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La Mettrie
Medicine, Philosophy, and Enlightenment
By Kathleen Wellman Duke University Press
Copyright © 1992 Duke University Press
All rights reserved.
ISBN: 978-0-8223-9710-6
CHAPTER 1
A Source of Medical Enlightenment
The Conflict between the Doctors and the Surgeons
Medicine was particularly important to the philosophes because of their concern with the social utility of the sciences. As one historian has neatly summarized this interest, "Nothing could be plainer than this: Medicine was philosophy at work; philosophy was medicine for the individual and society." This interest in science, particularly in medicine, proclaimed by Enlightenment thinkers themselves, should provoke us to seek an understanding of the practice and theory of science and medicine in the eighteenth century and its influence on Enlightenment philosophy. La Mettrie provides a particularly illuminating perspective from which to examine the intriguing relationship between science, medicine, and philosophy.
But despite the concern of the philosophes with medicine, concrete and explicit connections between medicine and the Enlightenment have not received a great deal of attention. Histories of eighteenth-century medicine quite frequently purport to treat the entire century but then rush eagerly from the chaos of eighteenth-century theory and practice to the more appealing saga of the medical reforms of the Revolution and the professionalization of medicine in the nineteenth century. Perhaps this neglect is the result of the fact that in some respects eighteenth-century medicine does not lend support to a Whiggish story of medical progress, since it confronts one at every turn with the arcane. The descriptions of diseases found in eighteenth-century medical texts are only sometimes recognizable to modern physicians. Even discussions of the treatment of diseases found in the works of the best-educated medical practitioners are much more likely to horrify than to edify. Poor education (or at least what seems an impractical education for the physician), dishearteningly ineffective methods of treatment (reflected in high patient mortality rates), bizarre and arcane discussions of diseases and treatments, and vested self-interest, venality, and chaos in medical practice are factors that might discourage one from investigating this unsavory scene in detail. In sum, eighteenth-century medicine is both baffling in its diverse manifestations and somewhat unedifying in its lack of efficacy.
In fact, the actual practice of medicine in eighteenth-century France might lead one to think that the nature of the relationship between Enlightenment and medicine was simply one of vain and unreasonably optimistic hopes on the part of the philosophes. But while the actual practices and professional standards of eighteenth-century medicine are not edifying, the records left by physicians in medical texts and case studies produce a more positive assessment thereof. In other words, removed from the considerations of whether the practices of physicians actually produced decisive improvements in health, medical texts treat issues in ways which can be correlated to Enlightenment concerns, especially to its crucial quest to ameliorate the human condition. The pamphlet war between the doctors and the surgeons, which was waged with particular intensity between 1724 and 1750, offers a possible source for reform which the philosophes recognized as implicit in the application of medicine to the ills of society. That is not to suggest that the philosophes were directly inspired by the intense vituperative and sometimes even violent demonstrations of professional rancor involved in this pamphlet war. (Indeed, the concerns of philosophes with the destructive tenor of the pamphlet war are explicitly demonstrated in Diderot's "Lettre d'un citoyen zélé.") Nonetheless, the issues developed during this polemic might well have suggested to the philosophes reasons to be hopeful about what medicine offered and might be able to accomplish.
The pamphlet war itself was the crucial professional issue for the doctors and surgeons of Paris in the formative years of the Enlightenment. In the narrowest sense it dealt with issues of professionalization and provided a particularly useful vehicle for gauging professional issues. While the heat of polemic invited charges and countercharges and promoted inflammatory rhetoric exaggerating the merits of one's case and the deficiencies of one's opponents, a pamphlet war also provided the opportunity for developing a clearand cogent set of arguments about good medicine and the social advantages good medicine would produce. And this particular pamphlet war advocated a new criterion by which medical practice and education should be judged. Some pamphlets were addressed to the king, the traditional adjudicator in disputes between doctors and surgeons, but as the arguments came to focus less on questions of precedent and more on the issue of public good, the surgeons in particular sought to present their case before a new body, one remote from royal strictures and a corporate hierarchy that deemed them subservient to the doctors; they made their arguments in the interest of the public and sought to bring those arguments before the undefined and unspecified authority of public opinion. Thus they sought to shift authority from the king and the medical corporation to public opinion and to redefine the nature of the profession as independent from traditional privilege, sustained instead by public service.
