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SURGEONS. The period between the Renaissance and the Enlightenment witnessed slow, then accelerating progress in surgery. Surgeons made advances in controlling hemorrhage; devised simpler and safer dressings for battle wounds; and improved methods and invented new instruments for amputating limbs, cutting for stone of the urinary bladder, operating for hernias and dilatations of arteries, combating the hazards of giving birth, and repairing certain deformities. In the 1740s, the time-honored procedure of couching for cataracts of the eye gave way to modern extraction, a rare example of radical innovation. Greater attention to cleanliness may have reduced infection, although the unsanitary conditions under which surgery was performed, especially in many hospitals, remained appalling even by standards of the time. Likewise, the pain of operations was likened to torture, even though it was masked in part by suffering due to the ailment. Skilled surgeons needed to work with great dexterity and speed to complete major procedures in just a few minutes. Only relatively few dared to undertake these high-risk interventions, and then infrequently, compared with ordinary tasksbloodletting, incision of boils, treatment of skin and venereal diseases, reducing dislocations, setting fracturesthat made up the ordinary barber-surgeon's stock-in-trade.

Progress in the social status and scientific knowledge of elite surgeons in large cities moved at a much more rapid pace than technical change. By the end of the eighteenth century, surgical guilds in Paris, London, Edinburgh, Madrid, Vienna, Copenhagen, and elsewhere had evolved into professional bodies with distinctive liberal institutions: colleges for education and academies for advancing knowledge. Major surgery in the sixteenth century remained the preserve of exceptional individuals of humble backgroundsthe renowned French barber-surgeon, Ambroise Paré, was the outstanding example of this sortor bold itinerants, and family dynasties like the Chamberlens, French/British Huguenots, who managed to keep the secret of their obstetrical forceps for well over a century. By the High Enlightenment, organized professionals shared a repertoire of surgical knowledge and practices. Expertise in the craft conferred exclusively by formal regulation, as well as custom, to guilds, appropriately known as "mysteries," began to be the province of new, more open institutional structures concerned with scientific progress. Academic surgical societies used publications and correspondence networks to share and propagate their work.

The centralized European state fostered the professionalization of surgery. In France, Louis XIV's surgeon used the occasion of his successful anal fistula operation on the king in 1686 to gain benefits for the guild of barber-surgeons. At the time, the status of royal surgeon was little more than that of a domestic servant. But during the Regency period (17131723) the office of premier surgeon to the king assumed an increasingly important professional leadership role. Georges Mareshal and François de la Peyronie, successively premier surgeons to Louis XV, consolidated centralized jurisdiction over guilds throughout the kingdom, established a central school of surgery in Paris in 1724 and a Royal Academy of Surgery in 1731, and secured legislation in 1743 requiring a university degree of surgeons and separating the company or college of surgeons from the barbers' guild. The precedent was emulated by larger provincial communities.

In Great Britain, the surgical profession developed in less centralized fashion. To be sure, kings lent their patronage to the London barber-surgeons guild, as depicted in Holbein's portrait of Henry VIII presiding over the union of the two guilds in 1540. And the London surgeons separated from barbers in 1745, just two years after their Paris counterparts. Capital cities in Prussia, Spain, and Russia followed suit. In Dutch and most German and Italian centers, barber-surgeons' guilds survived, but their members no longer did barbers' work, and they too enjoyed upward social mobility. Rembrandt's collective portrait of the Amsterdam guild in his Anatomy Lesson (1632) bears witness to their academic pursuits and bourgeois status.

During the second half of the eighteenth century, elite surgeons across Europe achieved a rank in society comparable to that of medical doctors. Since medieval times, medical superiority had derived from the educational attainment of physicians and their collective status alongside law and theology in the university. In principle, and by statute, the medical faculty had jurisdiction over surgical instruction, licensing, and practice. All this came under question and successful challenge when educated surgeons set up autonomous institutions. Surgeons gained admission to prestigious scientific academies in numbers equal to, if not surpassing, physicians. As classical humoral theory, along with the Latin language of medical discourse, declined, surgical knowledge anchored in sensory experience and anatomical pathology took the ascendancy. Anatomy was the surgical science par excellence. Surgeons performed dissections on the cadaver for various purposes: research, trainingespecially in private courses where students could purchase cadavers for hands-on learningand forensic autopsies seeking to reveal the causes of death. Surgical knowledge was associated with empirical epistemology, pathological anatomy, and a localist conception of disease, while medical knowledge, when not abstract and purely theoretical, could point only to chemistry for scientific validation. Given these contrasts, it is not surprising that the eighteenth-century philosophes extolled the practical usefulness of the surgical side of medicine. Diderot's Encyclopédie reproduced illustrations of operations and instruments recently published by the Academy of Surgery, while the Academy's secretary, Antoine Louis, contributed some seventy articles on his field to the encyclopedia project.

