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UBC Theses and Dissertations

The development of medieval medical ethics Amundsen, Darrel W 1980

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THE DEVELOPMENT OF MEDIEVAL MEDICAL ETHICS by . DARREL WALTER AMUNDSEN B.A., Western Washington University, 196? M.A., University of Washington, I969 A.THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES Department of History We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA Apr i l , I98O © Darrel Walter Amundsen, I98O In presenting th i s thesis in par t i a l fu l f i lment of the requirements for an advanced degree at the Univers ity of B r i t i s h Columbia, I agree that the Library shal l make i t f ree ly avai lable for reference and study. I further agree that permission for extensive copying of th i s thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It i s understood that copying or publ icat ion of th i s thesis for f inanc ia l gain shal l not be allowed without my written permission. Department nf History  The Univers ity of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 n.tp April 25. 1980 D E - 6 B P 75-51 1 E ABSTRACT In classical antiquity there were no restrictions on who could practise medicine. There were no enforceable professional standards. The physician sold his services at his own discretion to those who asked and paid for treatment; he exercised his art as he wished. In the early Christian centuries Christian charity and moral principles effected some significant changes in the perception of medical ethics and suggested a responsibility to exercise compassion and extend charity. Yet i t i s not until the late Middle Ages that we can speak of the development of a clearly-defined medical deontology and professional ethics resulting from two factors» 1) The development of licen-sure requirements (whether imposed by external authority or obtained by medical guilds) which reflects a funda-mental change in the very basis for the practice of medicine from a right to a privilege, with specific obligations at-tached to that privilege. 2) The clear definition and ex-pression by casuists of the moral responsibilities of phy-sicians. During the late Middle Ages some physicians wrote treatises on medical etiquette and ethics. When the con-tents of these treatises are supplemented by guild and uni-versity ethics and the moral expectations of the casuists, as well as by the evidence of physicians' conscientious response to the various outbreaks of pestilential disease i i i i n the l a t e Middle Ages, the picture that emerges i s of r e l a t i v e l y high e t h i c a l standards circumscribed by, and i n part the r e s u l t of, clea r l y - d e l i n e a t e d expectations of e c c l e s i a s t i c a l authority and the secular community. iv TABLE OF CONTENTS Acknowledgements v Chapter I . The Greco-Roman Background: Decorum and Enlightened Self-interest 1 Chapter I I . Early Christian and Early Medieval Medical Ethics: Duty to God and to Tradition 56 Chapter I I I . Licensure, Universities and Guilds: Duty to the State and to the Profession 116 Chapter IV. Casuistry and Professional Obliga-tions: Regulation by the Court of Conscience 219 Chapter V. Medical Ethics in Theory and Prac-ti c e : The Witness of Individual Physicians in the Late Middle Ages 289 Bibliography of literature cited 359 V ACKNOWLEDGEMENTS A special debt of gratitude i s owed to my Research Supervisor, Professor John Norris, for his conscientious diligence in reading and c r i t i c i z i n g this thesis at i t s various stages. Dr. Ronald Kotrc of the College of Phy-sicians of Philadelphia deserves special appreciation for his generous support during the summer of 1977 when much of the preliminary work on the casuistic literature was accom-plished. The criticisms and discussions evoked by presen-tations of various aspects of this study at meetings of the Death and Dying Research Group (now the Death, Suffering and Well-Being Research Group) of the Hastings Centeri In-stitute of Society,, Ethics and the Life Sciences, have proved most helpful. To my wife and children I extend my deepest gratitude for their patience in hearing with the deprivations that must be inevitable in any family where one is attempting to complete a doctoral thesis. CHAPTER I THE GRECO-ROMAN BACKGROUND: DECORUM AND ENLIGHTENED SELF-INTEREST D u r i n g t he e a r l y c e n t u r i e s o f t he C h r i s t i a n e r a , a s pagan i sm gave way t o C h r i s t i a n i t y , pagan m e d i c a l p r a c t i -t i o n e r s were s l o w l y r e p l a c e d by a t l e a s t n o m i n a l l y C h r i s -t i a n p h y s i c i a n s who i n h e r i t e d t h e i r p r e d e c e s s o r ' s m e d i c a l knowledge and a d o p t e d , a d a p t e d , o r r e j e c t e d v a r i o u s a s p e c t s o f t h e i r e t h i c s . Thus any s e r i o u s a t t e m p t t o t r a c e t he deve lopment o f m e d i e v a l m e d i c a l e t h i c s must b e g i n w i t h t h e Greco-Roman b a c k g r o u n d . The g e n e r a l s t a t e o f Greco-Roman m e d i c a l e t h i c s w i l l be d i s c u s s e d i n t h i s i n t r o d u c t o r y c h a p t e r . No a t t e m p t w i l l be made t o d e v e l o p a h i s t o r y o f a n c i e n t m e d i c a l e t h i c s o r t o a n a l y z e i t s v a r i e d p h i l o s o -p h i c a l r o o t s . * R a t h e r t h e c o n c e r n h e r e i s w i t h g i v i n g a 1. S e v e r a l s t u d i e s o f c l a s s i c a l m e d i c a l e t h i c s , o f v a r y i n g q u a l i t y and f r om d i v e r s e p e r s p e c t i v e s , a r e a v a i l a b l e ; e . g . , Ludw ig E d e l s t e i n , " The P r o f e s s i o n a l E t h i c s o f t h e Greek P h y s i c i a n , " i n A n c i e n t M e d i c i n e : S e l e c t e d Pape r s o f Ludw ig  E d e l s t e i n , e d . by Owsei and C. L i l i a n Temkin ( B a l t i m o r e : Johns H o p k i n s - U n i v e r s i t y P r e s s , 1967)1 319-3^ 8; D a n i e l l e G o u r e v i t c h , " Deon to l og - i e m e d i c a l e : q u e l q u e s p r o b l e m e s , " Me langes d ' a r c h e o -l o g i e e t d ' h i s t o i r e , 1969, 8 1 : 519-536, and 1970, 82 : 737-752; F r i d o l f K u d l i e n , " M e d i c a l E t h i c s and P o p u l a r E t h i c s i n G reece and Rome," C l i o M e d i c a , 1970, 5' 91-121; Geo r g W e i s s , " D i e e t h i s c h e n Anschauungen im c o r p u s H i p p o c r a t i c u m , " A r c h l y f u r  G e s c h i c h t e d e r M e d i z i n und d e r N a t u r w i s s e n s c h a f t e n , I9IO-I9II, ki 235-262; Ma rkwar t M i c h l e r , " M e d i c a l E t h i c s i n H i p p o c r a t i c Bone S u r g e r y , " B u l l e t i n o f t h e H i s t o r y o f M e d i c i n e , I968, h2: 297-311; A. P a z z i n i , " I I r e a l e s i g n i f i c a t o d e i l i b r i e t i c i d e l ' C o r p u s H i p p o c r a t i c u m , ' " P a g i n e d i s t o r i a d e l l a m e d i c i n a , 1970, lh (5): 52-56, and " L ' a t t u a l e v a l i d i t a d e l l e p r o s p e t -t i v e d e o n t o l o g i c h e n e g l i s c r i t t i d e l ' C o r p u s H i p p o c r a t i c u m , " ' i b i d . , 1971, 15 (1): 80-94; D a r r e l W . Amundsen, " H i s t o r y o f 1 2 b r o a d o v e r v i e w o f t h e p r a c t i c a l m e d i c a l e t h i c s o f t h e Greco-Roman p h y s i c i a n . S t r i c t l y f o r t h e sake o f c o n v e n i e n c e and o r g a n i z a t i o n , t h e d e s c r i p t i o n o f t h e m e d i c a l e t h i c s o f t he Greco-Roman p h y s i c i a n w i l l be b r oken down i n t o two d i f f e r e n t c a t e g o r i e s . A t t h e o u t s e t , however , i t s h o u l d be r e c o g n i z e d t h a t t h e s e two c a t e g o r i e s w i l l o v e r l a p and t h a t any g e n e r a l c a t e g o -r i z i n g o f m e d i c a l e t h i c s w i l l i n v a r i a b l y be somewhat a r t i -f i c i a l . The f i r s t c a t e g o r y w i l l be c a l l e d g e n e r a l e t i q u e t -t e . M a t t e r s o f g e n e r a l e t i q u e t t e appea r t o c o n s t i t u t e a code o f c onduc t f o r p r a c t i t i o n e r s , a l o o s e code o f e m i n e n t -l y p r a c t i c a l c o n c e r n s a d d r e s s e d t o t h e g e n e r a l good o f t h e a g g r e g a t e o f p r a c t i t i o n e r s . These r u l e s o f conduc t seem t o have r e s u l t e d f r om and answer t o t h e g e n e r a l d e s i r e f o r f a c i l i t a t i n g ha rmon ious r e l a t i o n s w i t h p a t i e n t s and c o l l e a -gues a l i k e . T h i s c a t e g o r y i n c l u d e s such m a t t e r s a s t h e i d e a l c h a r a c t e r and q u a l i t i e s r e q u i s i t e t o m e d i c a l p r a c t i c e , b e d s i d e manner, and g e n e r a l decorum. Such i s t he s u b j e c t m a t t e r w i t h w h i c h a n c i e n t t r e a t i s e s on m e d i c a l e t i q u e t t e 2 were m o s t l y c o n c e r n e d . These t r e a t i s e s a l s o were conce rned w i t h t h e s u b j e c t o f f e e s , a theme t h a t e x t e n d s i n t o ou r s e -cond c a t e g o r y . The second c a t e g o r y i s wha t , f o r t h e sake M e d i c a l E t h i c s : A n c i e n t G reece and Rome," i n The E n c y c l o -p e d i a o f B i o e t h i c s (New Y o r k : The F r ee P r e s s , and London : C o l l i e r M a c m i l l a n , 1978), v o l . 3, pp . 930-938. 2. E . g . , i n t h e H i p p o c r a t i c C o r p u s : The P h y s i c i a n , P r e c e p t s , and Decorum. .3 o f c o n v e n i e n c e , w i l l be c a l l e d d e o n t o l o g y . T h i s c a t e g o r y p a r t a k e s o f c o n s i d e r a t i o n s t h a t t r a n s c e n d t he immed ia te c o n c e r n s o f t h e p h y s i c i a n / p a t i e n t and t h e c o l l e a g u e / c o l l e a g u e r e l a t i o n s h i p s and i n c l u d e s such m a t t e r s as o b l i g a t i o n s ( i n t h e b r o a d e s t sen se ) t o t h e community t h a t a t t a c h t o t h o s e o c c u p y i n g t h e r o l e o f a p h y s i c i a n , and a l s o t h o s e i s s u e s t h a t can r e t r o s p e c t i v e l y be c a l l e d i s s u e s o f " r e s p e c t f o r l i f e . " C once rn s i n c l u d e d i n t h e s e two c a t e g o r i e s w i l l appea r r e p e a t e d l y i n t he subsequent t r e a t m e n t o f m e d i e v a l m e d i c a l e t h i c s . Two m a t t e r s s h o u l d be n o t e d b e f o r e d i s c u s s i n g s p e -c i f i c a s p e c t s o f Greco-Roman m e d i c a l e t i q u e t t e and d e o n -t o l o g y . One i s t h e s i g n i f i c a n c e o f t h e s o - c a l l e d H i p p o -c r a t i c O a t h ; t h e o t h e r i s t h e g e n e r a l s t a t e o f t h e a n c i e n t m e d i c a l p r o f e s s i o n . A l t h o u g h s c h o l a r l y o p i n i o n v a r i e s c o n s i d e r a b l y as t o how many ( i f any) o f t h e t r e a t i s e s i n t h e H i p p o c r a t i c Corpus were w r i t t e n by H i p p o c r a t e s , few ( i f any) s c h o l a r s t o d a y h o l d t h a t t h e Oath t h a t b e a r s h i s 4 name was w r i t t e n by h i m . E ven t h e d a t e o f t h e c o m p o s i t i o n 3» F o r a d i s c u s s i o n o f t h e p r o b l e m , see Ludw ig E d e l s t e i n , "The Genu ine Works o f H i p p o c r a t e s , " i n A n c i e n t  M e d i c i n e , pp . 