Parisian Surgeons of the Seventeenth Century and the Disciplinary Emergence of Modern Medicine
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1One of the defining features of surgery is that it consists of manual techniques that are performed with instruments on a living body to provide a technological fix. From the Middle Ages, physicians tended to adopt an individualized, physiological perspective to the cause and effects of diseases, whereas surgeons conceptualized illness in terms of localized anatomy-based pathology.1 Charles Bodemer has argued that the history of surgery in early modern Europe is a ‘tale of upward mobility’ that represents ‘the beginning transformation of a barbarous art dominated by illiterate and semi-literate practitioners into a disciplined science comprising well-educated and respected members of the medical profession.’2 Surgery, as a practical treatment, was certainly considered manual work. The name of surgery comes from the Greek χειρουργία, from χεὶρ, for hand, and ἔργον, meaning operation. As Roy Porter underlines, the common surgeon was ‘depicted as a man of flesh – bold and beefy, holding a knife and a saw’3 and, since surgeons often also undertook other trades such as hair-cutting, they were thus perceived as workers who simply used their hands, not their heads.
2However, alongside surgeons, the early modern period bore witness to a panoply of healers and surgical practitioners who were willing to offer manual treatment to their patients. Following Brockliss and Jones, whose comments on France might apply to much of the rest of contemporary Europe, this medical world can be defined as the ‘whole set of practitioners of health services, trained and untrained, educated and non-educated, male and female, working in France between the sixteenth century and the French Revolution.’4 It consisted of men or women5 who were young or experienced, worked in shops or on the roads, and belonged to trade guilds or learned colleges. These different practitioners dealing with the body, illness and healing were categorized, legitimized and formally organized in a variety of ways. Importantly, surgery in France was only formally charted and allowed to flourish when corporative bodies allowed surgeons to record but also share their knowledge. What had been a secretive skill passed down in families and from master to apprentice eventually became more systematized and overt. The evolution of surgery in France provides fascinating insights into the shaping of institutionalized medicine.
3Indeed, in early modern Europe, France was, in many ways, at the epicentre of the metamorphosis of medicine. As Tony Gelfand underlines, ‘French surgery assumed a position of European leadership in the late seventeenth century and the first half of the eighteenth. French, or to be more precise, Paris surgeons, built this reputation on major operations, new instruments and anatomical work.’6 The increased role surgeons came to play in military healthcare and in hospitals furthered their prestige and visibility. Paris became ‘the outstanding centre for learning anatomy and surgery’.7 But how did the changes manifest themselves and what did the medical world that Paris built upon and changed look like?
4The provision of medicine in the early modern period has typically been depicted in terms of a tripartite structure – a pyramid of legitimate practitioners consisting of physicians at the summit, apothecaries and surgeons in the middle, and a base layer of ‘unorthodox’ practitioners (healers, cunning folk, wise-women etc.) Although, as will be discussed, scholarship has subsequently challenged this hierarchical model, and shown that the divisions between these practitioner types were arguably more fluid in places than this neat picture suggests, it is useful to trace the broad categories that existed.
5Physicians were highly educated. They focused on ‘physic’, i.e. the maintenance of the internal workings of the body including the treatment of congenital conditions and diseases. Above all, they were men of letters who taught natural science and literature in universities (or in France also at the Collège de France). They tended to be humanists and poets, and were far more skilled in doctoral discourse than in clinical practice or intervention, which was delegated to students, barber-surgeons, or even apothecaries. As Brockliss and Jones note, medical students ‘were instructed in surgery and pharmacy to police their subordinates better, not to practice these arts personally.’8 In fact, medical students presented dissertations on surgery from the early seventeenth century but they were not expected to actually perform any operations. The physician, as a member of a liberal profession and the bourgeoisie, was granted tax exemptions, exemptions from military service, exemptions from certain municipal offices and the right to hold prestigious positions.
6In France, apothecaries were part of a merchant guild along with tradesmen such as spice merchants, chandlers, painters, or grocers.9 They benefited from certain privileges which came with obligations and an oath very similar to that of the current version of the Hippocratic oath. Pharmaceutical studies had been organized since the previous century into several years’ apprenticeship crowned by the presentation of a ‘masterpiece’, according to the term’s original meaning: a piece of work produced by an apprentice aspiring to become a master craftsman in his chosen guild. The apothecary dispensed medicine prescribed by the physician but also offered inexpensive advice to those who could not afford the physicians’ fees.
