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Both Linacre and More were concerned not just with the practice of medicine, but with the legislation which controlled that practice. Although Linacre's name does not appear on the earliest Act of Henry VIII's reign,1 Johnson, in his Life of Linacre,2 is confident that he was closely involved: 'As Linacre was for many years in strict intimacy with Colet [Dean of St Paul's, and the named person responsible for overseeing the registration of physicians in London] this first attempt to give dignity to the practice of medicine ... by ascertaining the competency of the practitioner, was probably suggested by the former.' More, when Chancellor, had responsibility for overseeing all legislation affecting medicine. The stage was being set for medicine to be properly controlled, and a previous paper3 has shown how important this regulation of medicine and surgery was for the future of dentistry.

More's intimate contact with medical men

Thomas More does not occupy the position of great innovator in medicine comparable to Linacre, with his foundation and housing of the College of Physicians, but he was a key part of the continuity of development not just in legislation, but through the widely influential tone of his household. He had himself been taught by Linacre, and when, as related in his book, the travellers to Utopia took with them 'Galen' and 'Hippocrates', the former was perhaps in More's mind in the new translation on which Linacre was working, and which he was to publish in 1517. His own son-in-law John Clement (?-1572) was to become a Royal Physician and President of the College of Physicians. There is a charming vignette (Fig. 1) by Ambrosius Holbein, (elder brother of Hans) of Clement, when as a youth he attended More in Antwerp during a diplomatic mission made to Flanders in 1515. It was while abroad at this time that More wrote Utopia, and this engraving was used on the title page for the first book in the third, Froben, edition. All the figures shown were real people except Hythlodaeus, the fictional Portuguese narrator of the story, though Holbein was probably working from imagination for their features. A true likeness of Peter Aegidius, (c.1486–1533) also known as Gilles or Giles, a native of Antwerp, as he looked at the time, was painted by Quentin Matsys in 1517. This shows him holding a letter from More so accurately done that More said it qualified Matsys as a forger.4 He was a close friend of More, intimately involved with Utopia, contributing a letter 'confirming' his presence on the day, and also the 'Utopian' alphabet and a poem in the language. John Clement is shown bringing out what looks like a picnic lunch to the men, who, as the text describes them, are seated on a turf bench in the garden of More's rented house.

Figure 1: Ambrosius Holbein (c.1494–c.1519).
figure 1

Engraving showing the real and imaginary characters concerned in the recording of the events of Utopia. They are sitting on a turf bench characteristic of the gardens of the sixteenth century, scented with roses. The young lad on the left, John Clement, later became President of the College of Physicians. Peter Gilles on the right colluded in the deceptions which p ortrayed Utopia as a real place. 10.5 x 6.2 cm. Third edition of Utopia, Froben, Basle, 1518, p25. By permission of the British Library. G2398

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We know from More's letters how proud he was of Clement, and with reason, for he already excelled as a grammarian by 1519: 'My Clement lectures at Oxford to an audience larger than has ever gathered to another lecturer ... Linacre ... admires him greatly'5 and later was counted as inheriting the mantle of Linacre in medicine. Both subjects were dear to More's heart, and both were subjects in which Clement's education had matured within More's household, alongside the other young members of the extended family who lived there. Clement completed his formal medical training in Louvain, was admitted to the College of Physicians in 1528, and by 1529 he was ranked alongside Dr Butts when he was one of the four physicians the King sent to minister to Cardinal Wolsey6 as he lay gravely ill at Esher. He became President of the College of Physicians in 1544. Very much an 'adopted son' in More's household, he married More's actual adopted daughter, Margaret Giggs (1508–1570), herself skilled in medicine, in 1530.

More's attitude to women and medicine

It is from a letter to his own daughter, another Margaret (1505–1544), that we can see both how important the education of women was to More, and the place he attached to medical studies '...I earnestly hope that you will devote the rest of your life to medical science and sacred literature, so that you may be well furnished for the whole scope of human life, which is to have a healthy soul in a healthy body.'7 He then follows up with a recommendation not to neglect humane letters and liberal studies. It should not necessarily be understood from this that More considered women should be admitted to the College of Physicians, though he may have privately thought so, for it is notable that women were not excluded from the (non-Christian) priesthood in Utopia. (Turner p124, Lupton p285)8