133-144, and G. E. R. L l o y d , "The H i p p o c r a t i c Q u e s t i o n , " C l a s s i c a l Q u a r t e r l y . 1975, 25s I7I-I92. 4 . Savas N i t t i s * t h e s i s t h a t H i p p o c r a t e s h i m s e l f com-posed the Oath i n A then s between March and O c t o b e r o f 421 B.C. i s u n c o n v i n c i n g ; "The A u t h o r s h i p and P r o b a b l e Date o f t h e H i p p o c r a t i c O a t h , " B u l l e t i n o f t h e H i s t o r y o f M e d i c i n e , 19^ 0, 8: 1012 -1021 . o f t he Oath i s unknown; some s c h o l a r s p l a c e i t a s e a r l y a s t he s i x t h c e n t u r y B.C. and o t h e r s as. l a t e as t h e f i r s t c e n t u r y A . D . ^ I t a p p a r e n t l y d i d n o t e x c i t e a g r e a t d e a l o f a t t e n t i o n on t h e p a r t o f p h y s i c i a n s o r o t h e r s e a r l i e r t h a n t he b e g i n n i n g o f t h e C h r i s t i a n e r a ; the f i r s t known r e f e r e n c e t o i t was made by S c r i b o n i u s L a r g u s i n t h e f i r s t c e n t u r y A .D . ^ Some o f t h e s t i p u l a t i o n s i n t he Oath a r e no t con sonant e i t h e r w i t h e t h i c a l p r e c e p t s p r e v a l e n t e l s e w h e r e i n t he H i p p o c r a t i c Co rpu s and i n o t h e r c l a s s i c a l l i t e r a t u r e o r w i t h t he r e a l i t i e s o f m e d i c a l p r a c t i c e a s r e v e a l e d i n t h e s o u r c e s . T h i s has i n s p i r e d a number o f a t t e m p t s e i t h e r t o e x p l a i n away t h o s e i n c o n s i s t e n c i e s o r t o a t t r i b u t e t h e Oath t o an a u t h o r o r s c h o o l whose v i e w s w e r e , i n o t h e r r e s p e c t s as w e l l , d i s c o r d a n t w i t h t h o s e 7 c h a r a c t e r i s t i c o f c l a s s i c a l s o c i e t y . Most s i g n i f i c a n t i s E d e l s t e i n ' s t h e o r y t h a t t h e Oath was a p r o d u c t o f t h e P y t h a g o r e a n s c h o o l . E d e l s t e i n ' s t h e s i s i s t e m p t i n g a n d , o i n my o p i n i o n , t h e most c o n v i n c i n g t h u s f a r a d v a n c e d . 5. L udw i g E d e l s t e i n d a t e s t he c o m p o s i t i o n o f t h e Oath t o t h e m i d - t o l a t e f o u r t h c e n t u r y B .C . ; "The H i p -p o c r a t i c O a t h : T e x t , T r a n s l a t i o n and I n t e r p r e t a t i o n , " i n A n c i e n t M e d i c i n e , pp . 55 • 6. S c r i b o n i u s L a r g u s , P r o f e s s i o m e d i c i , p. 2k i n K a r l D e i c h g r a b e r , P r o f e s s i o m e d i c i . Zum V o r w o r t des  S c r i b o n i u s L a r g u s (Abhand lungen d e r Akademie d e r W i s s e n -s c h a f t e n und d e r L i t e r a t u r n r . 9, M a i n z , I950). 7. E d e l s t e i n ' s d i s c u s s i o n o f t h e Oath ( o r i g i n a l l y p u b l i s h e d in.19^ 3) i n c l u d e s a summary o f p r e v i o u s s c h o -l a r l y t r e a t m e n t . 8. Much has been w r i t t e n on t he Oath s i n c e E d e l -5 The P y t h a g o r e a n o r i g i n o f t h e Oa th , however , s h o u l d n o t be c o n s i d e r e d p r o v e d . Not o n l y can p a r a l l e l s be f ound o u t s i d e P y t h a g o r e a n i s m f o r even t h e most e s o t e r i c i n j u n c -t i o n s i n t h e O a t h , ' bu t t h e Greek t e x t o f f e r s many v a r i a n t r e a d i n g s , some o f w h i c h can be t r a n s l a t e d i n somet imes s i g n i f i c a n t l y d i f f e r e n t ways . The O a t h , t a k e n a s a w h o l e , i s an e s o t e r i c document w h i c h i s o f t e n i n c o n s i s t e n t w i t h t h e l a r g e r p i c t u r e o f Greco-Roman m e d i c a l e t h i c s . We s h a l l see t h a t t h e Oath was p o p u l a r w i t h e a r l y C h r i s t i a n s and d u r i n g t h e M i d d l e Ages p r e c i s e l y because i t e spouses p o s i t i o n s more c o m p a t i b l e w i t h C h r i s t i a n e t h i c s t h a n w i t h v a l u e s most p r e v a l e n t i n c l a s s i c a l c u l t u r e . S e c o n d l y , a t no t i m e i n t h e c l a s s i c a l w o r l d was t h e r e any s y s tem o f m e d i c a l l i c e n s u r e . The c l o s e s t p a r a l l e l t o m e d i c a l l i c e n s u r e was i n t he a p p o i n t m e n t o f " p u b l i c p h y -s i c i a n s , " demos i euon te s i a t r o i o f G r e e c e , d e m o s i o i i a t r o i o f Roman E g y p t , and a r c h i a t r i o f Rome and some o t h e r a r e a s o f t he E m p i r e . These " p u b l i c p h y s i c i a n s " were n o t i n any sense " l i c e n s e d " t o p r a c t i s e m e d i c i n e . The r e a s o n f o r t h e i r a p p o i n t m e n t a p p e a r s t o have been s i m p l y t o en su re t h e a v a i -l a b i l i t y o f p h y s i c i a n s , a l t h o u g h i n Roman E g y p t t h e r e i s no e v i d e n c e t h a t t h e d e m o s i o i i a t r o i p e r f o r m e d any bu t a s t e i n ' s monograph, and s e v e r a l l e a d i n g s c h o l a r s have q u e s t i o n e d t h e v a l i d i t y o f h i s c e n t r a l t h e s i s o f t h e P y t h a g o r e a n o r i g i n o f t h e Oa th . S e e , f o r example , F r i -d o l f K .ud l i en , " M e d i c a l E t h i c s and P o p u l a r E t h i c s , " and K a r l D e i c h g r a b e r , P e r h i p p o k r a t i s c h e E i d ( S t u t t g a r t : H i p p o k r a t e s - V e r l a g , 1955), e s p e c i a l l y p. 4 0 . 9- C f . b o t h a r t i c l e s c i t e d i n t h e p r e c e d i n g n o t e , p a s s i m . 6 l o f o r e n s i c r o l e . Anyone c o u l d c a l l h i m s e l f a p h y s i c i a n and t r e a t p a t i e n t s . The re were no p r o f e s s i o n a l s t a n d a r d s e n f o r c e a b l e by s a n c t i o n s a g a i n s t p h y s i c i a n s who v i o l a t e d t h e " e t h i c s o f t he p r o f e s s i o n . " I n deed , even t o speak o f t h e " e t h i c s o f t h e p r o f e s s i o n " i s m i s l e a d i n g . A t no t ime were t h o s e who s i m p l y chose t o c a l l t h e m s e l v e s p h y s i c i a n s and u n d e r t a k e t he p r a c t i c e o f m e d i c i n e r e q u i r e d t o swear any o a t h o r t o a c c e p t and a b i d e by any f o r m a l o r i n f o r m a l code o f e t h i c s . Many o f t he p r i n c i p l e s o f e t i q u e t t e e x -p r e s s e d i n t h e m e d i c a l l i t e r a t u r e seem t o have r e s u l t e d f r om the p h y s i c i a n ' s c o n c e r n f o r h i s r e p u t a t i o n . When t a k e n out o f t h e c o n t e x t o f c l a s s i c a l a t t i t u d e s , t h i s a l m o s t c o n -s t a n t c o n c e r n w i t h r e p u t a t i o n can e a s i l y be m i s i n t e r p r e t e d and g i v e n a t one o f u n d e r l y i n g s e l f - i n t e r e s t , b u t the p h y -s i c i a n ' s o n l y c r e d e n t i a l was h i s r e p u t a t i o n . 10. On t h e demos i euon te s i a t r o i see L o u i s C o h n - H a f t , The P u b l i c P h y s i c i a n s o f A n c i e n t G reece ( Sm i t h C o l l e g e S t u d i e s i n H i s t o r y , v o l . 4 2 , No r t hampton , Mas s . : D e p a r t -ment o f H i s t o r y o f S m i t h C o l l e g e , 1956). F o r t h e d e m o s i o i  i a t r o i see O f e l i a N a n e t t i , " R i c e r c h e s u i m e d i c i e s u l l a m e d i c i n a n e i p a p i r i , " A e g y p t u s , 1941, 21: 301-314, and D a r r e l W. Amundsen and Ga ry B. F e r n g r e n , "The F o r e n s i c R o l e o f P h y s i c i a n s i n P t o l e m i c and Roman E g y p t , " B u l l e t i n  o f t he H i s t o r y o f M e d i c i n e . 1978, 52: 336-353. On t he a r c h i a t r i see V i v i a n Nu i t ton, " A r c h i a t r i and t h e M e d i c a l P r o f e s s i o n i n A n t i q u i t y , " P a p e r s o f t h e B r i t i s h S c h o o l a t  Rome, 1977, 191-226. In many ways o u t d a t e d bu t s t i l l u s e f u l i n Rene B r j a u , L ' a r c h i a t r i e roma ine ou l a medec ine  o f f i c i e l l e dans 1'empire r o m a i n ( P a r i s : L i b r a i r i e de l ' a c a d e m i e de medec i ne , 1877) • 7 Of v e r y r e a l , immed i a t e , and s u s t a i n e d c o n c e r n was g e n e r a l e t i q u e t t e . The p h y s i c i a n s hou l d l o o k h e a l t h y and be o f s u i t a b l e w e i g h t , " f o r t h e common crowd c o n s i d e r s t h o s e who a r e n o t o f e x c e l l e n t b o d i l y c o n d i t i o n t o be 11 u n a b l e t o t a k e c a r e o f o t h e r s . " T h i s i s o f p a r t i c u l a r 12 s i g n i f i c a n c e , e s p e c i a l l y i n c l a s s i c a l G reek c u l t u r e . A t l e a s t among t he G reek s o f t h e f i f t h c e n t u r y B.C. and l a t e r , h e a l t h was c o n s i d e r e d b o t h a v i r t u e and an i n d i -13 c a t o r o f v i r t u e . J H e a l t h was an i d e a l , i n d e e d t h e h i g h e s t good, s e t above b e a u t y , w e a l t h , and i n n e r n o b i l i t y . H e a l t h was a g o a l i n i t s e l f , f o r w i t h o u t h e a l t h a l l e l s e was w i t h o u t v a l u e . The s t a t e m e n t i n t h e H i p p o c r a t i c Co rpus t h a t w i t h o u t h e a l t h n o t h i n g a v a i l s , n e i t h e r money, n o r any other thing, 1^ expresses a strong popular, philoso-11. The P h y s i c i a n , 1. 12. C i c e r o w r i t e s , "Do n o t i m i t a t e bad p h y s i c i a n s who, i n t r e a t i n g t h e d i s e a s e s o f o t h e r s , c l a i m t o have m a s t e r e d t h e whole a r t o f h e a l i n g b u t canno t c u r e t h e m -s e l v e s " ( E p i s t u l a e ad f a m i l i a r e s , 4, 5» 5)- " P h y s i c i a n , h e a l y o u r s e l f " i s a p r o v e r b t h a t knows no c u l t u r a l b oun -d a r i e s ( c f . , L uke , 4:23; E u r i p i d e s , Fragment 10B6). B ab -r i u s ( F a b l e s , 120) and A v i a n u s ( F a b l e s , 6) b o t h p r e s e r v e a f a b l e i n v o l v i n g a d i s t e n d e d f r o g who t r i e d t o c o m f o r t a f f l i c t e d b e a s t s w i t h t he a s s u r a n c e o f t h e e f f i c a c y o f h e r m e d i c i n e s f o r r e l i e v i n g t h e i r d i s e a s e s and p r o l o n g i n g ; t h e i r l i v e s . The c a t t l e were c r e d u l o u s b u t a p e r s p i c a c i o u s v i x e n s a i d , "How i s t h i s f r o g , whose p a l e coun tenance i s marked by a s i c k l y hue , g o i n g t o p r e s c r i b e m e d i c i n e s f o r o t h e r s ? " 13. S e e , e . g . , L udw i g E d e l s t e i n , "The D i s t i n c t i v e H e l l e n i s m o f Greek M e d i c i n e , " i n A n c i e n t M e d i c i n e , pp . 386 f . , and Werner J a e g e r , P a i d e i a : The I d e a l s o f Greek C u l t u r e , t r a n s , by G. H i g h e t (New Y o r k : O x f o r d U n i v e r s i t y P r e s s , 1944), v o l . 3, pp . 44 f . 