Popular Science Monthly/Volume 47/June 1895/Professional Institutions II
II. PHYSICIAN AND SURGEON.
By HERBERT SPENCER.
ALREADY, in Chapter II of the preceding part, have been given illustrations of the general truth that in rude tribes it is difficult to distinguish between the priest and the medicine-man. Their respective functions are commonly fulfilled by the same person. In addition to the instances there given, here are some others. According to Humboldt, "the Caribbee marirris are at once priests, jugglers, and physicians." Among the Tupis "the Payes, as they were called, were at once quacks, jugglers, and priests." Passing from South America to North, we read that the "Carriers know little of medicinal herbs. Their priest or magician is also the doctor;" and, of the Dakotahs, Schoolcraft says—"The Priest is both prophet and doctor." In Asia we meet with a kindred connection. In Southern India, the Kurumbas act as doctors to the Badagas, and it is said of them—"The Kurumbas also officiate as priests at their marriages and deaths." So is it among peoples further north. "Native doctors swarm in Mongolia. . . . They are mostly lamas. There are a few laymen who add medical practice to their other occupations, but the great majority of doctors are priests." It is the same on the other great continent. Reade tells us that in Equatorial Africa the fetishman is doctor, priest, and witch-finder; and concerning the Joloffs and Eggarahs, verifying statements are made by Mollien and by Allen and Thomson.
This evidence, re-enforcing evidence given in the preceding part, and re-enforced by much more evidence given in the first volume of this work, shows that union of the two functions is a normal trait in early societies.
The origin of this union lies in the fact before named that the primitive priest and the primitive medicine-man both deal with supposed supernatural beings; and the confusion arises in part from the conceived characters of these ghosts and gods, some of which are regarded as always malicious, and others of which, though usually friendly, are regarded as liable to be made angry and then to inflict evils.
The medicine-man, dealing with malicious spirits, to which diseases among other evils are ascribed by savages, subjects his patients partly to natural agencies, but chiefly to one or other method of exorcism. Says Keating of the Chippewas, "their mode of treatment depends more upon the adoption of proper spells than the prescription of suitable remedies." Among the Nootka Sound people,—
"Natural pains and maladies are invariably ascribed to the absence or other irregular conduct of the soul, or to the influence of evil spirits, and all treatment is directed to the recall of the former and to the appeasing of the latter."
So, too, of the Okanagans we read:
"But here, as elsewhere, the sickness becoming at all serious or mysterious, medical treatment proper is altogether abandoned, and the patient committed to the magic powers of the medicine-man."
upon such beliefs in the supernatural origin of diseases are various usages elsewhere. It is said of the Karens that "when a person is sick, these people [medicine-men], for a fee, will tell what spirit has produced the sickness, and the necessaryoffering to conciliate it." Among the Araucanians, the medicine-man having brought on a state of trance, real or pretended, during which he is supposed to have been in communication with spirits, declares on his recovery—
"the nature and seat of the malady, and proceeds to dose the patient, whom he also manipulates about the part afflicted until he succeeds in extracting the cause of the sickness, which he exhibits in triumph. This is generally a spider, a toad, or some other reptile which he has had carefully concealed about his person."
Speaking of the Tahitian doctors, who are almost invariably priests or sorcerers, Ellis says that in cases of sickness they received fees, parts of which were supposed to belong to the gods: the supposition being that the gods who had caused the diseases must be propitiated by presents. A more advanced people exhibit a kindred union of ideas. Says Gilmour—
"Mongols seldom separate medicine and prayers, and a clerical doctor has the advantage over a layman in that he can attend personally to both departments, administering drugs on the one hand, and performing religious ceremonies on the other."
Hence the medical function of the priest. When not caused by angry gods diseases are believed to be caused by indwelling demons, who have either to be driven out by making the body an intolerable residence, or have to be expelled by superior spirits who are invoked.