From sewers to the Royal Court

As well as the theoretical instruction which he derived from conversation with Linacre and others, More was personally experienced in public health matters. In 1514, the year before writing Utopia, he was appointed Commissioner of Sewers along Thames bank, between East Greenwich and Lambeth.9 Routh says '...he undertook other public duties which gave him an insight into municipal and economic questions, and a perception of the great need for sanitary rules, then very little understood, and practised only in Utopia.'10

The difficulties of his middle years,11 and the much played-over old age and manner of his death, make appreciation of the young and gifted Thomas More difficult when seen in the company of his younger and possibly more gifted King. Such an appreciation is part of this essay, for when considering the Henrician Acts of the first half of the sixteenth century, which set the modern pattern for the management of the practice of medicine and surgery, it is our fortune that we have for comparative study, More's readily accessible social fantasy Utopia, which gives flesh to the dry legal bones of the Acts. The parallels in thought and philosophy between the work and the Acts are notable.

The preamble to the last of these Acts,12 which may be considered as the most mature and reasoned, places its emphasis firmly on the common wealth and health of the realm:

'The kyng our soveraigne lord by the advise of his lordes spirytuall and temporall, and the commons in thys presente parlyament assembled and by the auctortye of the same by all their common assentes duly ponderyng among other things necessary for the common welth of this realme, that it is very expedient and nedeful to provyde for men experte in the science of physicke and surgery, for the helth of mannes body, when infirmities and sickenes shall happen,'

How did this approach to public health fit with the thinking of the day, and were the ideas part of a wider pattern of thought discussed at the very highest level? As evidence for the possibility, a copy of Utopia13 annotated as having been King Henry VIII's own (Fig. 2) is now in the British Library. (Fig. 3, for amusement, shows the King reading, but as an old man, not the brilliant 25-year-old of Utopia's publication day14)

Figure 2: Title page of the second edition of Utopia.
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Gilles de Gourmont. Paris 1517. This copy is reputed to be Henry VIII's own, and the ink legend just legible at the top reads 'Hoc exemplar ipsos Regis Henrici videtur suisse' by permission of the British Library. C65 e1 Ai

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Figure 3: Artist unknown.
figure 3

Henry VIII reading, with his books apparently typically scattered around him. From a French book of hours. By permission of the British Library. ROY 2 AXV1

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A brief rÉsumÉ of Sir Thomas More's life

More was born in 1478, and became a close friend of Erasmus (1467–1536) after they met in 1497. He became a Member of Parliament in 1504, and a Bencher and Reader in Lincoln's Inn in 1511. (A 'Bench-eater' (traniborus) is, in Utopia, a Senior District Controller, and More's father and grandfather had held senior posts in Lincoln's Inn.) When Utopia was published in 1516, Erasmus himself supervised the printing in Louvain, and may have arranged the marginal notes. As a Privy Councillor from 1518 More was on good and close terms with Henry VIII, who was then 27-years-old, and he became Lord Chancellor from 1529 to 1532. More was sent to the Tower in 1534 and was beheaded in 1535, so he had no direct influence on the drafting of the Act of 1540. He was, however, very much involved in the 1530 Ordinances of the 'Crafte of Barbor Surgions', preceding that Act, and which he signed as Chancellor, together with the Duke of Norfolk, Treasurer of England, Sir John Ffitzjames, Chief Justice, and Sir Robert Norwich Chief Justice of the Common Bench. In the same year, 1530, a French translation of Utopia had been published (Utopians are mentioned in Rabelais lll.l, 1546).

This potted biography shows that the man who was capable of thinking in the terms of Utopia did not live in an academic ivory tower. He was at the centre of public life, and he was companionable, amusing, and possessed of a high degree of intellectual integrity. For those interested in further detail, the biography The Life of Thomas More by Peter Ackroyd is to be recommended.17 A recent close analysis of Utopia, though not of the medical aspects, is that by Dominic Baker-Smith.18

The genesis of Utopia

Utopia, literally Nowhere-land, started its existence as an elaborate practical joke, a witty exchange between More, Erasmus, and Gilles of Antwerp (the Aegidius of the illustration), and incorporating enough real events, most particularly Amerigo Vespucci's landings in America, to have fooled several people at the time.