14. Reg imen, 3» 69; c p . H e r o p h i l u s i n S e x t u s E m p i r i c u s , A d v e r s u s m a t h e m a t i c o s , 11, 50* 8 p h i c a l , and m e d i c a l s e n t i m e n t . P r o p h y l a x i s p l a y e d an e x -t r e m e l y v i t a l r o l e i n Greek m e d i c i n e and a p h y s i c i a n who d i d no t a p p e a r a b l e t o p r e s e r v e h i s own p h y s i c a l a r e t e wou l d p r o b a b l y have been v i e w e d a s b e i n g i n c a p a b l e o f a s s i s t i n g o t h e r s i n t h e p r e s e r v a t i o n o f h e a l t h . I n h i s c o n d u c t , t h e p h y s i c i a n s h o u l d be a " p e r f e c t 15 g e n t l e m a n . " J G a l e n i n s i s t s on t h e i d e a l o f n e a t n e s s and p r o p r i e t y t h a t e v e r y p h y s i c i a n ought t o have i n h i s d e -16 p o r t m e n t . E s p e c i a l l y i n d e a l i n g s w i t h h i s p a t i e n t s he 17 s h o u l d be c h e e r f u l and s e rene bu t n e i t h e r h a r s h n o r s i l -18 l y . He s h o u l d be r e s e r v e d , speak d e c i s i v e l y , use b r e -19 v i t y o f speech and be s e l f - c o n t r o l l e d and n o t e x c i t a b l e . ' P a r t i c u l a r l y a d i s p l a y o f o s t e n t a t i o n was r e g a r d e d w i t h d i s t a s t e : " A n o v e r - f o r w a r d o b t r u s i v e n e s s i s d e s p i s e d , 20 even though i t may be v e r y u s e f u l . " F u r t h e r , " i t i s d i s g r a c e f u l i n any a r t and e s p e c i a l l y i n m e d i c i n e , t o make a parade o f much t r o u b l e , d i s p l a y , and t a l k , and t h e n t o 21 do no g o o d . " D i s t a s t e f o r o s t e n t a t i o n ex tended i n t o any The P h y s i c i a n , 1. 16. G a l e n , I n H i p , e p i d . l i b r u m s ex , com. , 4 . 17. Decorum, 16. 18. The P h y s i c i a n , 1; c f . Decorum, 7. 19• Decorum, 12. 20. The P h y s i c i a n . 1. 21 . On J o i n t s , hh . 9 form of advertizing. The most common form of advertizing in classical antiquity was the public harangue, similar to that of the barker at a modern carnival. Physicians "were urged to refrain from holding lectures for the pur-pose of drawing a crowd. In general, conducting one's practice with much fuss, although i t might appeal to the vulgar crowd, smacked of charlatanism and was to be avoided . 2 3 as demeaning. y Pieces of advice on relations with fellow physicians appear very occasionally in. the literature on medical e t i -quette. Charlatans, by their very nature, we are told in 24 a treatise in the Hippocratic Corpus, avoid consultations; good physicians, recognizing their own limitations and res-pecting their colleagues' knowledge, should turn to other competent physicians for advice. Consequently, a physician does not violate etiquette even i f , being in d i f f i c u l t i e s on occasion over a patient and uncertain owing to inexperience, he should urge the calling in of others in order to learn by con-sultation. . . . A physician's reasoning should never make one jealous of another. This is a sign of weakness. 25 Consultations can lead to disputes and the author of Precepts urges that "physicians who meet in consultation must never quarrel or jeer at one another." Although 22. Precepts, 12. 23. Se^ e, e.g., The Physician, 4; On Joints, 42, 44 and 73; Precepts, 10; Celsus, 5, 26, 1, C. 24. E.g., in Precepts, 7: ". . . quacks . . . avoid calling in.other physicians, because they wickedly hate help." 25. Precepts, 8. 26. Ibid. 10 statements such as these are repeated in medieval treatises, i t i s not unti l the advent of medical guilds in the late Middle Ages that much emphasis on the physician's re-lations with his colleagues appears. There i s more concern in the literature with rules of etiquette guiding the physician in his treatment of patients than with those advising him in his relationship with colleagues. The physician's relationship with his patient usually commenced with an examination followed by a prognosis. It was then that the physician was faced with an ethical decision: what to t e l l the patient. Two considerations impinged upon the physician now: 1) the effect of his statement on the patient and 2) the effect of the outcome of the case on his own reputation. There was considerable hesitancy to take on hopeless or doubt-27 f u l cases. / Some physicians merely informed the patient that he was going to die and l e f t him i f they considered his case hopeless. Galen t e l l s us in disgust that a particular colleague of his, in responding to a patient's question whether he would live or die, gave this sarcas-28 t i c reply: "Patroclus also died, and he was a better man 29 than you." 7 Galen's castigation of such callousness should 27. This subject w i l l be discussed in detail below. 28. A legendary Greek hero. 29. Galen, In Hip, epid. l i b , sex, com., 4. Another example given in loc. is "If you are not the child of Leto [i.e., the mother of Apollo or Artemis], who is blessed with f a i r children, you w i l l die." 11 not be construed as a recommendation to withhold the truth. In actual practice, conditions must have varied considerably among individual physicians and the medical literature does not provide a consensus of opinions. In one treatise in the Hippocratic Corpus, the physician is advised to conceal most things from the patient while you are attending to him . . . revealing nothing of the patient's future or present condition. For many patients through this cause have taken a turn for the worse, I mean by the declaration I have mentioned of what is present, or by a fore-cast of what is to come.3° Surely revealing the prognosis of a rapid and painless recovery is not meant here. If the case was dangerous and the outcome uncertain but not absolutely hopeless, i t was sometimes suggested, at least in our later sources, that the patient's relatives be informed. Celsus, for example, enjoins the physician "to point out to the patient's relatives that hope is surrounded by d i f f i c u l t y , for then i f the art is overcome by the malady, he may 31 not seem to have been ignorant or mistaken." In Pror-rhetikon II the physician is instructed to t e l l a third 32 party. Others suggest that the patient himself should 30. Decorum, 16. 31. Celsus, 5, 26, 1, C. 32. On this passage in Prorrhetikon II, Ludwig Edelstein writes, "One may be sure that patients were often told the worst, without any consideration: that Prorrhetikon II advises the physician to t e l l his prog-nosis to a third party suggests that such was the case. be told and advised to make his w i l l since he is facing great d a n g e r . S e x t u s Empiricus (second century A.D.), a physician by profession, a member of the Empirical school of medical theory by persuasion, and a Sceptical philosopher in orientation, writing more as a philosopher than as a physician, argues that "the physician who says something false regarding the cure of his patient, and promises to give him something but does not give i t , is 3 4 not lying though he says something false"^ since in saying i t he has regard to the cure of the person he is treating. This rationale probably corresponds f a i r l y closely to that 3 5 behind the statement quoted above from Decorum. J But how did laymen react to the problem? Apuleius seems simply to assume that the physician, after he examines his patient, w i l l inform him of his condition: ". . . the physician sits down by the man's bedside, takes his hand, feels i t and ex-plores the beat and movements of the pulse. If he disco-vers any irregularity or disorder, he informs his patient The numerous statements in the Hippocratic writings, that the physician's words at the bedside should be cautious, give one an inkling of how often other physicians disap-proved of both the form and the content of what patients were told" ("Hir/pocratic Prognosis," in Ancient Medicine, p. 76). 33« Ctesias, in Oribasius, Collect, medic, reliquiae, 8, 8. Cf., Paulus Aegineta (6, 88): ". . . i f the result is dubious . . .we must make the attempt [sc., to treat, in this case, a serious wound], having f i r s t given warning of the danger." 34. Sextus Empiricus, Against the Logicians, 1, 43. 35. Above, at n. 30. 13 36 that he is seriously i l l . " ^ Seneca has l e f t a comment that is ambiguous, being either condemnatory of the phy-sician who does not inform the patient or else neutral: "If a physician does not recognize that his patient is fa i l i n g , he is a much poorer practitioner than i f he re-cognizes the fact and conceals his knowledge ."37 p n n y the Younger remarks, without question or indignation, that in a particular case the physician would not reveal to the patient his condition. Perhaps the strongest approval of such practice by a lay source is Cicero's comment that "physicians, although they know many times that their patients are going to die of a present disease, yet never t e l l them so; for a forewarning of an e v i l is justified only when to the warning is joined a means of escape."/7 It should be obvious from both the medical and the lay sources cited above that opinions on this delicate matter varied considerably then just as they do 40 now. 36. Apuleius, Florida, 23. 37. Seneca, Letters to Lucilius, 95. 9. 38. Pliny the Younger, Epistles, 1, 22. 39. Cicero, De divinatione, 2, 25. By "means of escape" he surely i s not considering escape from the disease via es-cape from l i f e , but rather escape from the disease without re-course to suicide or euthanasia. Given the Stoic attitude to suicide, Cicero must here be thinking of a terminal illness of relatively short duration. 40. We shall see in Chapters IV and V that this matter w i l l become a very important issue in the late Kiddle Ages. 14 Regardless of what he t e l l s the patient or the pa-tient's relatives, should the physician treat as confi-dential such information as he acquires in his contact with patients? In the so-called Hippocratic Oath, the following'injunction appears: "What I may see or hear in the course of the treatment or even outside of the treatment in regard to the l i f e of men,which on no account one must spread abroad, I w i l l keep to myself holding such kl things shameful to be spoken about." Ludwig Edelstem sees in this stipulation a clear indication of Pythago-rean purity, an insistence of secrecy "not as a precaution 42 but as a duty." In any event, those things, whether encountered within or outside of practice, that one ought not spread abroad, are categorized as things "shameful to be spoken about," or, in another translation, "holy sec-4 V rets." J We are not told what information would not f a l l into this category, although Edelsteih stresses Pythago-rean taciturnity to the point that one must wonder whether the Pythagorean physician would be held uncommunicative on a l l counts and in every area. But this somewhat peculiar injunction, appearing as i t does in an Oath in which ano-malous, or nearly anomalous, stipulations are indeed not uncommon, seems to go beyond a simply pragmatic recogni-41. Ludwig Edelstein's translation, "Hippocratic Oath," in Ancient Medicine. 