7The surgeon focused on operations, which included the treatment of external ailments, wounds, fractures and the removal of bodily parts, as well as the letting of blood, application of enemas and dentistry. This work was learnt by apprenticeship within the guild context: essentially an arrangement undertaken between the more experienced surgeon (master) and his pupil over a period of years.10 Danielle Jacquart argues that the idea of the surgeon limiting himself to the treatment of external disease was a reductive image constructed by Quesnay in the Encylopédie.11 Be that as it may, surgeons as a group, until after the middle of the eighteenth century were denied benefits afforded to physicians since they were characterized as a ‘mechanical’ profession, relegated with other métiers and pursued predominantly by the lower class of bourgeoisie and even common workers.12
8Empirics (often also dismissively termed ‘charlatans’) were practitioners who lacked formal qualification or certification that allowed them into the official medical community. This included a range of healers who specialized in parts of the body (oculists, tooth-drawers or bone-setters, for example), wise-women or herbalists; and although they were met with disdain by physicians who tried to curtail their reach, they provided a range of treatment to the population.13
9The predominant historiographical narrative in regard to the early modern medical world is a teleological one: ‘it begins with a picture of pre-modern and early modern medical pluralism (where there was not one medical profession but a whole range of occupational groups, often with unclear boundaries) which, over the course of the eighteenth and nineteenth centuries, is replaced by a more united medical profession.’14 This appreciation of the early heterogeneity of the medical profession stems from scholarship which flourished from the mid-1980s onwards, in which a number of Anglophone historians began to describe healthcare in early modern England as a ‘medical marketplace’ or ‘medical market’. This term was predominantly used to convey ‘an image of the pluralistic diversity of medical provision’.15 The attention given to the diversity of medical workers meant that scholars overturned assumptions relating to their stratified roles and tasks. Fundamentally, these studies argued that the boundaries between physicians, surgeons and apothecaries were blurred to the point that they became irrelevant. Attention certainly needed to be brought to the kaleidoscopic world of healers that existed but as David Harley has noted, the marketplace model can erroneously lead historians to treat practitioners ‘as social equals, supplying an undifferentiated commodity’ thereby eclipsing social stratification and restrictions that were placed on the freedom to trade.16
10Furthermore, France’s medical community was somewhat different to the unstructured ‘free-for-all seemingly characteristic of England’.17 The fundamentally corporatist nature of medicine in France meant that there existed a much more distinct medical community, even if it was surrounded by a ‘penumbra’ of informal and irregular healers.18 There was much earlier legislative and even direct royal involvement in defining the boundaries of the medical professions; a tendency which only increased over time. Surgeons and barbers belonged to royally assented guilds or companies from before 1400. Apothecaries established apothecary colleges and guilds from the 1570s though these were licensed and inspected by boards of physicians who jealously guarded what they perceived as their own territory. Indeed, they often accused apothecaries and herbalists of practicing medicine illegally and sought to curtail their work. Additionally, as will be shown, the formation of the guild of barber-surgeons with the academic surgeons in mid-seventeenth century France changed the landscape even more since it meant that, for the first time, a large number of people, ‘united by membership in a common institution began to combine theoretical training with practical experience.’19 This brought about significant change.
11In telling this story, this chapter seeks to explore disciplinary boundaries relating to the practitioners and their surgical work in the early modern period in France. A key question is whether, in this period, surgery was actually conceived of as a discipline. How was surgery defined? Was it a ‘craft’, a ‘practice’, an ‘art’, or a ‘profession’? How did such work and its importance in society impact on these labels or did these labels impact on how the work was received within society?20 How, more broadly, did the political, social and institutional contexts shape the work of surgery and those who performed it? And did the evolution of surgery as a distinctive medical profession have an impact on the shaping of the disciplinary field of medicine as a whole?21
12Early modern surgery in France can be understood as a field of knowledge, a therapeutic practice and a professional field. In his important monograph, Professionalizing Modern Medicine, Tony Gelfand presents the view that surgery can be considered the ‘fructifying craft’ with ‘medicine, the recipient profession’ and ‘the new epistemology, resting on clinical examination and pathological anatomy, the conceptual change’.22 I shall attempt to see if this description of a ‘fructifying craft’ offers a useful way of conceptualizing the way surgery evolved. Whilst Gelfand’s narrative offers a clear picture of evolution, I seek to examine questions he does not explicitly engage with, namely whether the surgeons were the conscious actors of the move to become a distinct occupational group and were instrumental in bringing about this ontological shift in categories, or whether it was the changing structural patterns that made way for their new kinds of professional roles. Additionally, I seek to explore the extent to which surgery managed to establish its own value system on practical competence (as distinct from the university world’s focus on abstract knowledge) and whether, once the surgeons had re-established links with the university, they then reverted back to a more academic model. Finally, in conceptualizing the new identity of surgeons, I seek to underline whether the surgeons sought to maintain their difference or rather were content to merge and fully integrate within the medical model of learning and practice.
13It has been argued that surgery ‘became “modern” when craft-surgery disappeared in the eighteenth century, and the term “surgeon” came to denote a formally educated practitioner essentially similar to a physician in status.’23 Its modernization entailed disciplinary unification and consolidation, with medicine and surgery coming to be viewed for the first time as ‘complementary and interpenetrating parts of a single, empirically and experimentally constituted “medical science.”’24 Wallis notes that this unification is novel and it certainly was, in the sense that the discipline of ‘medical science’ was a new formalised disciplinary framework. However, although this distinction presented a marked change from the early model, ancient medicine had not made such rigid demarcations between medicine and surgery. It was really from the medieval period onwards that this division became so entrenched.