But there is often a simultaneous use of natural and supernatural means, apparently implying that the primitive medicine-man, in so far as he uses remedies acting physically or chemically, foreshadows the physician; yet the apparent relationship is illusive, for those which we distinguish as natural remedies are not so distinguished by him. In the first volume, in the chapter on Plant-Worship, it was shown that powerful effects wrought on the body by plants, and the product of plants, are supposed to be due to spirits dwelling in the plants. Hence the medicine-man, or "mystery-man," being concerned solely with supernatural causation of one or other kind, foreshadows the physician only to the extent of using some of the same means, and not as having the same ideas.
As we shall presently see, it is rather from the priest properly so called, who deals with ghosts not antagonistically but sympathetically, that the physician originates.
While the medicine-man is distinctive of small and undeveloped societies, the priest proper arises along with social aggregation and the formation of established government. In the preceding division of this work, Chapters III, IV, and Y, we saw that since originally propitiation of the ghosts of parents and other members of each family is at first carried on by relatives, implying that the priestly function is generally diffused; and since this priestly function presently devolves on the eldest male of the family; and since, when chieftainship becomes settled and inheritable, the living chief makes sacrifices to the ghost of the dead chief, and sometimes does this on behalf of the people; there so arises an official priest, and it results that with enlargement of societies by union with subjugated tribes and the spread of the chieftain's power, now grown into royal power, over various subordinated groups, and the accompanying establishment of deputy rulers in these groups, who take with them the worship that arose in the conquering tribe, there is initiated a priesthood which, growing into a caste, becomes an agency for the dominant cult; and, from causes already pointed out, becomes the seat of culture in general.
From part of this culture, having its origin in preceding stages, comes greater knowledge of medicinal agents, which gradually cease to be conceived as acting supernaturally. Early civilizations show us the transition. Says Maspero of the ancient Egyptians:—
"The cure-workers are. . . divided into several categories. Some incline toward sorcery, and have faith in formulas and talismans only. . . . Others extol the use of drugs; they study the qualities of plants and minerals. . . and settle the exact time when they must he procured and applied. . . . The best doctors carefully avoid binding themselves exclusively to either method. . . their treatment is a mixture of remedies and exorcisms which vary from patient to patient. They are usually priests."
Along with this progress, there had gone on a differentiation of functions. Among the lower classes of the priesthood were the "pastophors, who. . . practiced medicine."
Respecting the state of things in Babylonia and Assyria, the evidence is not so clear. Says Lenormant of the Chaldæans:
"Il est curieux de noter que les trois parties qui composaient ainsi le grand ouvrage magique dont Sir Henry Rawlinson a retrouvé les débris, correspondent exactement aux trois classes de docteurs chaldéens que le livre de Daniel (i, 20; ii, 2 et 27; v, 11) énumère à côté des astrologues et des divins (kasdim et gazrim), c'est-à-dire les khartumin ou conjurateurs, les hakamin ou médecins, et les asaphin ou théosophes."
With like implications Prof. Sayce tells us that—
"The doctor had long been an institution in Assyria and. It is true that the great bulk of the people had recourse to religious charms and ceremonies when they were ill, and ascribed their sickness to possession by demons instead of to natural causes. But there was a continually increasing number of the educated who looked for aid in their maladies rather to the physician with his medicine than to the sorcerer or priest with his charms."
But from these two statements taken together it may fairly be inferred that the doctors had arisen as one division of the priestly class.
Naturally it was with the Hebrews as with their more civilized neighbors. Says Gauthier—
"Chez les Juifs la médecine a été longtemps sacerdotale comme chez presque tous les anciens peuples; les Lévites etaient les seuls médecins. . . . Chez les plus anciens peuples de l'Asie, tels que les Indiens et les Perses, l'art de guérir était également exercé par les prêtres."
In later days this connection became less close, and there was a separation of the physician from the priest. Thus in Ecclesiasticus we read:—
"My son, in thy sickness be not negligent: but pray unto the Lord, and he will make thee whole. Leave off from sin, and order thine hands aright, and cleanse thy heart from all wickedness. Give a sweet savor, and a memorial of fine flour; and make a fat offering. Then give place to the physician, for the Lord hath created him; let him not go from thee, for thou hast need of him." (xxxviii, 15.)