Erasmus had, in 1510, dedicated his Encomium Moria ('In Praise of Folly') written in the previous year, to More, and Utopia can be seen as More showing what he could do in turn. It is worth noting while reading More's Utopian encomium on the ethics of the healthy life, that Erasmus, while staying with More at his house in Bucklersbury, was the victim of a kidney ailment, possibly a stone, and if so the source of one of the most excruciating pains known to mankind, on a par with toothache. Linacre was his physician.

Utopia as a latin text

Utopia was written in Latin, which for most readers now has to be translated, and this gives it an advantage when compared with the Act uniting the Barbers and Surgeons in 1540, for as can be seen in the extracts given, although the Act is clear, its sixteenth century legal English and idiosyncratic spelling makes it not at all easy to read. Paul Turner, who made the idiomatic translation15 used for quotation here, says in his introduction 'Some obscurity is inevitable when a sixteenth-century author writes in English; but when he writes in Latin, it is quite unnecessary. For hundreds of years Latin served as a universal language through which one could speak directly, not only to people of other nationalities, but to people of other periods as well. Utopia is expressed in a timeless medium, which cuts it loose from its own particular age, and saves it from ever seeming linguistically old-fashioned or difficult.' The first English translation made by Ralph Robynson (1521-?) in 1551 is very agreeable, but quite hard work. In this paper, references to quotations are made giving the pages of Paul Turner's translation, and also of J. H. Lupton's benchmark book The Utopia of Thomas More16 which places the Robynson translation above the Latin text. This seems important where readers may wish to confirm the context and exact meaning of extracts and words.

Ethics in Utopia

'Utopia' has 15 paragraphs on ethics, of which five are directly related to health matters, both mental and physical, in fact stressing that the two are indivisible. There is also a separate section of three paragraphs dealing with euthanasia, and scattered throughout are references to public health measures. Dietary matters are discussed, with neither vegetarians nor omnivores being given the final say.

The following extracts from the 'Ethics' section of 'Utopia'19 serve to give the flavour. In the Latin original, Ethica is the actual word used in the marginal note, which may be Erasmus' contribution, and moribus is used in More's text. Lupton in his footnote refers to 'Ethics, or moral philosophy', and Robynson translates moribus as manners and vertue, so Turner's usage is appropriate:

'In Ethics they discuss the same problems as we do. Having distinguished between three types of 'good', psychological, physiological, and environmental, they proceed to ask whether the term is strictly applicable to all of them, or only to the first... Real pleasures they divide into two categories, mental and physical... Physical pleasures are subdivided into two types. First there are those which fill the whole organism with a conscious sense of enjoyment... Their second type of physical pleasure arises from the calm and regular functioning of the body — that is from a state of health undisturbed by any minor ailments.

Practically everyone in Utopia would agree that it's a very important one, because it's the basis of all the others. It's enough by itself to make you enjoy life, and unless you have it, no other pleasure is possible. However, mere freedom from pain, without positive health, they would call not pleasure but anaesthesia.

They don't think it matters whether you say that illness is or merely involves pain. Either way it comes to the same thing. Similarly, whether health is a pleasure, or merely produces pleasure as inevitably as fire produces heat, it's equally logical to assume that where you have an uninterrupted state of health you cannot fail to have pleasure.

As for the idea that one isn't conscious of health except through its opposite, they say that's quite untrue. Everyone's perfectly aware of feeling well, unless he's asleep or actually feeling ill. Even the most insensitive and apathetic sort of person will admit that it's delightful to be healthy — and what is delight, but a synonym for pleasure?

They're particularly fond of mental pleasures, which they consider of primary importance, and attribute mostly to good behaviour and a clear conscience... Of course, they believe in enjoying food, drink, and so forth, but purely in the interests of health, for they don't regard such things as very pleasant in themselves — only as methods of resisting the stealthy onset of disease. A sensible person, they say, prefers keeping well to taking medicine, and would rather feel cheerful than have people trying to comfort him.

(They) feel most grateful to Mother Nature for encouraging her children to do things that have to be done so often, by making them so attractive. For just think how dreary life would be, if those chronic ailments, hunger and thirst, could only be cured by foul-tasting medicines, like the rarer types of disease!'

The ethics section ends with this disclaimer:

'Well, that's their ethical theory, and short of some divine revelation, they doubt if the human mind is capable of devising a better one. We've no time to discuss whether it's right or wrong — nor is it really necessary, for all I undertook was to describe their way of life, not to defend it.'