Although the pamphlet war suggests that the surgeons succeeded in defining and implementing the agenda for medical reform in France, it is a limited source for the complicated social history of medical practice. Participants did not address the specific issues of medical education and practice outside of Paris, nor did the advocates on either side see their positions as rectifying medical deficiencies in rural areas. It was instead a controversy between the two most elite medical groups in France. And while they had influence outside of Paris and were certainly interested in extending it, they did not actually practice except among the wealthiest members of Parisian society. (The practice of elite surgeons would have been somewhat more extensive in both social and geographical terms.) Thus their contentious disputes over medical practice and theory would have had very little immediate impact beyond their narrow circle. However, this debate set the agenda and defined the shape of medical reforms that were more widely extended and imposed in the nineteenth century. Although the pamphlet war does not provide a detailed picture of the diversity of French medical practice, it effectively underscores the affinities between the positions taken by the surgeons of Saint-Côme and the optimistic expectations for medicine held by the philosophes.
The barrage of invective, charges, and countercharges produced suggest that the pamphlet war, which raged in Paris between 1724 and 1750, appears to be simply a particularly vociferous professional squabble. However, the professional issues and medical concerns which divided the doctors and surgeons had important ramifications. Within the context of this war, both doctors and surgeons came to articulate positions on medical practice and theory. From those positions emerged attacks on privilege and arguments for medical reform, criticisms of existing institutions and systems of education, and the beginnings of a campaign for public health. While the initial point of contention was whether the surgeons would be allowed to throw off their subservience to the doctors, especially insofar as the education of the surgeons was concerned, the debate had far broader implications.
The surgeons of Saint-Côme used every legislative gain to work toward the establishment of a university-educated surgical elite, a goal which set them definitively apart from the uneducated empirics. They also argued for reforms in medical education and practice, emphasizing, even as early as the 1720s and 1730s, the empirical and the clinical as the proper foundation of medicine. They asserted the necessity of practical education and the incorporation of chemistry and anatomy into medical education and practice. Offering an education based on both theory and practice, and identifying themselves with the promulgation of the fruits of the scientific revolution, the surgeons also defined the medical reforms that were decisive in the revolutionary period in France. Those reforms united the doctors and the surgeons under the surgeons' standards of medical practice and education rather than those of the physicians. In distinct contrast to the physicians, the surgeons argued for a new kind of medical education, one which was to be both empirical and theoretical. Their practice made extensive use of the clinics and the hospitals. Moreover, the surgeons of the eighteenth century proposed to set themselves up as men educated in the liberal arts and well studied in the practical application of their art and craft; the surgeon was to be a model of the Enlightenment man of science and a foreshadowing of the nineteenth-century physician. Thus the history of the surgeons may well be a key to bridging both the differences in medical practice of the eighteenth and nineteenth centuries and the epistemic differences between these periods as defined by Foucault.
Finally, the surgeons seemed to formulate and embrace Enlightenment hopes for medicine better than the doctors. The surgeons espoused the empirical, pragmatic perspective of the philosophes and adopted empirical modesty as a philosophical stance more readily than the more conservative physicians. They adopted a loosely Lockean epistemology, a stance characteristic of the Enlightenment, because it corresponded to the way they perceived disease. (No doubt this connection exists in part because Locke's Essay is so thoroughly colored by his close contact with the English empirical physician, Thomas Sydenham.) Furthermore, the surgeons were able to serve as a model of Enlightenment hopes for the integration of the mechanical and liberal arts; for example, the Encyclopédie used plates of surgical instruments as outstanding examples of the benefits derived from the craft tradition. Surgery rather than medicine also served as a model of the utilitarian benefits of medicine for two reasons. The surgeons were more successful in tying their goals to the broader issues of the Enlightenment. And the Faculty of Medicine, representing privilege, monopoly, and ignorance, and thus epitomizing some of the ills of the ancien régime, was too resistant to innovation.
The Historical Roots of the Conflict
The surgeons' specific concerns and projects for reform grew in part out of the long history of their problematic position within the medical community, particularly their relationship to the powerful Faculty of Medicine. A guild of surgeons, whose members came to be called "surgeons of the long robe," had been established in the fourteenth century. Although some of these early surgeons may have been university educated, they did not constitute an academic body until 1533, when the surgical College of Saint-Côme was established. In 1544 Francis I granted them the right to wear the cap and gown and to give public courses in anatomy and surgical operations, concessions which meant higher status and financial privileges for the small academic surgical community. The barber-surgeons, or "surgeons of the short robe," who had also established a guild at about the same time as the surgeons of the long robe, were a larger group who trimmed hair and performed minor operations.