In smaller towns, villages, and the countryside, surgeons were the only licensed medical practitioners available to serve people of modest means. Fragmentary evidence indicates that rural master surgeons, surprisingly numerous in proportion to the population, faced stiff competition from a variety of illegal healers, whose ranks included roving journeymen, empirics and "charlatans," women healers and midwives, clergy, and army and naval surgeons. Surgical guilds, in principle, but not often in practice, had licensing authority over midwives and socalled specialists: oculists, hernia experts, bonesetters, and tooth pullers, who had experience only in their particular craft skill.

At the level of country surgeon, distinctions drawn between external surgical diseases and internal medical ailments had little meaning. Surgeons and barber-surgeons did not hesitate to dispense purges and other medical remedies. Phlebotomy (bloodletting), for prevention as well as treatment of most ailments, was a mainstay. A medical recourse common to both barbers and surgeons, bloodletting helped perpetuate the link between the two crafts in continental Europe. In Great Britain, apothecary-surgeons, rather than barber-surgeons, took care of the medical needs of common folk.

As in other craft guilds, apprenticeship, followed by a period as a journeyman, constituted the core of training for barber-surgeons. By the eighteenth century, practical experience began to be supplemented by formal courses. In France, during the second half of the century, vast numbers of aspiring young surgeons (garçon chirurgiens) from all over the realm attended courses at the Paris surgical school.

Hospitals increasingly became a site for practical training for surgeons as these church foundations for poor relief came under secular administration and adopted medical objectives. Surgeons worked, learned, and sometimes resided in hospitals, where they displaced clerical healers and constituted an elaborate hierarchy of responsibility for patient care. Medical students and physicians seldom took on hospital employment. A similar preponderance of surgeons characterized medical services in European armies and navies. In public health matters, notably in the organized response to plague and other epidemics, surgeons outnumbered their medical counterparts, especially at the grassroots level.

The eighteenth century saw the rise of a subcategory of surgeons, known as man-midwives, who began to preside over childbirth in well-to-do families. To some extent, fashion paved the way for obstetricians (accoucheurs) to displace traditional midwives. But men also legitimated their takeover of this lucrative practice by means of demonstrably superior knowledge in anatomy, displayed in magnificent atlases of the stages of pregnancy, and their use of new techniques and instruments for delivery, notably the obstetrical forceps. Because of their systematic exclusion from surgical guilds as well as university medical faculties, women healers could only practice illegally. However, guild custom permitted widows of master surgeons to lease to journeymen the practice of their deceased husbands.

The prevalence of religious and magical healing is difficult to assess. Evidently, it persisted in the eighteenth century and beyond. Among the surgical elite, such beliefs and practices clearly declined. In the sixteenth century, Ambroise Paré had described monsters and marvels, attributed birth defects to maternal impressions, acknowledged witchcraft, and naively repeated accounts of travelers' sightings of mermaids. His eighteenth-century successors adopted a more critical, often skeptical, attitude. By the Academy of Surgery's rigorous criteria, medical miracles were judged to be either errors, products of religious fanaticism, or frauds. Surgical power, based upon pathological anatomy, could explain and often cure conditions heretofore ascribed to supernatural forces. Operations repaired the congenital deformity of harelip, restored sight to those blinded by cataracts, and cured impotence resulting from anatomical lesions of the urogenital organs.

Surgical progress, and more specifically, the social ascension of surgeons in urban centers of early modern Europe, paradoxically, planted the seeds of the demise of surgery as an autonomous profession. Success narrowed the social and cultural gap with physicians and introduced a more empirical and anatomical orientation to medicine in general. Suggestive analogies likened hidden, poorly understood internal ailments to familiar external lesions. Postmortems took on instructive significance for physicians. By the eve of the French Revolution, reformers had called for the abolition of separate institutions and the unification of medicine and surgery into a single profession. Future practitioners were to be trained in a common "school of health" and to practice the healing art as a whole. Country surgeons would be replaced by a subordinate level of health officers. In 1794 the National Assembly instituted the new professional order, a pattern that was subsequently adopted in other European countries.

See also Academies, Learned ; Anatomy and Physiology ; Magic ; Medicine ; Midwives ; Obstetrics and Gynecology ; Public Health ; Scientific Revolution .


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Toby Gelfand