Background
14In Antiquity, there were no individuals whose sole role was to perform surgical treatment. Operations were undertaken by the medical practitioners of the time.25 Communities or ‘schools’ of medicine (groups of philosophers, priest-physicians and students) developed throughout Greece, and Hippocrates, based at Cos, has come to be seen as ‘the father of modern medicine’. He moved decisively away from the religious mysticism that had characterized previous treatment and presented a systematized body of knowledge through a collection of seventy-two medical works which has come to be known as the Corpus Hippocraticum. This includes a range of texts on surgery.26 There is little existing written information on early Roman surgery; however, it was believed to have been strongly influenced by Greek medicine and in most aspects reflected the Greek healing traditions. Surgery in Rome was practised almost entirely by Greek physicians.27 Second only to Hippocrates, the most famous physician of the Roman period was Galen (AD 129–199) whose influence continued into the Renaissance. He was viewed as talented at surgery and wrote extensively on surgical instruments. His dissection techniques, however, were based on animal dissections (human dissection was not permitted) and this anatomical data (containing numerous errors in relation to humans) continued in medical texts well into the sixteenth century. Despite the advances and body of work in this period, Christopher Lawrence notes that it would be a mistake to talk about an ancient medical ‘profession’. Rather, we should view the practitioners as part of the occupation of healing. Even if the term professio medici existed, there were no regulatory bodies or examinations, and authorities were resistant to the formation of autonomous private corporations.28
15In the early Middle Ages, surgery and medicine were still combined in the person of the ‘doctor-surgeon’ (a kind of general practitioner); however, the view that surgery was an invaluable adjunct to medicine started to shift. In the thirteenth century, when medical work was the privilege of churchmen, physicians showed increasing resistance to the ‘manual’ side of this role. Furthermore, Canon 18 of the Fourth Lateran Council forbade the ‘shedding of blood’. This led to the de facto exclusion of surgery from both churchmen’s medical practice and the university curriculum, and its abandonment to secular society. The work thus fell to barbers who had previously assisted the monks in performing operations and had been an active presence in monasteries since 1092 (owing to the fact that beards were banned and monks had to have their hair maintained in accordance with their specific religious orders). On a practical level, the convergence of barbery and surgery principally rested on the ability to manipulate sharp instruments. Additionally, the medical theorization of hair as bodily excreta/secreta meant that cutting this part of the body was viewed as a surgical act.29
16The barbers soon widened the scope of their professional activities to include cupping, leeching, lancing boils and pulling teeth; and by the thirteenth and fourteenth centuries in France, they were using quite sophisticated surgical techniques. Crucially, from the thirteenth century onwards, the view that surgery ought to be a bounded occupation, distinct from physic, was institutionalized, as attested by the ‘guilds’, ‘mysteries’, ‘corporations of surgeons and barbers’ that were established throughout Europe. The practitioners pushed for these in order to have a more legitimate place within the market of healthcare. This is not to say that the theoretical, academic side of surgery was ignored. In this instance, we can see that the barbers were instrumental in the evolution of their own occupational group. Rather it meant that a more distinct line was drawn between those that would study the history of surgery and understand it conceptually, and those who would actually touch patients and perform procedures. Some surgeons tried to adhere to the more traditional physician’s focus on theory and claimed surgery was a learned discipline whereas others stressed surgery’s independence as a manual art.30 This accounts for a firm division that emerged between the academically-minded surgeons and the hands-on barber-surgeons.
17At the beginning of the fourteenth century, in Paris, a surgical community became affiliated with the parish church of Saint-Côme and those who passed their examinations were awarded the title of ‘masters of surgery’. These master-surgeons, sometimes known as surgeons of the ‘long gown’ in recognition of their academic status, used their new title to secure their position and to differentiate themselves from the barbers. Barbers, equally, wanted to make sure they were not pushed aside. The barbers eventually obtained their own special royal charter in 1372 which legalized their professional ambitions. This favourable legislation was secured since they had a powerful patron in the king’s first barber. In addition to barbering, they were subsequently entitled to treat carbuncles, bruises, boils, and any other ‘non-mortal’ open wounds. During the fourteenth century they essentially supplanted the master-surgeons of Saint-Côme in regards to minor operations (particularly bloodletting, a procedure used for the prevention and treatment of most ailments). The barbers also received support from the Paris Faculty of Medicine for whom they represented less of a threat. The physicians relied on the barbers, rather than the surgeons of Saint-Côme, when patients required minor surgical attention. In 1493, the faculty permitted the barbers to attend courses in Latin and to have a skeleton for anatomy lessons. From 1505, the barber-surgeon guild signed several contracts with the faculty with the proviso that they were to restrict themselves to manual dimensions of therapy and to treat patients only when the doctors of the Faculty had given their approval. Barbers were permitted to be students of the university. The barber-surgeons had to acknowledge openly that the physicians were their superiors and paid annual dues. They were also obliged to have physicians oversee the examination run within the guild where barber-surgeons would advance in their training to become ‘master barber-surgeons’.31 Although the barber-surgeons were differentiated from those within the world of learned medicine, they were obliged to live according to the hierarchy it imposed.
The rise of the barber-surgeons
18The status and reputation of the guild of barber-surgeons continued to improve in the early seventeenth century. In 1603 the Parlement of Paris granted master barber-surgeons the right to treat all kinds of wounds and the official title of the guild was recognized as that of ‘barber-surgeons’ as opposed to ‘barbers’ as it had previously been known. Keen to further themselves even more, in 1625 the barber-surgeons attempted to get their name changed to the guild of ‘surgeon-barbers’ but this was not granted. In 1634, King Louis XIII praised his dear community of ‘master barber-surgeons’ as the ‘principal source of the knowledge and practice’ of surgery in all the Kingdom. In this respect, the barber-surgeons had successfully managed to gain a degree of independent prestige by playing to their strengths in practical skill. The King’s comment, however, that the master-surgeons possessed the key necessary knowledge also underlines that they were not just seen as being good with their hands, but were deemed to be well-respected in terms of their expertise and understanding. Desiring to capitalize on their blossoming reputation, in 1643, the barber-surgeons also attempted to extricate themselves from their position of subordination within the Medical Faculty, but were unsuccessful. However, this did not prevent the guild from growing substantially and the barber-surgeon came to be a much more familiar figure than their academic counterparts.
19As Mary Lindemann points out, although definitions of what barber-surgeons were legally permitted to do varied throughout Europe, they frequently came into contact with the academic surgeons over the execution of surgical operations. She underscores that much depended on what was considered minor surgery. She notes that ‘barber-surgeons often overstepped legal boundaries and infringed on the province of the surgeons by letting blood or performing more complicated operations.’32 But they could also be victims of this sort of poaching from below, so to speak, and barber-surgeons constantly complained about surgeons who cut hair and thus interfered with their livelihood. Barber-surgeons served a broad spectrum of patients, as distinct from university-trained physicians, who collectively served very few patients of very high social standing, and usually had patronage. In practical terms, the barber-surgeons often seemed to offer more to the injured and the sick in terms of tangible treatment and so earned higher public confidence than the less accessible academic surgeons.33 However, Sandra Cavallo points out that an exclusive focus on medical activities has led scholars to neglect other important aspects of barber-surgeons’ work.34 Thus, she argues that they must be understood as operating amidst a range of different artisans ‘involved in various aspects of the care, comfort and appearance of the body’.35 Along with tailors, wigmakers and perfumers they were, as she calls them, ‘artisans of the body’ who all had a fundamental role in society and possessed professional training and important skill sets.36
20We can observe, therefore, that seventeenth-century surgeons partook of both ‘craft’ professions, in this artisanal nexus, but also ‘learned’ professions close to the academic setting. Above all, we need to appreciate how in urban France, surgery of all kinds came to be both legally and intellectually dominated by practitioners working within corporative frameworks. What prompted this organizational development? Firstly, trained practitioners facing increased competition from the array of healers offering their services began to lobby for it. In this way, they were agents of this change. Secondly, the monarchy actively supported the tendency. Keen to maintain his hold on the cities, the monarch set about ‘effectively buying the support of established professional and artisanal classes’.37 Thus, guilds and corporative bodies became agents of a centralized government. In so doing, the early modern state ensured that the core of the medical world, and indeed all the trade and craft guilds, were inextricably tied to it. Seen from this perspective, it was the changing structural systems and the orders from above that acted as an important engine for changing the landscape, not simply the practitioners themselves.