Parallels and inferences

This essay places extracts from the Act in the old spelling of the 'Black Letter' copy, reproduced in the Annals of the Barber Surgeons,20 in juxtaposition with extracts from 'Utopia' in Turner's idiomatic modern English. At times, the parallels are exact, and at times an inference is drawn. The point is not to say that those who drafted the Act prepared a Utopian document, but to show both how 'modern' the environment in which the Act was drawn up was, and how civilised a document the Act is. The earlier legislation of 1511 and 1518 which established the registration of Physicians and Surgeons, and the establishment of the College of Physicians, and which may be considered as the products of Wolsey and Linacre, do not contain as much of the public health and educational thought processes which are clear in the 1540 Act.

Public health and the isolation of infectious disease

The prime aim of the union of the two companies of Barbers and Surgeons was not to unite their respective activities, but most emphatically, and for reasons of public health, to divide them. (Dentistry then, as now, being considered separate). The 'Utopian' view is also plain, and may be compared with the statement in the Act:

Utopia

'it's a pretty poor doctor who can't cure one disease without giving you another' (Turner p61, Lupton p94)8

— oh yes, there are four hospitals in the suburbs, just outside the walls. Each of them is about the size of a small town. [the Capital of Utopia had city walls c.2 miles square] The idea of this is to prevent overcrowding, and facilitate the isolation of infectious cases.' (Turner p82, Lupton p159)8

1540 Act

'And for as muche as suche persones being the misterie or facultee of surgery, oftentymes medle and take into their cure and houses suche sicke and diseased persons as ben infected with the pestilence great pockes & such other contagious infirmityes... whiche is veraie perillous for infecting the kyngs liege people resortyng to their shoppes and houses ther beyng washed or shaven... after the feast of the nativitie if our lord God next coming using any barbary or shavyng, or that here after shall use any barbary or shaving within the sayd citie of London suburbes of the same or one myle circuite of the same citie of London he nor they nor none other for them to his or other use shall occupy any surgery lettyng of bloud, or any other thynge belongyng to surgery drawing of teeth only excepte.' Annals p58920

Education and the sharing of knowledge

In sharp contrast with the wish to avoid the sharing of diseases was the concern for sharing and transmitting information, and the desirability of education is stressed both in Utopia and in the Act, which is specific in regarding the union of the two companies as being in part to improve and facilitate medical education:

Utopia

'My friend had brought some medical textbooks with him, a few short works by Hippocrates, and Galen's 'handbook'. The Utopians think very highly of them, for, though nobody in the world needs medicine less than they (the Utopians) do, nobody has more respect for it. They consider it one of the most interesting and important departments of science' (Turner p101, Lupton p216-217)8

1540 Act

'...by their unyon and often assemble togythers to the good and dewe order exercise and knowlage of the sayd science or facultie of surgerie, ashould be as well in speculacions as in practyse, both to them selves and al other their servauntes and apprentises, nowe and herafter to be brought up under them, and by their lerninge and dilegent and rype informacions more perfect spedy and and efectuall remedy shuld be than it hath ben or should be...' Annals p58720

Exemption from public service

In 1513, an Act21 exempted 12 surgeons in London from public duty, so that their services would at all times be available. In Utopia, More extended such exemptions to include students, and in the 1540 Act the exemption was extended to all surgeons:

Utopia

...out of all the able-bodied men and women who live in a town, [max. 2000 households, none containing less than 10 or more than 16 adults, so at c.26,000, the size of a twenty-first century town like Hertford] or in the country round it, five hundred at the most are exempted from ordinary work.... It ... includes those who are permanently relieved of other duties so that they can concentrate on their studies. (Turner p79, Lupton p147)8

1540 Act

...al persons of the sayd Company now in corporate by thys present act, and their successours, that shal be laufully admitted and approved to occupie surgery after the forme of the statute in that case ordeyned and provyded shalbe exempt for bearing of armure or to be put in any watches or inquestes. Annals p58820

Continuing professional development

In the Act, as in Utopia, the teaching responsibility was given equal weight with the learning responsibility, and the Ordinances made both compulsory. The concept of continuing professional education is not new, and of all the parallels to which attention is drawn in the essay, this is perhaps the most 'Morean'.

