit of those in remote places lacking both physicians and drugs. However, a little later on, such an eminent physician as Juan de la Fuente left his chair in the to take up duties as Visitor of pharmacies in the City of Mexicoin 1563; he later filled the Catedra de prima de medicina in the University of Mexico from the Catedra's inception in 1580 to his death in 1595. As physician to the Holy Office, to the Hospital de Jesius and the Real Hospital de Indios, and to the Jesuit convent in the capital, Juan de la Fuente is likely to have been a figure of considerable local importance. During the 1560s there arrived also the physician Francisco Bravo (c.1530-1594) and the surgeon Alonso L6pez de Hinojosos (c.1535-1597). To Bravo belongs the honour ofpublishing the first medical monograph in the New World, his Opera medicinalia (Mexico, 1570), which also contains the first (and exceedingly crude) medical illustrations to be published in the Americas. His traditional education at the small city University of Osuna in Andalucia did little to prepare his mind for the rigours of the New World, and the occasional essays which his work contains caused 'no trespass on the realm of the old ideas'. L6pez de Hinojosos, whose work Summa, y recopilacion de chirugia (Mexico, 1578) was republished with a considerable addition in 1595 and thus doubled in size, attempted, not without invention, to advance the theory ofLuis Lobera de Avila (Figure 5), physician to Charles V, ofthe common origin ofa multiplicity ofdiseases in the rheum (or flux) ofthe ancients. This watery substance, he held, flows from the head to the members, producing its effects sometimes by coagulation, sometimes by heat. To this cause he assigns a remarkable range of symptoms from catarrh to pneumonia, hemiplegia, cataract, nasal polyps, pains in the teeth, goitre, bladder and kidney stones, hernia, varicose veins, rectal prolapse, and cancer of the breast.

lfte DoL1ot reccdit itc?umtion cditurus,quia in venerat ifios nobiles cgrotantes comedenrcs frudus et alia mali nucrimenifine coinfilio fuo.

Figure 5. Luis Lobera de Avila, Vanquete de nobles cavalleros, [Augsburg, 1530]. The doctor leaves his disobedient patient. (By courtesy of the Wellcome Trustees) It is to a 16th century metropolitan physician that we owe the most important book to come out of New Spain. Francisco Hernandez (1517/18-1587), Medico de ca'mara to Philip II, was sent by him to New Spain as special and general Protomedico with powers overriding those of the local protomedicos, to examine and record the plants, animals, and minerals of medical value. To Philip II and Hernandez we owe a remarkable series of observations, still of value today. His seven-year stay produced a final draft of sixteen manuscript volumes complete with illustrations, which were edited by order of Philip II and eventually published by the Accademia dei Lincei in Rome, probably between 1648 and 1651. This final version describes, illustrates, and comments on the therapeutic action of some 2000 plants. The illustrations are Journal ofthe Royal Society ofMedicine Volume 72 November 1979 873 on the whole both accurate and beautiful, and the descriptions of the plants and their therapeutic action are remarkably detailed. Almost at the end of our period, a work by one Juan de Barrios (Figure 6) appeared in Mexico in 1607 entitled Verdadera medicina, cirugia y astrologia, whose liveliness of presentation and freshness of subject epitomizes the expanding horizons of medicine in the Spanish . It is a work not much known, and it was not republished. The most complete copy of the three known to exist is preserved in the Wellcome Institute. Little is known of the author except that he was born at Colmenar Viejo near Madrid, studied at and graduated from Alcal'a, practised in Valladolid, and moved to New Spain within the years 1586/96. Cast in the form of a dialogue, the book covers most of the usual aspects of contemporary medicine; but it also includes sections on cosmetics, beauty, the necessity of supplying more water to the City of Mexico and the means of doing so, and the first and much abbreviated version of Hernandez's work on the medicinal plants of New Spain to appear in print.