21A profound change came when the barber-surgeons merged with the academic surgeons of Saint-Côme in 1655. A prior attempt (in 1613) had been made to merge the guild with the company but despite the government agreeing to this, the majority of academic surgeons at that time were not in favour of the union and thus managed to prevent it. Yet some forty years later, the Saint-Côme members did merge with the guild of barber-surgeons and all surgeons officially became barber-surgeons, much to the satisfaction of the physicians. In fact, the merger was viewed in the eighteenth century by historians as a coup organized by the Faculty of Medicine and the barber-surgeons to undermine the power of the academic surgeons as a separate body of workers, by bringing them under the same umbrella organization. However, as Gelfand underlines, this erroneously portrays the academic surgeons as ‘passive victims’.38 In reality, the academic surgeons and the barber-surgeons initiated the merger and the Faculty of Medicine was not involved until later. The merger must have made sense financially to the Saint-Côme surgeons who could not compete with the large guild. Barber-surgeons actually charged more for their services. As for the barber-surgeons, the union gave them important prestige.
22Why would the gens de lettres (i.e. the academic surgeons) want to join with artisan barber-surgeons at the risk of losing their disciplinary standing within the domain of learned surgery? It was undeniable that the academic surgeons had long suffered at the hands of physicians who feuded with them over their status. The physicians had favoured the barber-surgeons who were more docile. So, in some senses, the merger provided the academic surgeons with a firmer footing, even if they had to allow for a significant shift of focus and loss of independent status. In the merger, the academic surgeons had hoped to retain some of the honorific privileges of the college of Saint Côme but, regrettably for them, this was not granted. On a practical level, few surgeons could survive by practising just surgery (excluding barber’s work). A mixed practice brought far greater financial rewards. The barber-surgeons’ guild was also linked with the parish church of Saint-Sepulchre whose merchant patrons were richer than those of Saint-Côme. So, it seems that in this case, pecuniary considerations won out over the allure of academic standing.
23It is important to note that the Paris academic-surgeons of Saint-Côme were somewhat anomalous in the mid-seventeenth century. There was no equivalent in other major provincial cities where barber-surgeon guilds were the only surgical organizations. Barber-surgeons usually held the desired posts at the court of Versailles, in hospitals and noble households. Most naval surgeons had served as barber-surgeons. Across Europe, there were no other companies of ‘pure’ surgeons, and barber-surgeons predominated. Italy was unusual in the sense that in major cities surgeons there often obtained medical degrees and subsequently took up places in medical faculties; but even then, surgical practice was dominated by barber-surgeons.
24Clearly nervous about the merger in Paris which had created a substantial amalgamated group of surgeons, the Faculty of Medicine contested it before Parlement in 1660, and successfully diminished the new group’s status. All were made strictly subordinate to physicians, as had been the case with the former barber-surgeon’s guild, and none of the surgeons in the new group were permitted to wear the long gown. Stripped of learned titles such as ‘doctor’, they could not do any public teaching and surgical students were not permitted to defend theses. However, the surgeons, grouped together, consolidated their power and, no longer pitted against each other, grew to become more emancipated from the physicians. Incentives were given for the surgeons to concentrate their efforts only on actual surgical work, as evidenced by the statutes of 1699. These stated that those masters who gave up barber’s work (or petite chirurgie as it was known) and only undertook ‘the art of surgery purely and simply [would] be considered to practice a liberal art and [would] enjoy all the privileges attributed to the liberal arts.’39 Ironically, then, by becoming nominally ‘barber-surgeons’ the opportunity was created for specialization in the purely surgical field.
25Additionally, contemporary progress in anatomy and its application to surgery provided a scientific basis for surgery’s increased importance. Anatomical and physiological research (bolstered by Harvey’s discovery of the circulation of the blood) flourished in the late seventeenth century. Surgery began to embrace this way of thinking – surgeons ‘adopted the new sciences and scientific methods and began to see themselves as part of a progressive movement.’40 Improvements for a range of operations were made and surgeons experimented with more complex equipment. Their work came to be increasingly based on more empirically-oriented anatomical theory and innovative operative techniques. An analogous process was taking place in medicine at the same time: it developed to become ‘more self-consciously scientific’ in its critical re-examination of the empirical tradition and thus created ‘a rationally founded pathology and therapeutics’.41 The result was a new framework for rapprochement between medicine and surgery. The potential of the technical and professional space thus created is exemplified by an increase in the activities of medically-trained surgical writers. Ironically then, the medical faculty’s push to drive surgeons from the medical establishment allowed the surgeons to grow in strength and expertise in a way which facilitated their ultimate re-integration into the disciplinary mainstream of modern medicine. Later, as France moved towards the ideology of the Enlightenment, with its insistence on the bettering of the human condition and its bias towards the practical, surgery came to be viewed as an exemplary science.