In 1505 the barber-surgeons signed the first of many agreements with the doctors, agreeing to deal only with the manual operations of surgery and to treat patients only after the doctors-regent of the Faculty of Paris had given their approval. This document in effect conceded the doctors' superiority and control and provided them with the basis for their arguments from legal precedent in the pamphlet war. In 1655 the situation was further complicated by the formal union of the barber-surgeons and the surgeons of the long robe. For the eighteenth-century surgical polemicists, the most famous of whom was the influential physiocrat, François Quesnay, this union was the product of a conspiracy by the doctors to gain control over all the surgeons and produced the decline of French surgery. He described the relationship this way: "On the one side, one sees the barbers, pushed by ambition, revolting against their masters, usurping the rights of our Art. In league with the Faculty of Medicine to support their charges, they became the instruments of the hate of all doctors against the surgeons. On the other side, one finds the surgeons completely tied to their profession, enemies of trouble, regretfully obligated to refute injustice and jealousy, and always disposed to sacrifice a portion of their interests for the love of country." As a corrective to this obviously biased account, Toby Gelfand has pointed to the economic factors that inclined the surgeons of the long robe to work with the barber-surgeons. For example, the state of the surgical art in the sixteenth century could not support an academic surgical guild whose principal medical function was to perform major operations. Given the pain, expense, and very low success rate of major operations, it is not surprising that there was little demand for them.
But even if the surgeons and the barber-surgeons had reasons to unite, their expectations of the union were strikingly different from its actual results. The barber-surgeons wished to unite with the surgeons to escape the chafing confines of medical subjugation. The surgeons wished both to share some of the more lucrative practices of the barbers' craft and ultimately to establish a faculty of surgery to rival the medical faculty. But the doctors quickly precluded these possibilities and used the move toward union for their own ends. By appealing to the king they gained the letters-patent of 1655, which granted them the right to order and supervise all "médicaux secours," including surgical operations; the surgeons were to be considered merely instruments of physicians. Instead of gaining a surgical faculty equivalent to the medical faculty, or at least independent of the doctors, the surgeons lost all control over the education of surgeons. And the barber-surgeons did not evade medical control but instead found it more consistently applied.
Whether or not it was a misapprehension of their past, the theory that the union of 1655 was a conspiracy on the part of the doctors allowed surgical polemicists of the eighteenth century to portray the pre-1655 company of surgeons of the long robe as a Utopian picture of the proper role and status of surgeons. More realistically, it gave them a historical precedent for an academic company of surgeons which they would attempt to reestablish throughout the course of the eighteenth century.
Moreover, the doctors, not content with the subjugation of the entire surgical profession, continued to lobby for and to gain legislative strictures against the surgeons late in the seventeenth century. For example, in 1660 the Parlement of Paris decreed that this new community had to submit itself to the Faculty on the same basis as the barber-surgeons. This meant that all signs of academic status were prohibited, and public teaching and the defense of academic theses by surgical students was forbidden. In 1670 further legislation required that the surgical community of Saint-Côme render financial and honorific signs of deference to the medical community.
Although these strictures were considered insufferable by eighteenth-century surgeons, they in fact separated the entire surgical community from the Faculty of Medicine and provided an opportunity for the surgical company to develop on its own. Although the legal status of the surgeons did not change from 1650 to 1699, this period witnessed a strengthening of the surgical company and a separation, in practice though not in legislation, of the surgeons from the barber-surgeons. The dictates of fashion had heightened the demand for barbers, and thus those barber-surgeons who were primarily barbers were quick to take advantage of the lucrative sideline of wigmaking. A royal ordinance of 1673 separated the wigmaker from the surgeon, forbidding the barber-wigmakers to perform any act of surgery and the members of Saint-Côme to sell wigs. The separation that had developed between the spheres of practice of the academic surgical community and other surgeons was recognized in the statutes of 1699, which explicitly enjoined that those surgeons who gave up barbers' work and limited themselves to "the art of surgery purely and simply will be considered to practice a liberal art and will enjoy all the privileges attributed to the liberal arts." It should be noted that while these distinctions were clearly defined in law, they were not maintained in practice even in Paris, and in the provinces such distinctions tended to break down entirely.
The surgeons of the long robe also offered an alternative to the doctors in terms of medical practice. Even though the surgeons were legally restricted to external symptoms, in fact they also treated medical problems with internal symptoms because of the great demand for medical services which the doctors could not meet. It was in part simply a question of numbers. The case of Paris, where surgeons were the principal medical practitioners, provides a telling example. In the eighteenth century, the Faculty of Medicine of Paris consisted of about 100 physicians for a population of half a million. The Faculty of Medicine maintained that number to ensure their control over the profession and the ability of their members to support themselves and maintain their social position. At the same time in Paris there were approximately two hundred and fifty master surgeons and about the same number of "privileged surgeons," those who rented the privilege of working under a master surgeon. Since the ratio of surgeons to doctors was about 5 to 1, it is not surprising that they encroached on the physicians' practice of medicine and were in fact the principal licensed medical practitioners of Paris.
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Excerpted from La Mettrie by Kathleen Wellman. Copyright © 1992 Duke University Press. Excerpted by permission of Duke University Press.
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