Utopia

'Most people spend these free periods on further education, for there are public lectures first thing every morning. Attendance is quite voluntary, except for those picked out for academic training, but men and women of all classes go crowding in to hear them.' (Turner p77, Lupton p143)8

1540 Act

And by occasion therof many expert personnes be brought up under them, as their servauntes apprentices and others, who by thexercyse and diligent informacion of their sayd maysters, as wel now as hereafter shal exercise the sayd science within divers other parties of this realme, to the great relyefe comfort and succour of much people, and to the sure safegarde of theyr bodily health, theyr limmes and lyves. Annals p58620

The Ordinances of 1530, in which as has already been said, More was personally involved, are much more direct:

1530 Ordinances

Also it is ordained that every man enfraunchesed in the said ffeliship occupying Surgery shall come to their hale to the Redyng of the lecture concerning Surgery every day of assemble therof and every man after his course shall rede the lecture hym selffe or ells ffynde an able man of the said ffeliship to Rede for hym and not to absent hym selffe at his daye of the same Redyng without cause Reasonable and without he give lawfull warnyng thereof before the daye upon the payne to fforfate and lose for every tyme doyng the contrarie xxs (20 shillings, a living wage at the time was 50 shillings annually)...'22

It was for these lectures that the great John Caius later gave his anatomy demonstrations.23

Scientific medicine

Of great interest, is the Utopian (and therefore Morean) attitude to science. The Act contains a provision for human dissection which, while the need might now be seen to be obvious, required, at the time, to have a theological justification for interfering with the highest of God's creation, as well as a surgical one. The idea of using convicted felons prevailed late into the last century.

Utopia

'- and, as they see it, the scientific investigation of nature is not only a most enjoyable process, but also the best possible method of pleasing the Creator. For they assume that He has the normal reactions of an artist. Having put the marvellous system of the Universe on show for human beings to look at — since no other species is capable of taking it in — He must prefer the type of person who examines it carefully, and really admires His work, ...' (Turner p101, Lupton p217-218)8

1540 Act

And further be it enacted by thauctoritie aforesayd, that the sayd maysters or governours of the mistery and comminaltie of barbours and surgeons of London, and their successours yerely for ever after their sad discrecions at their free liberte and pleasure shal and mae have and take without contradiction foure persons condempned adjudged and put to deathe for feloni by the due order of the kynges lawe of thys realme for anatomies without any further sute or labour to be made to the kyngs highnes his heyres or successours for the same. And to make incision of the same deade bodies or otherwyse to order the same after their said discrecions at their pleasures for their further and better knowlage instruction in sight learnyng and experience in the sayd scyence or facultie of surgery. Annals p58820

More's 'mission statement'

It seems appropriate to close with a quotation from More's Utopia which, as a mission statement, would be hard to beat:

'(Utopian) hospital patients get first priority (in allocation of food rations) These hospitals are so well run, and so well supplied with all types of medical equipment, the nurses are so sympathetic and conscientious, and there are so many experienced doctors constantly available, that, though nobody's forced to go there, practically everyone would rather be ill in hospitals than at home.' (Turner p83, Lupton p160)8

Conclusion

That More was influenced by his close association with Erasmus, and by Linacre, Wolsey, Colet, and others in the London (formerly known as the Oxford) group based around the Mercer's Company, and Doctor's Commons, is known. A fusion of their thoughts and the product of their discussions should be what we read in the medicine of Utopia and is what this essay wishes to promote, for such a view gives vitality and immediacy to a world not only not too different from our own, but one with a Renaissance excitement in which, despite knowledge of the dangers, one would dearly have wished to have been a part. (But for which a lack of education would probably render the modern wholly inadequate.)

Also important is the evidence of the impression made on him by More's involvement in such public works as the sewerage and drainage of London's south bank, and other public health measures. Utopia provides a piped clean water supply to each dwelling (as had the real life Hampton Court at the time).

It is worth repeating that Utopia was a humorous 'esprit', of which some parts are today wholly indigestible (slavery for example). The sections dealing with euthanasia are also potential sources for controversy. Nevertheless it is to be hoped that this essay will encourage more to read it, for within the light ironic or satirical coating is a strong message. The Henry VIII Acts deserve reading for the humane documents they are, and we shall indeed be fortunate if any replacement treats both citizens and medical practitioners with equal courtesy. It is a very 'grown-up' document in its liberties.