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.’’