MEDICINE AND SURGERY

12 May

On at least one important point  Galen and Vesalius were in full agree- ment. Both argued that medicine and anatomy  had degenerated because physicians had given up the practice of surgery and dissection.  During the  Middle  Ages,  the  distinction   between  theoretical   and  practical medicine had been exaggerated  by learned physicians, and power plays within  university  faculties  exacerbated  this  tension.  To  enhance  the dignity of the medical faculty,  theoretical,  logical, and  universal  ideas concerning the nature  of human  beings were emphasized at the expense of empirical and mechanical aspects of the healing art. While the Scien- tific Revolution produced  little  change  in  medical  practice,  even the most highly educated  physician was becoming susceptible to the germs of skepticism. Instead  of admitting  their limitations,  physicians tried to maintain  the illusion  of the  infallibility  of the rules and  principles  of medicine, while blaming failures on errors made by patients and apothecaries.

During this period, however, patients could still select specific kinds of practitioners out of a diverse field in order to fit their budget and their own  perception   of  their  medical  condition.   There  is  evidence  that patients  expected the healers they hired  to produce  significant  results. The  records  of the Protomedicato, the judicial arm  of the College of Medicine  in Bologna,  for  example,  contain  cases where patients  sued practitioners for breach  of contract. That  is, healers entered  into  con- tracts  that  promised  to cure patients  within  a specific time. However, when the healers were actually physicians, the courts endorsed payment for services rather than for results, because physicians were professionals rather  than  craftsmen.

Physicians might have been engaged in increasingly  sophisticated debates  about  the nature  and  cause of disease, but  their  therapeutics lagged  far  behind  their  most  novel  theories.  Wise or  cynical  laymen noted  that  life and  death  appeared  to be unaffected  by medical treat- ment.  A king  might  have  the best physicians  in the world,  but  when ill, his chances  of recovery were not  really any better  than  those  of a poor peasant  with no doctor  at all. When therapeutics  was the weakest link  in  medicine,  psychological  comfort  was the  practitioner’s  major contribution. Under  these  conditions,  the  quack  might  provide  more comfort,  at lower cost.

Although  surgery and medicine could not be totally  disentangled, traditions and laws delineated the territorial rights of practitioners. As a general  rule,  surgeons  were expected  to  deal  with  the  exterior  of the body and physicians dealt with its interior. Surgeons dealt with wounds, fractures,  dislocations,  bladder  stones, amputations, skin diseases, and syphilis. They  performed  bleedings under  the  direction  of physicians, but were expected to defer to physicians in the prescription  of postop- erative care. Surgical practice  was itself divided into  separate  areas  of status,  competence,  and  privilege  among  surgeons,  barber-surgeons, and barbers.

University-trained physicians  were a tiny  minority  of those  who professed  knowledge of the healing arts,  but  they were especially con- cerned with the status of the medical profession.  Physicians considered themselves  men  of letters.  Still echoing  Galen,  physicians  contended:

‘‘He that  would be an excellent physician must first be a philosopher.’’ Physicians argued that medicine was a science that must be learned from classical texts, not a craft to be learned  by experience. Elite physicians could  command  a  salary  many  times  greater  than  that  of  surgeons. The status differential between physicians and surgeons is also apparent in the services they were willing to  provide.  For  example,  judiciously appraising  service in plague  pesthouses  as a potential  death  sentence, physicians  remained  outside  and  shouted  advice to the surgeons,  who examined  and  treated  the patients.  Despite  such hazardous duty,  sur- geons  were  poorly  paid.  For  example,  a  young  surgical  apprentice appointed to a pesthouse in 1631 (after two surgeons died of the plague) was later  awarded  just enough  money to buy new clothing  so that  he could burn the clothes he had worn for eight months  while in the pest- house.  If the sick could  not  afford  physicians  or surgeons  they could consult apothecaries, practitioners who had secured the right to a monopoly  on preparing  and selling drugs.

In many areas, a license to practice medicine could be obtained  on the basis of education  or by an examination  measuring  practical  skills. Learned   physicians  saw  the  latter  form  of  licensing  as  a  loophole through  which their unlettered,  ignorant  competitors  gained legal recog- nition.  This ‘‘loophole’’—the demonstration of skill and  experience— was especially important to  women,  because  they  were denied  access to  a university  degree.  Most  women  practitioners seem to  have  been the widows of physicians or surgeons,  but some were licensed for their skill in treating  particular problems.  Female practitioners were occasionally recruited by the public health authorities  to care for female patients  quarantined in pesthouses  during  plague outbreaks.

Today,  specialization  is regarded  as a sign of maturity  in the evo-lution of a profession.  However, in premodern times, ‘‘specialists’’ such as oculists, bonesetters,  and cutters  of the stone were more likely to be uneducated empirics than  learned  physicians.  Licensed physicians con- stantly  complained  about  competition  from  great  hordes  of ignorant empirics.  Not  all educated  laymen  agreed  with the physicians’ assess- ment  of the  distinction  between  physicians  and  the  empirics.  In  par- ticular,  the  plague  years  convinced  many  observers  that  much  that had been written by learned doctors produced ‘‘much smoke’’ but ‘‘little light.’’

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