Facts of congruous kinds are remarked on by Draper:—
"In the Talmudic literature there are all the indications of a transitional state, so far as medicine is concerned; supernatural seems to be passing into the physical, the ecclesiastical is mixed up with the exact: thus a rabbi may cure disease by the ecclesiastical operation of laying on of hands; but of febrile disturbances, an exact, though erroneous explanation is given, and paralysis of the hind legs of an animal is correctly referred to the pressure of a tumor on the spinal cord."
Concerning the origin of the medical man among the Hindus, whose history is so much complicated by successively superposed governments and religions, the evidence is confused. Accounts agree, however, in the assertion that medicine was of divine origin: evidently implying its descent through the priesthood. In the introduction to Charaka's work, medical knowledge is said to have indirectly descended from Brahma to Indra, while "Bhâradvâja learned it from Indra, and imparted it to six Rishis, of whom Agnivâsa was one." The association of medical practice with priestly functions is also implied in the statement of Hunter that "the national astronomy and the national medicine of India alike derived their first impulses from the exigencies of the national worship." The same connection was shown during the ascendancy of Buddhism. "The science was studied in the chief centers of Buddhist civilization, such as the great monastic university of Nalanda, near Gayá."
Similar was the genesis of the medical profession among the Greeks. "The science [of medicine] was of divine origin, and the doctors continued, in a certain sense, to he accounted the descendants of Asklepios." As we read in Grote—
"The many families or gentes called Asklêpiads, who devoted themselves to the study and practice of medicine, and who principally dwelt near the temples of Asklêpius, whither sick and suffering men came to obtain relief all recognized the god [Asklêpius] not merely as the object of their common worship, hut also as their actual progenitor."
In later times we see the profession becoming secularized.
"The union between the priesthood and the profession was gradually becoming less and less close; and, as the latter thus separated itself, divisions or departments arose in it, both as regards subjects, such as pharmacy, surgery, etc., and also as respects the position of its cultivators."
Miscellaneous evidence shows that during early Roman times, when there existed no medical class, diseases were held to be supernaturally inflicted, and the methods of treating them were methods of propitiation. Certain maladies ascribed to certain deities prompted endeavor to pacify those deities; and hence there were sacrifices to Febris, Mephitis, Ossipaga, and Carna. An island in the Tiber, which already had a local healing god, became also the seat of the Æsculapius cult: that god having been appealed to on the occasion of an epidemic. Evidently, therefore, medical treatment at Rome, as elsewhere, was at first associated with priestly functions. Throughout subsequent stages the normal course of evolution is deranged by influences from other societies. Conquered peoples, characterized by actual or supposed medical skill, furnished the medical practitioners. For a long time these were dependents of patrician houses. Say Guhl and Koner—"Physicians and surgeons were mostly slaves or freedmen." And the medical profession, when it began to develop, was of foreign origin. Mommsen writes:—
"In 535 the first Greek physician, the Peloponnesian Archagathus, settled in Rome and there acquired such repute by his surgical operations, that a residence was assigned to him on the part of the state and he received the freedom of the city; and thereafter his colleagues flocked in crowds to Rome. . . the profession, one of the most lucrative which existed in Rome, continued a monopoly in the hands of the foreigners."
Opposed to paganism as Christianity was from the beginning, we might naturally suppose that the primitive association between the priestly and medical functions would cease when Christianity became dominant. But the roots of human sentiments and beliefs lie deeper than the roots of particular creeds, and are certain to survive and bud out afresh when an old creed has been superficially replaced by a new one. Everywhere pagan usages and ideas are found to modify Christian forms and doctrines, and it is so here. The primitive theory that diseases are of supernatural origin still held its ground, and the agency of the priest consequently remained needful. Of various hospitals built by the early Christians we read:—
"It was commonly a priest who had charge of them, as, at Alexandria, S. Isidore, under the Patriarch Theophilus; at Constantinople, St. Zoticus, and after him St. Samson."
Concerning the substitution of Christian medical institutions for pagan ones, it is remarked:—
"The destruction of the Asclepions was not attended by any suitably extensive measures for insuring professional education. . . . The consequences are seen in the gradually increasing credulity and imposture of succeeding ages, until, at length, there was an almost universal reliance on miraculous interventions."