26Since the Parlement in 1660 prohibited the united surgical community from giving public lectures, they could only give anatomical demonstrations and ‘private exercises’ (related to the exams for surgical mastership). This did not prevent them from actively disseminating their work. The demonstration lessons they set up became very popular and led to the construction of a new amphitheatre in 1694 which could accommodate up to 750 people. This amphitheatre was in fact granted by the King in recognition of the successful surgery that he himself had undergone in 1686 (as detailed in the next section). Public interest, royal support, and active dissemination by the company had all helped promote the group’s visibility and status. By the beginning of the eighteenth century, courses in anatomy, osteology, and operative surgery were run at this site. But this ‘School of Surgery’, as it was sometimes called, was not the only location in Paris for demonstrations relating to surgery. The Jardin du Roy (originally founded in 1635 by the King with non-university professorial chairs for botany, chemistry, and anatomy) also added, in 1673, a chair for anatomy and surgery which helped it become the leading centre for anatomical teaching in the kingdom. The first occupant was Pierre Dionis, a renowned Parisian surgeon whose lessons were so popular that the large hall in which they were held could not house even half the number of eager attendants. His textbook, Cours d’opérations de chirurgie, based on his lectures, was popular throughout Europe until late into the eighteenth century. Additionally, the admission of several Paris surgeons into the Academy of Sciences helped dispel the stereotype of the surgeon as simply a manual worker. Louis Gayant was one of the first members when the Academy was founded in 1666,42 and Jean Mery joined in 1684.43 The intellectual and professional identity of the surgeon, trained independently of the medical Faculty in a specific teaching and research institution combining theory and practice, had been forged. Although the surgeons stood institutionally outside the university, their learning was nevertheless based on an academic model, albeit with an increased focus on mastering practical techniques.
New institutions
27A further notable consequence of the union of the two guilds was that the King’s premier surgeon was elevated to a position of leadership. It is important to note that within the royal households, the position of medical practitioners (such the role of premier chirurgien) were positions outside of the guild system. Instead, these practitioners worked within the jurisdiction of the court. The royal medical household infringed on the rules of trade incorporation, much to the anger of those in the guild and despite the latter’s attempt to have monopoly over the city’s own medical practice. However, whilst nominally outside the system, they nevertheless managed to wield considerable power over the very guilds whose rules they did not have to follow. Interestingly, the office of premier surgeon, although important since the holder was the personal surgeon to the monarch, had not, initially, been a position that wielded power over the Paris community of Saint Côme or over the barber-surgeons. It was the King’s premier barber who had ruled over all the communities of barber-surgeons.
28However, when in 1660 the Parlement decreed that the united community had the status of the old barber-surgeons’ guild, the new united community was passed over to the King’s premier barber. The royal government believed it inappropriate for a barber to be head of the only Parisian surgical guild and therefore in 1668 the King’s council ordered the premier barber, Jean de Rety, to sell his rights to the premier surgeon, François Félix. This role meant that Félix was also given authority over the barbers who focused on barber’s work and wig-making, effectively removing all the power Rety had once enjoyed. Félix helped lay the foundations for a unified medical profession which grew over the last three decades of the seventeenth century. Power was centralized with the premier surgeon ruling over Paris surgeons serving under him, chosen through a meritocratic system. The premier surgeon was made chief of all the communities of amalgamated surgeons and barber-surgeons (and also of barber-wigmakers), with the result that guilds then became overseen and organized in a much more centralized fashion. Barber-surgeons progressively disappeared to become either barber-wigmakers or worked to become surgeons through the necessary training.
29The path to this ‘unified medical profession’, however, also involved a distinct demarcation of surgery within formalized institutions. By the 1740s, the Jardin du Roy and the Académie royale des sciences (the traditional place for the propagation of scientific thought in the seventeenth and eighteenth centuries) were replaced in importance by specifically surgical institutions. The Collège de chirurgie at Saint-Côme was set up in 1724 by Louis XV’s royal letter patent as a teaching institution that granted degrees, and the Académie royale de chirurgie, founded in 1731, was devoted to recording and publishing the research and careers of renowned surgeons of the time. Additionally, another royal patent in 1768 guaranteed surgery its institutional independence in the construction of the Academy and Schools of surgery (completed in 1774, under Louis XVI). According to Dianah L. Jackson, these brought about ‘the legitimization of surgery’s institutional status – and its independence as a discipline in the early part of the eighteenth century.’44 Looking beyond this, however, we can also see that its legitimization then afforded it a place within the formalized discipline of medicine. In 1820, the Académie royale de chirurgie and the Société royale de medicine (founded in 1776) were brought together to become one institution, the Académie royale de medicine.
30This account of the way in which the medical faculty and the surgeons were finally united through a centralised academic system has sought to underline how guild and royal practitioners, physicians and surgeons, barber-surgeons, and master surgeons had all once had distinct statuses but eventually came together through this new organizational pattern. It would appear that the narrative that marks these changes is fundamentally one of power and politics: practitioners marking their territory and seeking to survive and thrive; the ability to obtain royal support and harness the authority it afforded. However, the story of surgery is also one of shifts in attitudes; not only in the way anatomical approaches and scientific discovery brought surgery to the fore, and not only from the perspective of the royal establishment who buttressed the whole organizational system, but also from the larger public who were themselves the patients of these practitioners. What happened at court was always a talking point so when the King went under the knife for a major procedure, the nation turned their attention and admiration more than ever before to the skill of surgery. The following case study traces this significant moment.