Figure 6. Portrait of Juan de Barrios from his Verdadera medicina, cirugia, y astrologia, Mexico, 1607. (By courtesy of the Wellcome Trustees) This book, however, represents the last and perhaps the highest point in the early transfer of European medicine to the colonies of Spain. Until the 18th century medicine reverted to more traditional lines; but the hospitals, hospices, and orphanages already founded continued to the end of the colonial era, with some additions to their number, to serve for the most part as their founders had intended. The end ofexplorative work is well symbolized by the publication by the of New Spain in 1616 of an Order forbidding astrological and other superstitious practices and forbidding 'easy women' to take 'drinks of herbs and roots' to 'deceive and stupefy the senses', and hence proclaiming a survival of primitive Indian intoxication by psychotropic drugs. It is significant that the next work of even minimal medical importance published in New Spain 874 Journal ofthe Royal Society ofMedicine Volume 72 November 1979 was the Tesoro de medicinas (Mexico, 1672) by the hermit Gregorio L6pez, arranged in alphabetical order of symptoms or necessity. The Age closes, therefore, with the return to safe and traditional thought, and to the enclosed ecclesiastical world which was the legacy of the decisions and actions of Charles V and Philip II, a legacy which was enhanced by their successors' ineptitude and folly. Limits had been set and enterprise expunged by the Inquisition, the ejection ofthe Jews, the conquest of Granada, the victory of Charles V over the Comuneros (1520-21), the victory of Philip II over the malcontents in Catalonia in 1568, the transportation of some 275 000 to Africa in 1609-14, the Censorship Pragmatic of 1558, the promulgation of the Index of 1559, the veto on attendance at foreign universities of 1559, and the increasing requirement of limpieza de sangre after the middle ofthe century for university education and appointment to public office. All this inevitably meant the adoption in all classes of an attitude of exclusion rather than inclusion, of fear rather than creativity. However, within 120 years of high activity the medical sciences in Spain had produced competent anatomists, highly expert surgeons, and physicians who creatively questioned the traditions in which they had been raised. These skills were transferred to the medical elite of the New World. Having set the pace, a weakened Spain retreated behind the Pyrenees, took refuge in traditionalism, exalted her glorious past, and left the race to others. Bibliographical note This paper attempts to be no more than a highly selective survey of the very rich material available from Renaissance Spain. The best rapid survey of medicine during this period is by the distinguished scholar Luis S Granjel (Historia de la medicina espaniola. Barcelona, Sayma, 1962; Chap. II, pp 37-69) to whom the author is indebted for the basis of this paper. For medical education in an important new university at this time, Luis Alonso Mufnoyerro's La Facultad de Medicina en la de Alcala de Henares (Madrid, Consejo Superior de Investigaciones Cientificas, 1945) is invaluable. For the place oftradition in the contemporary scene, the introduction (pages 1-4) of Teresa Santander Rodnrguez's Hip6crates en Espania (siglo xvi) (Madrid, Direccion General de Archivos y Bibliotecas, 1971) provides a remarkably well-informed and succinct summary. The Navy Orders are quoted from the facsimile version of Ordenancas del Buen Govierno de la Armada del Mar Oceano de 24 de Henero de 1633 (Barcelona 1678, published in Madrid by the Instituto Historico de Marina, 1974), available in the Wellcome Institute Library. In most cases the primary material cited in the text has been used; all the references in the text have been verified against the catalogues of the Library of the Facultad de Medicina of the University of Madrid and ofthe Biblioteca Nacional in Madrid, whose officials courteously allowed the author access to their files and to the material in their charge. He is also indebted to the Library of the Wellcome Institute for the History of Medicine, whose holdings in some areas of Spanish Renaissance medicine are unexpectedly rich. Background sources include J H Elliott: Spain 1469-1716. (London, E Arnold, 1963); and J Lynch: Spain under the Habsburgs. (2 vols. Oxford, Basil Blackwell, 1965-69); both are excellent in their very different ways. R Trevor Davies: Spain in Decline 1621-1700 (2nd edn. London, Macmillan, 1965) provides a graphic account of the causes and effects of Spain's retreat from greatness.