But a more correct statement would be that the pagan conceptions of disease and its treatment re-asserted themselves. Thus, according to Sprengel, after the sixth century the monks practiced medicine almost exclusively. Their cures were performed by prayers, relics of martyrs, holy water, etc., often at the tombs of martyrs. The state of things during early mediæval times, of which we know so little, may be inferred from the fact that in the twelfth century the practice of medicine by priests was found to interfere so much with their religious functions that orders were issued to prevent it; as by the Lateran Council in 1123, the Council of Reims in 1131, and again by the Lateran Council in 1139. But the usage survived for centuries later in France and probably elsewhere; and it seems that only when a papal bull permitted physicians to marry, did the clerical practice of medicine begin to decline. Says Warton, "The physicians of the University of Paris were not allowed to marry till the year 1452."
In our own country a parallel relationship similarly survived. In 1456 "the practice of medicine was still, to some extent, in the hands of the clergy." That ecclesiastics exercised authority over medical practice in the time of Henry VIII, is shown by a statute of his third year, which reads:—
"It is enacted that no person in London, or seven miles thereof, shall practice as a physician or surgeon without examination and license of the Bishop of London, or of the Dean of Paul's, duly assisted by the faculty; or beyond these limits, without license from the bishop of the diocese, or his vicar-general, similarly assisted."
And it is alleged that down to the early part of our own century there remained with the Archbishop of Canterbury a latent power of granting medical diplomas. So that the separation between "soul-curer and body-curer," which goes on as savage peoples develop into civilized nations, has but very gradually completed itself even throughout Christian Europe.
This continuity of belief and of usage is even still shown in the surviving interpretations of certain diseases by the Church and its adherents; and it is even still traceable in certain modes of medical treatment and certain popular convictions connected with them.
In the minds of multitudinous living people there exists the notion that epidemics are results of divine displeasure; and no less in the verdict "Died by the visitation of God," than in the vague idea that recovery from, or fatal issue of, a disease, is in part supernaturally determined, do we see that the ancient theory lingers. Moreover, there is a predetermination to preserve it. When, some years ago, it was proposed to divide hospital patients into two groups, for one of which prayers were to be offered and for the other not, the proposal was resented with indignation. There was a resolution to maintain the faith in the curative effect of prayer, whether it was or was not justified by the facts; to which end it was felt desirable not to bring it face to face with the facts.
Again, down to the present day epilepsy is regarded by many as due to the possession by a devil; and the prayer-book contains a form of exorcism to be gone through by a priest to cure maladies supernaturally caused. Belief in the demoniacal origin of some diseases is indeed a belief necessarily accepted by consistent members of the Christian Church; since it is the belief taught to them in the New Testament—a belief, moreover, which survives the so-called highest culture. When, for example, we see a late Prime Minister, deeply imbued with the university spirit, publicly defending the story that certain expelled devils entered into swine, we are clearly shown that the theory of the demoniacal origin of some disorders is quite consistent with the current creed. And we are shown how, consequently, there yet remains a place for priestly action in medical treatment.
Let me add a more remarkable mode in which the primitive theory has persisted. The notion that the demon who was causing a disease must be driven out, continued, until recent times, to give a character to medical practice, and even now influences the conceptions which many people form of medicines. The primitive medicine-man, thinking to make the body an intolerable habitat for the demon, exposed his patient to this or that kind of alarming, painful, or disgusting treatment. He made before him dreadful noises and fearful grimaces, or subjected him to an almost unbearable heat, or produced under his nose atrocious stenches, or made him swallow the most abominable substances he could think of. As we saw in the case cited from Ecclesiasticus, the idea, even among the semi-civilized Hebrews, long remained of this nature. Now there is abundant proof that, not only during mediæval days but in far more recent days, the efficiency of medicines was associated in thought with their disgustingness: the more repulsive they were the more effectual. Hence Montaigne's ridicule of the monstrous compounds used by doctors in his day—"dung of elephant, the left foot of a tortoise, liver of a mole, powdered excrement of rats, etc." Hence a receipt given in Vicarie's Treasure of Anatomy (1641)—"Five spoonfuls of knave child urine of an innocent." Hence "the beliefs that epilepsy may be cured by drinking water out of the skull of a suicide or by tasting the blood of a murderer;" that "moss growing on a human skull, if dried, powdered, and taken as snuff, will cure the headache;" and that the halter and chips from the gibbet on which malefactors have been executed or exposed have medicinal properties. And there prevails in our own days among the uncultured and the young a similarly-derived notion. They betray an ingrained mental association between the nastiness of a medicine and its efficiency: so much so, indeed, that a medicine which is pleasant is with difficulty believed to be a medicine.