42. Ibid., p. 37-43. Thus W. H. S. Jones, The Doctor's Oath: An Essay  in the History of Medicine (Cambridge: Cambridge University Press, 1924), 11. !5 . • tion of the expediency of reticence in one's dealings with laymen. Elsewhere in the Hippocratic Corpus the physician is advised not to gossip to laymen, ""but say only what is necessary. For he realizes that gossip may cause criticism 44 of his treatment." In another treatise the physician is urged to be "careful of certain moral considerations - not only to be silent but also of a great regularity of l i f e , 45 since thereby his reputation w i l l be greatly enhanced." -Such remarks as these last two quoted must be distinguished from the stipulation in the Oath. While the latter may, in fact, be motivated by a sense of duty to keep invio-lable especially those things to which his practice makes him privy, the other two must be placed in the context of a u t i l i t a r i a n regard for reputation, generated much more by the physician's concern for self than by his concern for the "rights" of his patient. Surprisingly l i t t l e em-phasis on confidentiality is found in the medical l i t e r a -ture. Neither in the fragmentary "Ancient Poem on the it 6 Duties of a Physician nor in a "second oath" of unknown 47 . date is any reference to confidentiality made. Galen seems to have taken particular delight in' disparaging the 44. Decorum, 7. 45. The Physician, 1. 46. James H. Oliver and Paul Lazarus Maas, "An Ancient Poem on the Duties of a Physician," Bulletin of the History  of Medicine, 1939, 7: 315-323. 47. Published in Corpus Medicorum Craecorum, vol. 1, 1, pp. 5-6. views of his detractors "by describing in intimate detail his successful treatment of the various ailments of the 4 8 emperor Marcus Aurelius and of the peripatetic philo-sopher Eudemus.^ vJe shall find that confidentiality •is an infrequently recurring theme in the medieval l i t e r a -ture of medical etiquette as well. Another very practical stipulation in the Oath reads, "Whatever house I may v i s i t , I w i l l come for the benefit of the sick, remaining free of a l l intentional injustice, of a l l mischief, and in particular of sexual relations with both female and male persons, be they free or slaves." Edelstein stresses again the Pythagorean tone of this in-junction, especially the emphasis on justice and sees in the prohibition of sexual relations with members of the patient's household, female or male, free or slaves, evi-dence of Pythagorean severity in sexual morality. Indeed, he goes so far as to write, "Everything, then, that the Oath stipulates in regard to sexual continence agrees with the tenets of Pythagorean ethics, in fact with the ideals 48. Galen, De praenotione ad Posthumum, 11. 49. Ibid., 2. One should bear in mind, however, the prevailing hypochondria of Galen's time, the period of the second Sophistic, and the pride with which illness and dis-comforts of both a large and petty nature were flaunted about, which merely a glance at the correspondence between Marcus Aurelius and Fronto w i l l demonstrate. 50. Ludwig Edelstein, "Hippocratic Oath," in Ancient  Medicine, p. 6. 17 of these philosophers alone. "-^  In this he surely presses his interpretation too far. While i t i s safe to say that the stipulation under consideration is f u l l y consonant with Pythagorean values, nevertheless, i f this injunction were taken out of the context of the esoteric Oath and were read independently, i t would not evoke exclamations of surprise. Whether this advice was motivated "by ideals of purity or by merely pragmatic concerns, i t is obvious that the physician who used his close contact with patients or their households to .satisfy his sexual passions would earn not only disrespect and contempt but also strong distrust. Having a reputation as a mischievous, lascivious seducer of patients and their family members simply does not en-hance one's medical career. In terms of its practical aspect, i t f a l l s under the same rubric as such aspects of general etiquette as have been discussed above. It is in the context of a discussion of general demeanor that the following statement occurs in a Hippocratic treatise: "The intimacy also between physician and patient i s close. Patients in fact put themselves into the hands of their physicians, and at every moment he encounters women, gir l s 52 and very precious possessions."-^ Further, the anonymous poem on the physician's duties declares that he "should not burn with desire when handling lovely ladies and g i r l s . " - J 51. 52. 53. Ibid., p. 35. The Physician. 1. "Ancient Poem on the Duties of a Physician," p. 320. 18 The eminent practicality of urging the sexual continence of physicians toward patients should be obvious. It is a piece of advice that w i l l appear with some regularity in the medico-ethical literature of the Middle Ages. The subjects discussed thus far have been drawn p r i -marily from treatises on medical etiquette. The concerns expressed were directed toward the highly practical as-pects of physician/patient and colleague/colleague rela-tionships. I have called i t "general etiquette;" i t is usually referred to as medical ethics. Indeed, tradi-tionally when physicians have written on medical ethics, they have been almost exclusively concerned with matters of etiquette. Seldom have they, in their "ethical" trea-tises, addressed the more fundamental questions of the nature of their role in society and of the obligations incumbant'upon them as exercisers of that role. What was the physician, the taxpoQ of the Greek, the medicus of the Roman? By the most basic definition, he was one who practised the art of preserving or res-toring health. If the primary function of the classical physician was preserving or restoring health, ideally he should be a compassionate man. When I say "ideally,".I am thinking in terms of the "ideal" physician as he appears, at least in simile and metaphor, especially in philosophi-cal or p o l i t i c a l literature. When thus used, the word "physician" was not a neutral term. Unless modified by a pejorative adjective, i t denoted a "compassionate, objective, 19 unselfish man, dedicated to his responsibilities." In this manner, the good ruler, legislator, or statesman was sometimes called the physician of the state. According to Thucydides, "the statesman should be to the state what the physician is to his patient."^ Similar sentiments are expressed by Euripides, P l a t o , ^ Aristotle, by the author of an oration falsely attributed to Demosthenes, " by Aeschines-^ and Cicero.^ 0 Even epigraphy yields an 61 example, further demonstrating the pervasiveness of the popularly-held ideal of the physician as a dedicated, un-selfish, and compassionate preserver or restorer of health. Regardless of how far short of the ideal many physicians f e l l , nevertheless the ideal did exist, at least figurative-ly, and we shall see that i t was adopted by early Christian authors and remained a constant throughout the Middle Ages. 54. Thucydides, The Peloponnesian War, 6, 14. 55. Euripides, The Phoenician Women. 893-56. Plato, The Statesman. 293 A-C; Laws, 862 B, 720 D-E (cf., Gorgias, 464 B); Republic, 342 D. 57. Aristotle, Nicomachean Ethics, 1180 b; Po l i t i c s , 1287 a. 58. Pseudo-Demosthenes, Against Aristogeiton, 2, 26. 59. Aeschines, Against Ctesiphon, 225 f• 60.. Cicero, Republic, 1, 62; 5, 5; De oratore, 2, 186; Disputations, J, 82. 61. Supplementum Spigraphicum Graecum, 10, 98, 14. 20 Although there is much in the medical literature dealing with etiquette, there is l i t t l e said about the "ideal* physician or the moral basis for medical practice. In the Hippocratic Corpus appears the statement, "Where 62 there is love of man, there is also love of the art," which is often cited as i f ancient medical ethics were founded upon this lofty principle. Indeed on the basis of this adage P. Lain Entralgo argues that the Creek phy-sician's relationship with his patients was based on a combination of philanthropia (love of man) and philotechnia 6 3 (love of the a r t ) , ^ He maintains that "a careful study of the Hippocratic writings leads to the conclusion that Hip-i pocrates and his direct and indirect followers were 'philan-64 thropists' avant la lettre." His thesis rests upon his i belief that "there i s an 'instinct to help' at work in human nature, moving a man to succour the sick. . . ."^^ This, of course, is a highly debatable premise upon which to base such a sweeping assertion. The statement from the Precepts that is central to Lain Entralgo's argument occurs in the context of a discussion about fees introduced by the admonition, "I urge you not to be too unkind." Attempts to find any assertions in the Hippocratic Corpus that would . 62. Precepts, 6. 63. P. Lain Entralgo, Doctor and Patient, trans, by F. Partridge (New York: McGraw H i l l , 1969), 17 f f . 64. Ibid., p. 245, n. 1. 65. Ibid., p. 45. set up philanthropy as an indispensable motivation for practising medicine are f r u i t l e s s , For Galen, the phy-sician who is also a philosopher is the best physician; 66 such w i l l be motivated by love of humanity. But this philanthropy is the basis of medical practice for only a small number of physicians. The rest are motivated by love of money, love of honor, love of glory. Whether these are physicians or not depends on their proficiency 67 in the healing arts, not on their motivations. ' "The motive . . . is a matter of personal choice," as Edelstein summarizes Galen's opinion; " i t has no intrinsic connection ' 68 with the pursuit of medicine." Other sources are found, however, that strongly emphasize that the ideal physician "should promise aid in equal measure to a l l who ask for 69 help." In an anonymous poem on the duties of a physician (third century A.D.) i t is stated that he shoiald be savior "equally of slaves, of paupers, of rich men, of princes, 7 0 and to a l l a brother . . . for we are a l l brothers." 66. Ludwig Edelstein, "Ethics of the Greek Physician," in Ancient Medicine, pp. 334 f. 67. Galen, De p l a c i t i s , 9, 5-68. Ludwig Edelstein, "Ethics of the Greek Physician," in Ancient Medicine, p. 336. For a discussion of Galen's attitudes to philanthropy and medical practice, see Owsei Temkin, Galenism: Rise and Decline of a Medical Philosophy (Ithaca: Cornell University Press, 1973). 48 f f . 69. Scribonius Largus, p. 24 in Deichgraber's edition. 70. James Oliver and Paul Maas, "An Ancient Poem . . '. For a discussion of the changing attitudes in classical ant quity toward philanthropy as the basis for medical practice, 22 Naturally, the patient would prefer to be treated by.a physician who is truly a "lover of man." But this can lead to some inconsistencies. Seneca, for example, writes that if. one's physician treats him just as any other pa-tient, he owes him nothing but his fee, payment for his s k i l l . But i f the physician gives him more attention than is professionally necessary, even at the explicit expense of other patients, then "such a man has placed me under 71 obligation, not as a physician, but as a friend." It is not the seriousness of Seneca's condition that would necessitate the solicitude he wants; that would, in Seneca's view, be part of the physician's responsibility. It is rather the extra care and attention, motivated by concern and affection for Seneca the individual, that would qua-l i f y his physician as a friend. But i t could, by the same token, disqualify him as an ideal physician who, i f indeed motivated by his philanthropy, would give care equally to a l l who ask for help, rich and poor alike. It should not be surprising that the subject of fees was of concern to ancient medical writers. Here again pragmatic considerations occupy their attention. Physi-cians were undoubtedly aware that the appearance of greed could have a detrimental effect on their reputations. The see Fridolf Kudlien, "Medical Ethics and Popular Ethics," especially pp. 91-97. 