Louis XIV’s operation
31Court medicine in the seventeenth century was organized under a premier physician to the King and eight physicians-in-ordinary, two of whom attended over a three-month period before passing on to another pair from the eight. There was also a first surgeon to the King and eight surgeons-in-ordinary, whose attending schedule corresponded with that of the physicians.45 The King suffered a variety of ailments throughout his life, as attested by the Journal de la Santé du Roi maintained under the King’s orders from 1647–1717, by the first physicians D’Aquin and Fagon. However, the surgical treatment of his fistula-in-ano would become one of the great medical events of his reign. As Bodemer notes, this was to ‘change the life of Louis XIV, provide conversation for the inhabitants of Versailles for months, lead to a fête of massive proportions, enrich the court medical staff, raise the status of surgeons, and mark a significant point in the evolution of surgery.’46
32The King had begun to be troubled by a small tumour towards the perineum on 15 January 1686. The tumour hardened and grew; on January 31, it was considerable enough to make the King take treatments to try and reduce it. Lancing and various medicines were ineffectual. A new concoction by the court apothecaries was used but only made the abscess flare up more. The apothecaries then sought to use injections of water of ‘woundwort’, and on 8 March, when it had become even more painful, they tried other caustics and occasional application of leeches. By 17 March the journal recorded that the King’s anus was in a good condition and he appeared to be on the way to full recovery. The physicians felt vindicated. However, on 17 May a fistula-in-ano was noted and officially recognized by court physicians and surgeons alike on 21 May.
33This condition was not an unknown one. In antiquity, surgery of the anal region had been popular and a surgical approach had also been actively adopted in the Middle Ages using a syringotome, a semi-circular instrument developed by Galen.47 In the sixteenth century, a professor of Anatomy and Surgery at Padua (Hieronymus Fabricius) had modified the instrument and worked on perfecting the operative procedure, but during the seventeenth century, most authors discouraged incision and recommended instead the ancient method (of Hippocrates) of introducing a probe into the fistula and putting a caustic onto the walls. Fabricius’s method however was revived by Pietro Marchetti who in 1654 published observations on 600 operations on anal fistulae. This method had gained in popularity by the time Louis XIV was suffering the condition. A variety of treatments were thus available to Louis’s physicians. After many consultations and different diagnostic recommendations, they decided to perform the operation.
34Charles-François Félix, first surgeon to the King since 1676, started to prepare for this particular operation (which he had hitherto never performed) by practising on patients at the Hôtel-Dieu in order to perfect the operative technique. As Bodemer notes, ‘he was very conscious of the fact that Cardinal Richelieu had died from that procedure and that D’Aquin and Fagon, representatives of the larger Medical Faculty, were peering over his lowly surgeon’s shoulders.’48 He studied all the ancient texts dealing with the surgical treatment, spent time at the Jardin du Roy and after two months of operations became deft at the techniques. With Bessières (another surgeon), he developed a modified version of Fabricius’s falzetta which was itself a modification of Galen’s syringotome. This was named le bistoury à la Royale. On the 18 November the surgery was performed with opium pills and hot wine serving as an anaesthetic and four solid apothecaries holding the King still. Once completed, Félix packed the wound and rectum with linen and applied bandages and the King even attended a meeting with ministers that afternoon. In less than two months, the wound had healed and Louis apparently never had a relapse.
35The Sun King’s successful operation advertised the effectiveness of surgery, and had consequences upon the status of surgery that extended far beyond France. The cult status of the patient ensured that the newly-designed operation made a considerably greater impact than had been managed by earlier medieval versions. Significantly, the successful operation enhanced the respectability of surgeons and surgery. News spread throughout Europe, and people flocked to the country to be treated by skilful French surgeons.49 The surgeon Félix had become a national figure and was paid 300,000 francs, given a large estate and a title. This ennoblement raised Félix to the status of physician within the court. All the attending surgeons and physicians and apothecaries also received sizeable rewards. It is believed that all surgeons in Paris then benefited from Felix’s success.50 The treatment for fistula-in-ano became fashionable amongst the high society of Versailles and Paris. The court surgeon Pierre Dionis recounted how he had around thirty cases of courtiers who confidentially approached him to have the same procedure done. Each of them only had mild cases involving a weeping wound on the anus or simply hemorrhoids but they were keen for the surgeon to make incisions. Furthermore, Dionis noted that they appeared upset when he told them there was no need. Some courtiers, even though they had not undergone the surgery, took to wearing bandages around their backsides in honour of what Louis had endured.51 In a brief moment, surgery had been transformed from a brutal and risky business to a fetishized and highly-coveted treatment, literally fit for a king.
Conclusion
36Although surgery is now clearly recognized as a disciplinary specialization of modern medicine, we have seen that, for a considerable time, it was far from comfortably positioned within ‘learned medicine’. Surgery’s hybridity of knowledge and praxis meant that it straddled different worlds. I have shown how surgery was initially a guild craft, specifically an artisanal trade where practitioners performed what could be described as their art, service, or ‘trade’. It then morphed into a more distinct profession. Once it had earned a semi-independent status, surgery was able to have a stronger impact upon medicine. By the mid-eighteenth century, it had come to be viewed as a progressive science and a branch of medicine in its own right. Surgeons had been pushed away from the medical faculty but when they were eventually welcomed into the fold, they did not simply reintegrate and try to conform to a traditional discipline. Rather, the learned tradition was prompted to change in line with their work, with an increased emphasis on practical training and empiricism. Disciplinary structures are not always formed with a continuous, unswerving trajectory, and the manner in which surgery and surgical practice shaped the formalised medical framework is a good example of this.