As with evolution at large, as with organic evolution, and as with social evolution throughout its other divisions, secondary differentiations accompany the primary differentiation. While the medical agency separates from the ecclesiastical agency, there go on separations within the medical agency itself.
The most pronounced division is that between physicians and surgeons. The origin of this has been confused in various ways, and seems now the more obscure because there has been of late arising not a further distinction between the two but a fusion of them. All along they have had a common function in the treatment of ordinary disorders and in the uses of drugs; and the "general practitioner" has come to be one who avowedly fulfills the functions of both. Indeed in our day it is common to take degrees in both medicine and surgery, and thus practically to unite these sub-professions. Meanwhile the two jointly have become more clearly marked off from those who carry out their orders. Down to recent times it was usual not only for a surgeon to compound his own medicines, but a physician also had a dispensary and sometimes a compounder: an arrangement which still survives in country districts. Nowadays, however, both medical and surgical practitioners in large places depute this part of their business to chemists and druggists.
But the apparent nonconformity to the evolutionary process disappears if we go back to the earliest stages. The distinction between doctor and surgeon is not one which has arisen by differentiation, but is one which asserted itself at the outset. For while both had to cure bodily evils, the one was concerned with evils supposed to be supernaturally inflicted, and the other with evils that were naturally inflicted—the one with diseases ascribed to possessing demons, the other with injuries inflicted by human beings, by beasts, and by inanimate bodies. Hence we naturally find in the records of early civilizations more or less decided distinctions between the two.
"The Brahmin was the physician; but the important manual department of the profession could not be properly exercised by the pure Brahmin; and to meet this difficulty, at an early period, another caste was formed, from the offspring of a Brahmin with a daughter of a Vaishya."
There is evidence implying that the division existed in Egypt before the Christian era; and it is alleged that the Arabians systematically divided physics, surgery, and pharmacy into three distinct professions. Among the Greeks, however, the separation of functions did not exist: "the Greek physician was likewise a surgeon"—was likewise a compounder of his own medicines. Bearing in mind these scattered indications yielded by early societies, we must accept in a qualified way the statements respecting the distinctions between the two in mediæval times throughout Europe. When we remember that during the dark ages the religious houses and priestly orders were the centers of such culture and skill as existed, we may infer that priests and monks acted in both capacities; and that hence, at the beginning of the fifth century, surgery "was not yet a distinct branch of the practice of medicine." Still, it is concluded that clerics generally abstained from practicing surgery, and simply superintended the serious operations performed by their assistants: the reason being perhaps, as alleged, that the shedding of blood by clerics being interdicted, they could not themselves use the operating knife. And this may have been a part cause for the rise of those secular medical practitioners who, having been educated in the monastic schools, were, as barber-surgeons, engaged by the larger towns in the public service. Probably this differentiation was furthered by the papal edicts forbidding ecclesiastics from practicing medicine in general; for, as is argued, there may hence have arisen that compromise which allowed the clergy to prescribe medicines while they abandoned surgical practice into the hands of laymen.
Along with this leading differentiation, confused in the ways described, there have gone on, within each division, minor differentiations. Some of these arose and became marked in early stages. In ancient India—
"A special branch of surgery was devoted to rhinoplasty, or operations for improving deformed ears and noses, and forming new ones."