71. Seneca, De beneficiis, 6, 16. physician is urged to be more concerned with his reputa-72 tion than with financial reward.' He is also advised to give his "services for nothing, calling to mind a previous kindness or his present reputation.""'7^ It was also recog-nized that beginning a case by discussing fees could ad-versely affect the patient, particularly i f his condition was acute: . . . should you begin by discussing fees, you w i l l suggest to the patient either that you w i l l go away and leave him i f no agreement be reached, or that you w i l l neglect him and not prescribe any immediate treatment. So one must not be anxious about fixing a fee. For I consider such a worry to be harmful to a troubled patient, particularly i f the disease be acute. For the quickness of the disease, offering no opportunity for turning back, spurs on the good physician not to seek his profit but rather to lay hold on reputation. Therefore, i t is better to re-proach a patient you have saved than to extort money from those who are at death's door.7^ And, later in the same treatise: "For some patients, though conscious that their condition i s perilous, recover their health simply through their contentment with the goodness of the physician. Physicians were admonished to consider their patient's economic situation in setting fees, as we have seen. It was also suggested that less expensive remedies should be pro-vided for the poor than for the rich."^ Although a degree 72. Precepts, h. 73' Ibid., 6. Ttapeouoav £U6OHLT)V can be transla-ted either "present reputation" or "present satisfaction." 7*K Ibid., 4. 75' I b i d . , 6 . On these two passages, see Edelstein, "Ethics . . . ." in Ancient Medicine, p. 321, n. 4. 76. .On Diet. 3. 24 of compassion is shown in these passages, Ilza Veith's statement that the Hippocratic physician acted "without 7 7 impulse to charity"' is probably correct. Indeed, phy-sicians of the Empirical school justified the making of 78 money as the primary motive of a physician's calling. Edelstein writes of Greek physicians generally that they "wanted to make money and were not ashamed of admitting 7 9 i t . . . physicians on the whole were businessmen."'7 This view, however, is not adequate. A hotly debated point in Greco-Roman medical history is the extent to which physicians were viewed or viewed themselves as craftsmen or as exercisers of a l i b e r a l art. . It is well known that the physicians of Greece were performers of a techne, a craft, and their status was essentially that of crafts-men. On the other hand, in the Roman Republic, physicians (often being slaves and usually being Greeks as well) were viewed with contempt. But even by the mid-first century B.C., Cicero classified medicine as a respectable pursuit along with such companions as architecture and teaching. There was undoubtedly much fluctuation in status over the period under consideration and also some, perhaps even much, fin within the profession at any given time. The primary 77- Hza Yeith, "Medical Ethics throughout the Ages," Quarterly Bulletin of the Northwestern University Medical  School, J957. 31: 354. ; 78., Cohn-Haft, Public Physicians, p. 39, n. 33. 79. Quoted by Cohn-Haft, ibid. 80. There is much literature on the subject, the most recent by Fridolf Kudlien, "Medicine as a 'Liberal Art' and 25 sources conflict on this question and i t is undoubtedly true that many physicians considered themselves as per-forming a service for a fee while others saw their role as one rewarded at the discretion of the patient in the 81 form of an honorarium." Galen writes that he never "demanded a fee from any of his pupils and patients but . . . often provided in many ways for patients who were 82 in want." Although this conduct is consistent with Galen's strong emphasis on philanthropy, i t is not conso-nant with the actions and avowed interests of the majority 83 of ancient physicians as displayed in the l i t e r a t u r e . 0 If the Greco-Roman physician was motivated in part by philanthropia as Lain Entralgo maintains, i t certainly did not evidence i t s e l f in any overwhelming display of charity. Let us now consider the extent to which he was the Question of the Physician's Income," Journal of the  History of Medicine and the Al l i e d Sciences, 1976, 31; 4.4 8-4 59. 81. Particularly under the Roman Empire the problem is intricately entangled in the complexities of the laws of contract and mandate (see Karl-Heinz Below, Per Arzt im  romischen Recht, Munich: C. H. Beck, 1953, 56 ff . ) and has not been satisfactorily resolved by modern scholarship (see Pavid Daube's review of Below, Journal of Roman Stu-dies. 1955. 45: 179-180). : 82. Owsei Temkin, Galenism, p. 47. 83. For a discussion of the practice of medicine within classical conceptions of charity, see A. R. Hands, Charities and Social Aid in Greece and Rome (London: Thames and Hudson, 1968), 131 f f . 26 guided by philotechnia. Buried in a footnote in one of Ludwig Edelstein's papers is a significant appraisal of the Greco-Roman physician's attitude toward the advance-ment of medical knowledge: "One must not assume that the ancient physician experienced the restlessness of the mo-dern scientist, who sees medicine as science in a perpe-tual process of change through one discovery after another. . . . the concepts of knowledge in ancient and modern me-dicine are poles apart." This, of course, i s not to say that ancient physicians did not strive to improve their proficiency and the efficacy of their art. It was recognized that without attempting new procedures and re-medies, medical knowledge and techniques would not advance. The author of On Joints, after describing the failure of a novel attempt at a reduction, writes, "I relate this for a purpose: Those things which after a t r i a l show themselves to have failed and which show why they failed, also pro-vide good i n s t r u c t i o n . " ^ It was with the same healthy attitude that physicians were urged to study incurable 86 cases. But we shall never know whether, for example, 84. Ludwig Edelstein, "The Hippocratic Physician," in Ancient Medicine, p. 9 0 , n. 9. 85. On Joints, 47 . 86. Ibid. , 58. 27 Scribonius Largus was in the least concerned with possible ethical implications when he f i r s t applied an electric eel (the large Mediterranean torpedo) to the forehead of a pa-8 7 tient to numb him against headache. Galen suggests that the effect of simples be observed when administered to a perfectly well person, a slightly i l l man, and a very sick op patient. But in several instances he asserts that he re-frained from testing some remedies when he had others at his disposal of whose effects he was more certain and he points out that rash experimentation presents a danger to 89 the l i f e of the patient. Outside of the fear that he might be charged with premeditated murder or with mal-90 practice, the physician w i l l have been deterred from i r -87. Mention of this practice by Scribonius Largus is made by John F. Fulton, The Frontal Lobes and Human Beha-viour (Springfield, 111.1 Charles C. Thomas, 1952), 5 f. I wish to thank Dr. William C. Gibson, University of B r i -tish Columbia, for bringing this reference to my attention. 88. Galen, In Hip, de humor, com., 1, 8j De simp. medic, temp, ac f a c , 2, 20. 89. Galen, In Hip, be humor, com., 1, 8. 90. Contrary to the complaint occasionally encoun-tered in the classical sources that only the physician can commit homicide with complete impunity, there were at least some, albeit limited, means for seeking redress against the dolose, negligent, or incompetent physician. The t r a d i t i o -nal opinion i s that the physician qua physician in Greece was immune from prosecution except in bona fide cases of intentional homicide. I have argued elsewhere ("The Lia-b i l i t y of the Physician in Classical Greek Legal Theory and Practice," Journal of the History of Medicine and A l -l i e d Sciences. 1977, 32s 172-203) that the physician could be held liable for negligent or incompetent malpractice, at least in Attic law. In Roman law a physician could be sued for damages when the victim was a slave and the majo-r i t y of relevant passages in Roman law involve damages to 28 responsible experimentation on his patients primarily by concern for his reputation. Medical experimentation was not an area in which the state sought to exercise any con-t r o l s . ^ 1 When new knowledge and techniques were discovered or developed, the physician was faced with the question of whether or not he should disseminate this information to his colleagues (that i s , to his competitors) and to the public at large. The so-called Hippocratic Oath, whether Pythagorean or not, was apparently composed for an exclu-sive, though unrepresentative, sect. The physician swears, slaves. Since no pecuniary valuation could be placed on the l i f e of a free man, the l i a b i l i t y of the physician ex-tended only to compensation for expenses. See Darrel W. Amundsen, "The L i a b i l i t y of the Physician in Roman Law," in International Symposium on Society, Medicine and Law, ed. by H. Karplus (Amsterdam, New York, and London: E l -sevier, 1973), 17-31• Indeed in the classical world the state seemed l i t t l e interested in attempting to regulate medical practice at a l l . 