37The position of surgical practitioners shifted over the course of the seventeenth century. This was as a result of institutional changes, with an apparently rather downgrading alliance unpredictably fostering enhanced visibility. The hair-cutting/barber aspect of the work became less of a focus and they specialized on procedures for medical healing on the body. The increase of more transparent teaching and learning that embraced an occupational competence, inflected with the new scientific method, along with the required cognitive and manipulative skills, allowed it to flourish. As a field of knowledge, surgery expanded; as a therapeutic practice it became more targeted and refined; and as a professional field it was increasingly differentiated from untrained healers’ work. If surgery is understood to be the ‘fructifying craft’ whose ‘recipient’ profession is ultimately medicine, such expertise ‘bears fruit’ or is productive in the sense that it was finally accepted into the profession of ‘medicine’ which it fundamentally changed. However, surgery won its place against the discipline’s institutional will. The medical faculty of early modern France exhibited both fear and contempt for what surgeons were able to achieve in their workings on the body and the position they could hold with patients, both in the general populace and at court. Physicians, through the medical faculty, tried for a considerable time to distance themselves from such work, but surgery garnered respect and authority despite their powerful opposition. Royal support, however, played a significant role in helping to break down these hierarchies. Surgery then shaped medicine into what we know it to be today, a broad-based disciplinary field in which anatomy and physiology, practical and theoretical knowledge, tools and technique, and ‘internal’ and ‘external’ medicine are all brought together.
Notes de bas de page
1 On this see, Michael McVaugh, ‘Cataracts and Hernias: Aspects of Surgical Practice in the Fourteenth Century,’ Medical History 45 (2001): 320. The specific distinction made in the early modern period between physicians dealing exclusively with internal workings of the body and surgeons with external workings has been questioned. In the opinion of some authors, it was primarily the diversity of therapeutic methods used rather than disorders treated that distinguished the work of the surgeon from that of the physician. See Sandra Cavallo, Artisans of the Body in Early Modern Italy: Identities, Families and Masculinities (Manchester: Manchester University Press, 2007), 16. On how common diseases were dealt with on a day-to-day basis, see Michael Stolberg, Experiencing Illness and the Sick Body in Early Modern Europe (Basingstoke: Palgrave Macmillan, 2011). For pertinent work on surgeon-physician encounters, see Harold Cook’s afterword in Empires of Knowledge: Scientific Networks in the Early Modern World, ed. Paula Findlen (London: Routledge, 2019), 378–385. The intersection between making and knowing and the way in which artisanal skills influenced the formulation of scientific or scholarly ‘higher learning’ is charted in Ways of Making and Knowing: the Material Culture of Empirical Knowledge, ed. Pamela H. Smith, Amy R. W. Meyers and Harold J Cook (Ann Arbor (Michigan): University of Michigan Press, 2014). Hannah Murphy’s monograph, A New Order of Medicine: the Rise of Physicians in Reformation Nuremberg (Pittsburg: University of Pittsburg Press, 2019) also offers insightful analysis on the changing professional contours of medicine.
2 Charles W. Bodemer, ‘France, the Fundament, and the Rise of Surgery,’ Diseases of the Colon and Rectum 26 (1983 December): 743.
3 Roy Porter, Blood and Guts: a Short History of Medicine (London: Penguin, 2003), 30.
4 Laurence Brockliss and Colin Jones, The Medical World of Early Modern France (Oxford: Clarendon Press, 1997), 8.
5 Indeed, an ordinance of 1311 which was renewed several times shows that in Paris, admission to the practice of surgery was also open to women. See Daniel de Moulin, A History of Surgery. With Emphasis on the Netherlands (Dordrecht: Martinus Nijhoff, 1988), 46 on this. See also Susan Broomhall, Women’s Medical Work in Early Modern France (Manchester: Manchester University Press, 2004).
6 Tony Gelfand, Professionalizing Modern Medicine: Paris Surgeons and Medical Science and Institutions in the Eighteenth Century (Westport: Greenwood Press, 1980), 9.
7 Gelfand, Professionalizing Modern Medicine, 9.
8 Brockliss and Jones, The Medical World of Early Modern France, 103.
9 Selling as they did ingredients and the medicine they prepared wholesale.
10 Characteristically, in guilds, masters were only allowed to have one apprentice at a time. French regulations stated that an apprenticeship had to last for a minimum of four years which possibly suggests a longer period was typical. On this, see Vern L Bullough, ‘Training of the Non-University-Educated Medical Practitioners in the Late Middle Ages,’ Journal of the History of Medicine and Allied Sciences 14 (October 1959): 450–51.
11 Danielle Jacquart, La médicine médiévale dans le cadre parisien (xive-xve siècle) (Paris: Fayard, 1998), 266.
12 Gelfand, Professionalizing Modern Medicine, 41.
13 Collectively, women did have a large role in medicine and, recently, historians have noted the medical nature of domestic care and the circulation of remedies among female networks. See Leigh Whaley, Women and the Practice of Medical Care in Early Modern Europe, 1400–1800 (London: Palgrave MacMillan, 2011). On midwifery in France, see Wendy Perkins, Midwifery and Medicine in Early Modern France: Louise Bourgeois (Exeter, UK: University of Exeter Press, 1996), and Lianne McTavish, Childbirth and the Display of Authority in Early Modern France (Burlington, VT: Ashgate, 2005). Monica H. Green’s Making Women’s Medicine Masculine: the Rise of Male Authority in Pre-modern Gynaecology (Oxford: Oxford University Press, 2008) is an excellent study on the transition from medieval to early modern practices of women’s medicine across Europe which shows that gynecology, previously the domain of women, and infertility cures in particular, became the realm of the male expert.
14 Thomas Schlich, ‘Introduction: What is Special About the History of Surgery,’ in The Palgrave Handbook of the History of Surgery, ed. Thomas Schlich (London: Palgrave, 2018), 9. In at least one sense this picture is rather too neat since internal divisions continued to exist between specialisms.
15 M. S. R. Jenner and P. Wallis, ‘The Medical Marketplace,’ in Medicine and the Market in England and its Colonies c. 1450–c. 1850, ed. M. S. R. Jenner and P. Wallis (London: Palgrave, 2007), 1.
16 D. Harley, ‘“Bred up in the Study of That Faculty”: Licensed Physicians in the North-West of England, 1660–1760,’ Medical History 38 (1994): 398.