That the specialization thus illustrated was otherwise marked, is implied by the statement that "no less than a hundred and twenty-seven surgical instruments were described in the works of the ancient surgeons;" and by the statement that in the Sanskrit period—
"The number of medical works and authors is extraordinarily large. The former are either systems embracing the whole domain of the science, or highly special investigations of single topics."
So was it, too, in ancient Egypt. Describing the results, Herodotus writes:—
"Medicine is practiced among them [the Egyptians] on a plan of separation; each physician treats a single disorder, and no more: thus the country swarms with medical practitioners, some undertaking to cure diseases of the eye, others of the head, others again of the teeth, others of the intestines, and some those which are not local."
Though among the Greeks there was for a long period no division even between physician and surgeon, yet in later days "the science of healing became divided into separate branches, such as the arts of oculists, dentists, etc."
Broken evidence only is furnished by intermediate times; but our own times furnish clear proofs of progress in the division of labor among medical men. We have physicians who devote themselves, if not exclusively, still mainly, to diseases of the lungs, others to heart diseases, others to disorders of the nervous system, others to derangements of digestion, others to affections of the skin; and we have hospitals devoted some to this and some to that kind of malady. So, too, with surgeons. Besides such specialists as oculists and aurists, there exist men noted for skillful operations on the bladder, the rectum, the ovaria, as well as men whose particular aptitudes are in the treatment of breakages and dislocations, to say nothing of the quacks known as "bonesetters," whose success, as has been confessed to me by a surgeon, is often greater than that of men belonging to his own authorized class.
In conformity with the normal order of evolution, integration has accompanied this differentiation. From the beginning have been shown tendencies toward unions of those who practiced the healing art. There have arisen institutions giving a certain common education to them; associations of those whose kinds of practice were similar; and, in later times, certain general, though less close, associations of all medical men. In Alexandria—
"The temple of Serapis was used for a hospital, the sick being received into it, and persons studying medicine admitted for the purpose of familiarizing themselves with the appearance of disease, precisely as in such institutions at the present time."
In Rome, along with the imported worship of Æsculapius, there went the communication of knowledge in the places devoted to him. During early mediæval times the monasteries, serving as centers of instruction, gave some embodiment to the medical profession, like that which our colleges give. In Italy there later arose institutions for educating physicians, as the medical school of Salerno in 1140. In France before the end of the thirteenth century the surgeons had become incorporated into a distinct college, following, in this way, the incorporated medical faculty; and while thus integrating themselves they excluded from their class the barbers who, forbidden to perform operations, were allowed only to dress wounds, etc. In our own country there have been successive consolidations. The barber-surgeons of London were incorporated by Edward IV, and in the fifteenth century the College of Physicians was founded, and "received power to grant licenses to practice medicine—a power which had previously been confined to the bishops" Progress in definiteness of integration was shown when, in Charles I's time, persons were forbidden to exercise surgery in London and within seven miles, until they had been examined by the company of barbers and surgeons; and also when, by the 18th of George II, excluding the barbers, the Royal College of Surgeons was formed. At the same time there have grown up medical schools in various places which prepare students for examination by these incorporated medical bodies: further integrations being implied. Hospitals, too, scattered throughout the kingdom, have become places of clinical instruction, some united to colleges and some not. Another species of integration has been achieved by medical journals, weekly and quarterly, which serve to bring into communication educational institutions, incorporated bodies, and the whole profession.
Two additional facts should be noted before closing the chapter. One is the recent differentiation by which certain professors of anatomy and physiology have been made into professors of biology. In them the study of human life has developed into the study of life at large. And it is interesting to see how this specialization, seemingly irrelevant to medical practice, eventually becomes relevant; since the knowledge of animal life obtained presently extends the knowledge of human life and so increases medical skill. The other fact is that along with incorporation of authorized medical men there has arisen jealousy of the unincorporated. Like the religious priesthood, the priesthood of medicine persecutes heretics and those who are without diplomas. There has long been, and still continues, denunciation of unlicensed practitioners, as also of the "counter-practice" carried on by chemists and druggists. That is to say, there is a constant tendency to a more definite marking off of the integrated professional body.