91 . As already mentioned, there was no system of me-dical licensure. The closest that they came (aside from the public physicians mentioned above) was under the Roman Empire in denying to certain types of practitioners the right to sue cognito extraordinaria for fees. Digesta, 50," 13, 1, 3: ''Some probably w i l l accept also those phy-sicians who promise the cure of any particular part of the body or of a certain disease: for instance an eye doctor, or a specialist in fistulae or teeth. Nevertheless, not one who makes incantations, or imprecates, or (I shall use the common word for deceivers) exorcises; such things are not kinds of medicine, although there are those who assert with praise that these have been useful to them." This by the jurist Ulpian in the late second or early third century A .D. 29 in essence, not to impart his knowledge to anyone outside his sect. Similar sentiments are expressed in The Law; "Things . . . that are holy are revealed only to men who are holy. The profane may not learn them until they have 92 been initiated into the mysteries of the science." Apart from such statements, a desire to share new techniques or knowledge with other physicians permeates the medical l i -terature. This should not be surprising since those who publish their medical knowledge and experience did so p r i -marily to instruct others; they obviously did not desire to keep them secret. Galen's p r o l i f i c pen was motivated in 93 part by the wish to help physicians after h i m . B u t many physicians undoubtedly guarded their special techniques with jealousy. Galen shows no surprise at a surgeon in-tentionally concealing his operative procedures from view but expresses disappointment that even some of his own pupils would not share their anatomical knowledge with 9*5 others. J Owsei Temkin succinctly summarizes Galen's posi-tion: "Galen's philanthropy i s not only that of the phy-sician, but more comprehensively that of a philosopher who subjectively delights in study and objectively labors for the good of mankind. He thinks of his work as belonging 92. The Law, 5. 93' Galen, De methodo medendi, 1, 1. 9^. Galen, In Hip, de med. o f f i c . l i b , com., 1. 95' Galen, On Anatomical Procedures, 2, 1; cf., De  dignoscendis pulsibus, 1, T~. 30 96 to posterity. . . ."• An apocryphal Athenian honorary decree is thus addres-sed to Hippocrates: "Whereas Hippocrates of Cos, a physi-cian . . . has unselfishly published medical books in his desire to see many physicians prepared to save people. . . .** Celsus also praises Hippocrates' willingness to publish exam-ples of his own errors: "Such a sincere confession of the truth suits a great mind." The highest claim to greatness l i e s " i n performing the task of handing down knowledge for the benefit of posterity so that no one else may be deceived 98 again by what has deceived him."7 Not only did some phy-sicians write to instruct other physicians but also they composed some treatises for the medical edification of lay-99 men. It is in this desire to share medical knowledge with contemporaries and with posterity that at least a few Greek and Roman physicians achieved their highest manifestation of philanthropia and philotechnia, a r e a l i -zation of social responsibility and of the benefit of the medical art to their community. 96. Owsei Temkin, Galenism, p. 50. 97. Quoted from Henry E, Sigerist, A History of Me-dicine (New York: Oxford University Press, 1959)» vol. 2, p. 269. This was only one of several praiseworthy items in the decree. 98. Celsus, 8, 4, 3 f. 99. E«g.» many treatises on the preservation of health were written. Galen's De sanitate tuenda is a good example of the genre. Laymen also tried their hand at the production of such pieces; e.g.* Plutarch's De sanitate tuenda praecepta 31 We must remember that the ancient physician ,was com-pletely a free agent. This i s emphasized in a passage in The Disinherited by Lucian, p r o l i f i c Greek writer of the second century A.D. In this essay a young physician has cured his father of an illness but has refused to treat his stepmother. His father then disinherits him. In the course of the imaginary hearing, the physician says: In the case of the medical profession, the more distinguished i t is and the more serviceable to the world, the more unrestricted i t should be for those who practise i t . It is only just . . . that no compulsion and no commands should be put upon a holy calling, taught by the gods and exercised by men of learning? moreover, i t should not be subject to enslavement by the law . . . . The physician ought to be persuaded, not ordered; he ought to be willing, net fearful; he ought not to be hailed to the bedside, but to take pleasure in coming of his own accord.1 0 0 Although written by a lay author, the sentiments expressed seem to be an accurate reflection of the role of the phy-sician in classical antiquity. The physician sold his services at his own discretion to those who asked and paid for treatment; he exercised his art at his own plea-sure. Owsei Temkin's assessment deserves to be quoted: The ancient physician, then would consider himself bound to society chiefly by the intrinsic value of medicine which he might feel called upon to c u l t i -vate and further to the best of his a b i l i t y . . . . . . . the existence of a rational medical science, as the Greeks created i t , was in i t s e l f a social factor of the highest significance. But apart from this i t seems that ancient physicians were l i t t l e concerned about making medicine useful to the com-munity. 100. Lucian, The Disinherited. 23. 101. Owsei Temkin, "Changing Concepts of the Relation 32 While the ancient physician may have had an elevated sense of duty to his art, as he conceived i t , mixed feelings toward his colleagues and competitors, a varying sense of responsibility to his individual patients, and l i t t l e feeling of duty to his community, how did the physician qua physician view his responsibility to nature and, more specifically, to l i f e ? Did the Greco-Roman physician feel 102 bound by any sense of "duty to prolong life?** First, we should ask, what is meant by the phrase "the physician's duty to prolong l i f e ? " If this question were asked of a physician in classical antiquity, he might quite reasonably ask us whether, by prolonging l i f e , we mean increasing longevity generally! preserving health by prophylaxis; combating curable diseases and injuries; tem-porarily prolonging the unhealthy l i f e of a terminally i l l patient; refusing to assist in terminating the l i f e of any man with or without his consent, whether healthy or i l l , and i f i l l , whether with a painful but curable or an in-curable ailment; or refusing to terminate the " l i f e " of a fetus. He might also ask what we mean by l i f e : Would we limit the term to useful, productive, happy and healthy l i f e ; to that of the citizen, the foreigner, the free man, the slave; and what then of the fetus? And of the word "duty" he might quite rightly ask, "duty to whom? to the of Medicine to Society: In Early History," in Social Medi-cine: Its Derivations and Objectives, ed. by I. Galdston (New York» Commonwealth Fund, 1949), 5. 102. Much of the remainder of this chapter is based on my paper "The Physician's Obligation to Prolong L i f e : A Medical Duty without Classical Roots," The Hastings Center Report, 1978 8 (4): 23-30. 33 patient, even against the patient's wishes? to the medical art or profession? to public opinion, to the state, to religion? to his own conscience, simply as a man, or as a physician?* We should note at this point that regardless of the motivation behind engaging in medical practice, an apparent-ly constant ideal was that the physician was "to help, or at least to do no harm," a familiar aphorism found in the Hippocratic Corpus. J This famous adage appears m a variety of forms in other classical medical literature and 104 probably seems to be axiomatic. Aside from obvious exam-105 pies of using the art of medicine to cause harm, were there other a c t i v i t i e s that would commonly have been so classified? It i s here that we come to the crux of the problem of understanding the ancient physician's conception of his duty to his patients and to the art of medicine. Let us exclude from our discussion the probably extremely small number of physicians who might have admitted to disagreeing with the proposition that as physicians they should render 103. Epidemics, 1, 11. 104. See the discussion by C, Sandulescu, Primum non nocerei Philological Commentaries on a Medical Aphorism," Acta Antigua Hungarica, I 9 6 5 , 13: 3 5 9 - 3 6 8 . 105. E.g., using opportunities provided by his prac-tice to k i l l a patient for p o l i t i c a l , financial, or other selfish or malicious reasons. help, or at least not cause harm. How then would the ancient physician have defined or delimited the terms "helping" and "harming"? Would he have thought i t helping or harming 1) to agree to perform an abortion at the request of the parents; 2) to refuse to treat a terminally i l l patient i f medical intervention would only temporarily prolone the patient's l i f e ; or 3) to agree to assist a man who, for any reason, wished to end his l i f e ? Now i t can be objected that such questions are meaningless. They can only be addressed i f fleshed out by specific sets of circumstances of defi-nite cases, real or hypothetical. But i f forced to put these three questions under the rubric of helping or har-ming, a probably strong, i f not overwhelming, majority of Greco-Roman physicians would have classified these actions as "helping, or at least not harming." Addressing f i r s t the question of abortion, we find the following injunction in the so-called Hippocratic Oath: " I w i l l not give a pessary to a woman to cause abortion."'''0^ Here again we encounter a stipulation in the Oath that simply runs counter to the re a l i t i e s of ancient medical practice. The prohibition i s compatible with the tenets 107 of Pythagoreanism, as Edelstein argues. ' But many physi-106. I have followed W. H. S. Jones' translation (The Doctor's Oath, p. 11). Ludwig Edelstein's trans-lation - "I w i l l not give to a woman an abortive remedy" - (Hippocratic Oath," in Ancient Medicine, p. 6) appears broader in scope than the Greek: OLIOICOQ 6e ou6e yvvaml neoadv cp06piov owaoo. 107. Ibid., pp. 13 f f . 35 cians did perform abortions without qualms and various techniques are described in the medical l i t e r a t u r e . 1 0 ^ 109 110 Both Plato 7 and Aristotle encouraged abortion as a means of population control. Plato also stressed that abortions should be required for women who become preg-nant after the age of forty on the ground that women be-yond that age tend to give birth to less robust and healthy children. Aristotle's attitudes were complicated by his doctrine of the tr i p a r t i t e soul and he would forbid abor-tions after the fetus* change from vegetative to animal 111 soul l i f e , i.e., Hquickening." Objections to abortion were relatively rare, before the beginning of the Chris-tian era, and in both Greek and Roman law abortion was permitted, although i t was a criminal offense i f performed without the father's consent. During the early Christian era, some pagan physicians, influenced by the Oath, re-fused to perform abortions under any circumstances. Sora-nus gives three reasons for which a woman seeks an abortion: to r i d herself of the consequence of adultery, to maintain her beauty, and to preserve her health. Only for the last 108. ^  Probably s t i l l the best treatment of the subject i s Ruth Hahnel, "Der kunstliche Abortus in Altertum," Archiy  fur Geschichte der Medizin und der Naturwissenschaften~j 1936, 29: 224-255- : 109. Plato, Republic, 461 C. 110. Aristotle, P o l i t i c s , 1335 111. Forty days after conception in the case of a male, eighty or ninety in the case of a female; Aristotle, Historia  animalium, 583 b. We shall see, in Chapter IV, that this was adopted by some casuists in the late Middle Ages. 36 112 cause would Soranus himself perform abortions. Soranus, moreover, was highly c r i t i c a l of those physicians who so s t r i c t l y adhered to the injunction in the Oath that they refused to perform an abortion even to save the l i f e of the mother. There appear then to have been some physicians who would perform abortions on request, some who refused to do so for any reason, and others who assumed a position on therapeutic abortion consonant with that of Soranus. The decision ultimately rested on the moral convictions of the individual physician. The moral stand of some physicians on the issue of abortion was undoubtedly tempered by the not uncommonly encountered principle in various cults that induced abortion, or even miscarriage, caused pollution, 113 an attitude not by any means peculiar to the Pythagoreans. J We shall return presently to the question of abortion within the context of a general discussion of respect for l i f e in Greco-Roman medicine. Plutarch preserves a favorite saying of Pausanias, King of Sparta from 408 to 39^ B.C., to the effect that the best physician was the man who did not cause his patients 114 to linger on, but buried them quickly. Although Pausanias 112. Soranus, Gynaecia, 1, 60. 