17 Jenner and Wallis, ‘The Medical Marketplace,’ 4.
18 Brockliss and Jones, The Medical World of Early Modern France, 14.
19 Gelfand, ‘Preface,’ Professionalizing Modern Medicine, xii.
20 Saveur François Morand (founding member of the Académie de chirurgie), in his opening address for the inauguration of the Collège de chirurgie, in 1743, was keen to underscore the multifaceted nature of surgery, quoting Guy de Chauliac’s sixteenth century description: ‘Chirurgia est duplex docens quae appropriatur nomine Scientiae, & utens quae nomine Artis’ (‘Surgery is twofold: when it teaches, it takes the name of Science, as a practice that of Art’). See Morand, Opuscules de chirurgie (Paris, 1768), 119. We see that surgery could be conceived of in a variety of ways.
21 As Martin Dinges and Stolberg underline in Medical Practice, 1600–1900: Physicians and their patients, ed. Martin Dinges et al. (Leiden: Brill Rodopi, 2016), 1: historically, ‘“practice” has always had a prominent place in medicine. Medicine was an applied science par excellence, techne or ars as well as episteme or scientia.’
22 Gelfand, Professionalizing Modern Medicine, 3.
23 Faith Wallis, ‘Pre-modern Surgery: Wounds, Words, and the Paradox of “Tradition”,’ in The Palgrave Handbook of the History of Surgery, ed. Thomas Schlich (London: Palgrave, 2018), 50.
24 Wallis, ‘Pre-modern Surgery: Wounds, Words, and the Paradox of “Tradition”,’ 50.
25 See Wallis, ‘Pre-modern Surgery: Wounds, Words, and the Paradox of “Tradition”,’ 50–51 on this. The first mention of surgical details in Greek civilization can be seen in the Homeric poems of The Iliad and The Odyssey, (generally dated from 800 to 700 BC.) In these works, there are more than a hundred different passages that describe battle wounds (spearings, sword thrusts, slingshot injuries) along with their treatment. On the history of surgery, see also Ira M. Rutkow, ‘Origins of Modern Surgery,’ in Essential Practice of Surgery. Basic Science and Clinical Evidence, ed. J. A. Norton, R.R. Bollinger et al. (New York: Springer, 2003), 3–19.
26 Including on ‘Wounds and Ulcers’, ‘Hemorrhoids’ ‘Fistulas’, ‘Injuries of the Head’, and ‘Fractures’, among others.
27 However, a detailed account of surgery was written by Cornelius Celsus (25 BC to AD 50), who was in fact, a Roman nobleman. Owing to the fact that he wrote in Latin, not Greek, and because he was not a physician, his works were not influential in his own time, however they became highly-esteemed in the Renaissance. Celsus’s De Medicina came to be viewed as the most important medical document after the Corpus Hippocraticum. Of the eight sections or books, the last two discuss diseases considered to be surgical issues.
28 Christopher Lawrence, ‘Surgery and its Histories: Purposes and Contexts,’ in The Palgrave Handbook of the History of Surgery, Schlich (London: Palgrave, 2018), 30.
29 Christelle Rabier, ‘Medicalizing the Surgical Trade, 1650–1820: Workers, Knowledge, Markets and Politics,’ in The Palgrave Handbook of the History of Surgery, ed. Thomas Schlich (London: Palgrave, 2018), 76.
30 See Lawrence, ‘Surgery and its Histories: Purposes and Contexts,’ 32 on this.
31 See Bullough, ‘Training of the Non-University,’ 451–2 on this.
32 Mary Lindemann, Medicine and Society in Early Modern Europe (Cambridge: Cambridge University Press, 1999), 219.
33 Rabier, ‘Medicalizing the Surgical Trade, 1650–1820,’ 83.
34 Cavallo, Artisans of the Body in Early Modern Italy, 1.
35 Cavallo, Artisans of the Body in Early Modern Italy, 1.
36 Cavallo, Artisans of the Body in Early Modern Italy, 1.
37 Brockliss and Jones, The Medical World of Early Modern France, 9.
38 Gelfand, Professionalizing Modern Medicine, 24.
39 Statuts (1699), art 4.
40 Gelfand, Professionalizing Modern Medicine, 36.
41 Matthew Ramsey, ‘The popularisation of medicine in France, 1650–1900,’ in The Popularization of Medicine 1650–1850, ed. Roy Porter (London: Routledge, 1992), 98.
42 He became a leading anatomist and contributed to Pecquet’s discovery of the thoracic duct.
43 Mery gained great European standing through his work on comparative and human anatomy and physiology, specifically his work on fetal circulation and discovery of bulbo-urethral glands.
44 Dianah Leigh Jackson, ‘Anatomy of Observation: from the Académie Royale de la Chirurgie to the Salons of Denis Diderot,’ Canadian Journal of History 36 (April 2001): 30.
45 Bodemer, ‘France, the Fundament, and the Rise of Surgery,’ 745.
46 Bodemer, ‘France, the Fundament, and the Rise of Surgery,’ 746.
47 In 1376, the English surgeon John Arderne wrote Treatises of Fistula in Ano; Haemmorhoids, and Clysters, which described particular techniques of fistulotomy and using seton (a special kind of suture).
48 Bodemer, ‘France, the Fundament, and the Rise of Surgery,’ 747.
49 See Pierre-Louis Choukroun, L’Histoire de la chirurgie: du silex à nos jours (Paris: Éditions du Dauphin, 2018), 63–66.
50 Gelfand, Professionalizing Modern Medicine, 34.
51 Pierre Dionis, Cours d’opérations de chirurgie démontrées au Jardin royal (Paris: 1715), 342. On this see Colin Jones, ‘The King’s Two Teeth,’ History Workshop Journal 65, no 1 (Spring 2008): 80.
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