113. See Fridolf Kudlien, "Medical Ethics and Popu-lar Ethics," pp. 109 f. 114. Plutarch, Moralia. 23I A. 37 was well known as a detester of physicians, his remark just quoted represents an attitude that was quite commonly held. The medical art's two functions were preserving and res-toring health. Preserving or restoring health was the emphasis, not prolonging l i f e per se. Plato i s perhaps better known than any other classical source for ardently opposing any effort on the part of physicians to prolong the lives of patients who had no chance of regaining their health. 1 1^ Plato, at least within the context of the Republic, may be an extreme case, for there his con-cern was much more with eugenics than with the personal worth of the individual. But aside from Utopian l i t e r a -ture, there is abundant evidence that, as mentioned above, at least among the Greeks, health was considered both a virtue and an indicator of virtue. Health was an ideal, indeed the highest good, set above beauty, wealth, and inner nobility. Health was a goal in i t s e l f , for without health a l l else was without value. Let us now directly address the second ethical ques-tion poseds Would the ancient physician have thought i t helping or harming to refuse to treat a terminally i l l patient i f medical intervention would temporarily prolong the patient's l i f e ? The treatise entitled The Art in the 115. Plato, Republic. k06 C, k07 D, k08 Bs cf., Euripides, The Suppliant Women. 1109 f f . (quoted by Plu-tarch in his "Consolation to Apollonius," Moralia, 110 C); cp., Aristotle, Rhetoric, I36I b; Demosthenes, Third Olyn-thiac, 33. 116. At n. 13. 38 Hippocratic Corpus defines medicine as having three roles: doing away with the sufferings of the sick, lessening the violence of their diseases, and refusing to treat those who are overmastered "by their diseases, realizing that 117 in such cases medicine i s powerless. ' Let me emphasize again that in classical Greece and Rome there was no system of medical licensure. Anyone who wished could practise medicine and, bound by no duty to a licensing authority or professional organizations, the physician exercised his art at his own pleasure. He sold his services at his own discretion to those who asked and paid for treatment^ That the physician should be completely free to treat or to re-fuse to treat is emphasized by Lucian in a passage quoted 118 above. To such a physician, any whim or reason to re-fuse to treat a particular patient would be a j u s t i f i c a -tion not to give treatment. It could be merely a matter of personal and arbitrary sentiment. If, however, the phy-sician were basing his decision whether or not to under-take a case only on the consideration that the treatment he gave would simply prolong the l i f e of a patient for whom there was no hope of recovery, he of course would s t i l l be completely free to refuse. There would be no legal or, even in the broadest sense of the word, ethical pressures that could compel him to undertake treatment. 117. The Art. 3i cf., Diseases. 2, 48. 118. At n. 100. 39 It was entirely his decision and, regardless of what he decided, he could receive approbation from some medical and lay persons and condemnation from others. I have already mentioned that in a treatise in the Hippocratic Corpus one role of medicine was to refuse to treat those who are overmastered by their diseases, r e a l i -zing that in such cases medicine is powerless. This re-presents a very strong and, in my opinion, prevailing sentiment among at least those ancient physicians whose writings have survived or who are mentioned in the l i t e r a -ture. It i s one for which precedent could easily have 119 been found in Egyptian and Assyro-Babylonian medicine. In Greco-Roman medicine, the decision to refuse to treat such a patient was motivated by a variety of factors. If treatment would simply prolong l i f e , the patient's interests would not have been served. Indeed the physician would have been considered by many physicians and lay persons alike as having harmed rather than helped the patient. While the patient's interests may have been a partial motiva-tion behind the decision not to treat, the most frequently articulated concern in the medical sources was the possible damage that such a case might cause to the physician's re-putation. As stressed on several occasions above, many, i f not most, of the "ethical 1* principles expressed in the medi-119. See Darrel W. Amundsen, "History of Medical Ethics*. Ancient Near East," in The Encyclopedia of Bio- ethics (New York: The Free Press, and London: Collier Macmillan, 1978), vol. 2, pp. 880-884. 40 cal literature appear to have arisen from the physician's concern for his reputation. Although from a modern van-tage point this seems reprehensible, we must remember 120 that the physician's only credential was his reputation. But earning and preserving a good reputation was a pre-carious enterprise. Charlatans were c r i t i c i z e d for avoi-ding dangerous cases and exaggerating the severity of a i l -121 ments that yielded easily to treatment. Thus the con-scientious physician, although he might shy away from hope-less cases, was urged in the medical literature not to re-122 fuse dangerous or uncertain ones. But the decision of whether to take on a dangerous case was entirely the i n d i v i -dual physician's. Some cases in the therapeutic treatises in the Hippocratic Corpus are introduced with the advice that certain procedures should be followed i f the physician 123 chooses to attempt treatment. J Indeed i t appears that physicians might have based their decisions on whether they were liable to earn less reprobation from refusing to treat than from agreeing to treat such cases. 120. See Ludwig Edelstein, "Hippocratic Prognosis," in Ancient Medicine, pp. ?6 f . t and "The Hippocratic Phy-sician," ibid.. pp. 88 f f . ; Henry E. Sigerist, A History  of Medicine, vol. 2, p. 305. 121. E.g., in the Hippocratic Corpus, Precepts, 7; elsewhere, Celsus, 5, 26, 1, C; Menander, Phanium, 497 K. 122. E.g., in the Hippocratic Corpus,Precepts, 7; Ancient Medicine, 9s On Joints, 69; cf., The Art, 8; else-where, Paulus Aegineta, 6, 88; Ctesias in Oribasius, Col-lect, medic, reliquiae, 8, 8. 123. E.g., De morbis, 3, 7; De intern, affect.. 12. If the physician did elect to take on a dangerous case, the importance of the art of prognosis or forecas-ting became evident. The physician who declared before beginning treatment that the prospects of a cure were only slight thereby avoided responsibility for an unfavorable 124 outcome. The medical literature i s divided on the question of whether a physician should withdraw from a case once i t became clear that he would be of no meaning-f u l help. Some urged that the physician ought not to with-draw, even i f by so doing he might avoid blame. ^ Others f e l t that he should withdraw i f he had a respectable ex-cuse, particularly i f continuing treatment might hasten the patient-s death. 1 2 6 There is no denying, however, that physicians did sometimes attend to cases considered incurable. In the Hippocratic Corpus many diseases that ended in death are described with no mention of prognosis and with no recom-124. What responsibility a physician may have f e l t i s open to discussion. There are many passages in the Hip-pocratic Corpus where the concern with incurring blame is expressed. See, e.g., On Joints, 67; Decorum, 14, Ancient  Medicine, 9- Gert Preiser (Uber die Sorgfaltspflicht der Arzte von Kos," Medizin-historisches Journal, 1970, 5* 1-9) maintains that there seems to have been no l i a b i l i t y for the physician in Greek law. Thus, according to Preiser, although the concern with the use of prognosis as a means to protect the physician from accusations suggests legal l i a b i l i t y , this concern was motivated by a professional res-ponsibility based upon the Hippocratic physician's broad con-ception of his duty to his techne. 125. See Ludwig Edelstein, "Ethics of the Greek Physi-cian" and "The Hippocratic Physician" in Ancient Medicine, pp. 323 and 90 f f . 126. E.g., in the Hippocratic Corpus, On Fractures, 36; cp., Aphorisms, 6, 38; Prorrhetic, 2, 9. mendation to the physician that such cases be undertaken or rejected. In most of these, medications to be employed are named. It was recognized that i t was necessary to deal with incurable complaints in order to learn how to prevent curable states from advancing to incurability, particularly in the case of wounds. Even a cursory look at the Epidemics in the Hippocratic Corpus should con-vince the reader that the author's intention was not to show how to cure. Nearly sixty percent of the cases end in death and treatment i s very seldom mentioned. Such a physician's medical attendance was perhaps less designed for the individual patient's good than for the advance-ment of medical knowledge. W. H. S. Jones writes that the author's aim was to discover the sequence of symptoms, to set down the successes and failures of Nature in her efforts to expell the disease. The physician is acting, not qua physician but qua scientist; he has l a i d aside the part of healer to be for a time a spectator looking down on the arena, exercising that eecopta which a Greek held to be the highest human activity.127 Opinions certainly varied on the physician's respon-s i b i l i t y to undertake treatment of hopeless or dangerous cases. But the following quotation from Celsus represents what appears to have been the mainstream of medical thoughts For i t is the part of a prudent man f i r s t not to touch a case he cannot save, and not to risk the appearance of having k i l l e d one whose lot is but to die; next when there i s grave fear without, however, absolute despair, to point out to the patient's relatives 127. In vol. 1 of Hippocrates in the Loeb Classical Library, p. 144. 4 3 that hope is surrounded by d i f f i c u l t y , for then i f the art is overcome by the malady, he may not seem to have been ignorant or mistaken.^28 Taking on a hopeless or, under some circumstances, an ex-tremely dangerous case i s perhaps the closest issue in an-cient medicine to the modern question of employing "extraor-dinary measures." Danielle Gourevitch writes of the Greco-Roman phy-sician, that "far from feeling any l i a b i l i t y for abandoning his patient, he would feel guilty i f he undertook a cure he 129 could not successfully carry out." This i s , perhaps, somewhat of an overstatement. While i t is true that i f the physician were motivated by greed to continue inef-ficacious treatment he would be viewed as acting repre-hensibly, nevertheless, i f he were attempting a novel treatment in an effort to effect a cure, the ethical im-130 plications would not be as clear-cut. J Markwart Michler views the "Hippocratic" admonition to refuse to treat patients overwhelmed by their diseases ("an inhuman attitude") as a taboo f i n a l l y broken by the authors of the treatises On Fractures and On Joints in the Hippocratic Corpus. In these works the authors are said to be motivated by a desire to advance medical know-128. Celsus, 5, 26, 1, C. 129. Danielle Gourevitch, "Suicide among the Sick in Classical Antiquity," Bulletin of the History of Medicine. 1969, «+3« 503. 130. See, for example, Pseudo-Quintilian, Declama-tiones maiores, 8, where both sides of the question are argued. 44 ledge so as to be able, ultimately, to render more effec-tive treatment to the suffering. v The objective, even here, was not an ethically based imperative to prolong the l i f e of the incurable patient, but rather a very pragmatic desire to increase the boundaries of the art. Lain Entralgo bases much of his understanding of Greek medical ethics on the idea that the Greek physician's sense of responsibility both to his art and to his patient rested on his physio-ph i l i a , i.e., love of nature. Since, in Lain Entralgo's view, physis (nature) was "divinity'* to the Hippocratic doctor, he was deeply and spontaneously conscious of the religious and ethical imperative to respect the limits of his art. . . . The frequency and sternness with which [the] injunction to abstain from therapy is formu-lated in the Corpus Hippocraticum . . . clearly shows that i t was not a mere piece of technical advice, but a religious and ethical injunction. Under the influence of his beliefs about nature, man and his own art, the Greek physician understood that i t was his duty to abstain from treating the incurably and mortally i l l . . . .132 In the primary sources that have survived, the issues were usually not wrestled with, and modern appraisals of ancient attitudes often are not tempered by the considera-tion that divergent opinions existed side by side in anti-quity and that society was not static. There are s i g n i f i -cant differences between, for example, fifth-century B.C. Athens, third-century B.C. Rome, and the Roman Empire of the 131. Markwart Michler, "Medical Ethics in Hippocratic Bone Surgery," passim. 132. P. Lain Entralgo, Doctor and Patient, p. 48. f i r s t century A.D. The attitudes toward old age and death held by the Athenian gentleman of the f i f t h century B.C. were, in certain respects, significantly different from those of a Roman aristocrat of a later period. Edelstein writes that "generally speakiner, the Greeks judged old age unfavorably. The Romans, however, cherished and res-133 pected i t . " JJ- This statement is generally true; but i t would be an easy task to c u l l from Greek literature senti-ments of reverence for old age and from Roman sources statements of the opposite opinion. On the basis of the available evidence, however, I am confident that, although attitudes varied, i t is responsible to say that generally a physician who prolonged, or attempted to prolong, the l i f e of a man who could not ultimately recover his health was viewed as acting unethically. We turn now to the third ethical question: Would the ancient physician have thought i t helping or harming to agree to assist a man who, for any reason, wished to end his l i f e ? To this question probably a majority of ancient physicians would also have given the reply "Helping, or at least not harming." It is absolutely essential that we con-sider the ancient physician as a functioning member of a highly complex and diverse society whose moral responses arose from ethical foundations sometimes strikingly d i f -ferent from those of the Middle Ages and of the Western world today, for that matter. Except among some groups 133' Ludwig Edelstein, "The Distinctive Hellenism of Greek Medicine," in Ancient Medicine, p. 381. 46 on the periphery of classical thought, the "sanctity of human l i f e " was an idea partially obfuscated by, or at least subservient to, the belief in the inherent right of the free man to dispose of his l i f e as he saw f i t , i f not always in i t s l i v i n g , at least in i t s termination. Sui-cide was a concern of the state in neither Greek nor Roman law except the suicide of a slave or of a soldier. Indeed even murder, at least in Greek law, was not a crime against the state (a public offense); i t was thought as solely a matter between the victim (and his family) and the k i l l e r . Although murder was classified as a public offense in Roman law, i t did not follow that suicide was viewed as self-murder but instead was, under most c i r -cumstances, outside the purview and interest of the law. Should a person who wished to commit suicide enlist the aid of a second party, the latter, in rendering such assistance, was not culpable. Turning to extra-legal sources, we find few objections in classical literature to suicide in general, fewer s t i l l to the suicide of the hopelessly i l l . J Granted, there were some few cults or philosophical schools that condemned a l l suicide, re-gardless of the circumstances. But these were both com-13^. There is extensive literature on the history of suicide. A classic study i s Rudolf Hirzel, "Der Selbst-mord," Archiv fur Religionswissenschaft, 1908, 11: 75-104, 243-284, 417-476. David Daube's "The Linguistics of Sui-cide," Philosophy and Public Affairs. 1972, 1: 387-437, is well worth consulting for i t s historical perspective. Danielle Gourevitch's a r t i c l e , "Suicide among the Sick," is of the most immediate relevance for the subject under discussion. >7 paratively small in number and quite insignificant in long-range influence. Christianity is of course an ex-cept ion,but the rise of i t s influence corresponds roughly with the decline of classical culture. Platonists, Cynics,and Stoics considered suicide an honorable alternative to hopeless illness; some philo-sophers regarded i t as the greatest triumph of man over 136 fate. J The Aristotelean and Epicurean schools did not 13? censure suicide, but condoned i t under many circumstances. J f Porphyry wrote a treatise entitled "On Sensible Removal," and some authors went so far as to compose l i s t s of con-138 ditions justifying suicide. D Pliny, for example, con-135. See especially Rudolf Hirzel, ibid., pp. 279 f f . A very cogent expression of the Stoic attitude toward sui-cide i s Seneca's Letters to Lucilius, 77- See also Dio-genes Laertius, Lives of the Eminent Philosophers, 4, 3, and 6, 18, where criticism i s directed against those who would cling to l i f e when suffering from di s a b i l i t y or ex-treme pain. 136. Rudolf Hirzel, ibid.. p. 279, n. 1. It should be noted that Plato, for example, condemned suicide as opprobrious i f one is not compelled to i t by the occurrence of some intolerable and inevitable misfortune" (Laws, 873 C). On the origin of the famous prohibition in the Phaedo, see J. C. G. Strachan, "Who Did Forbid Suicide at Phaedo 62 B?", Classical Quarterly, 1970, 20: 216-220. 137. See Ludwig Edelstein, "The Hippocratic Oath," in Ancient Medicine, p. 17. 138. For some examples, see Danielle Gourevitch, "Suicide among the Sick," pp. 509 f f . 48 sidered pain due to bladder stones, stomach disorders, and headache valid reasons for suicide. J Whether or not to commit suicide was completely up to the individual; whether or not to assist in the act was up to the physician, i f asked. The literature contains references to physicians cutting the veins of patients, both i l l and well, who 140 asked for such a procedure. Poison was even more common than sustained phlebotomy, and various poisons were deve-loped by physicians who were praised for employing their toxicological knowledge in the production of drugs for in-141 ducmg a pleasant and painless death. Assisting in suicide was a relatively common practice for Greco-Roman physiciansj the very infrequent criticism of such physi-cians was made primarily by sources that would have to be considered as atypical of classical thought. The so-called Hippocratic Oath must be placed into such a category. In the Oath appears the following injunction: "I w i l l neither give a deadly drug to anybody, not even i f asked for i t , nor w i l l I make a suggestion to this effect." 1 This statement immediately precedes the prohibition of abor-139. Pliny the Elder, Historia naturalis. 25, 7, 23. 140. See, for example, Tacitus, Annals, 15, 69. Cf., Suetonius, Life of Lucan. 141. See Danielle Gourevitch, "Suicide among the Sick," p. 508. 142. I have followed Fridolf Kudlien's translation ("Medical Ethics and Popular Ethics," p. 118, n. 47). 49 tion. Both prohibitions have at least this much in common: they are inconsistent with values expressed by the majority of sources and atypical of the r e a l i t i e s of ancient medi-cal practice as revealed in both medical and lay literature. It is known that, while these two prohibitions remained atypical of medical ethics for the entirety of the c l a s s i -cal period, during the f i r s t and second centuries A.D. a greater sensitivity to them began to be evidenced. During the early Christian era some pagan physicians, influenced by the Oath, refused to perform abortions under any c i r -cumstances, others would perform them only to preserve the health of the mother, and others would perform them on re-143 quest for any reason. J Some physicians began emphasizing philanthropy as their essential motivation and extended philanthropy to include what we may generally term "res-144 pect for l i f e . " Stressing, on the basis of the Oath0 that medicine is the science of healing, not of harming, Scribonius Largus credits "Hippocrates," in condemning abor-tion, with going "a long way toward preparing the mind of the learners for the love of humanity. For he who consi-ders i t a crime to injure future l i f e s t i l l in doubt, how much more criminal must he judge i t to hurt a f u l l 143. So writes Soranus, Gynaecia. 1, 6 0 . 144. For a discussion, see Owsei Temkin, "The Idea of Respect for Life in the History of Medicine," in Owsei Temkin, William K. Frankena, and Sanford H. Kadish, Respect for Life  in Medicine, Philosophy, and the Law (Baltimore: Johns Hop-kins University Press, 1977), 1-23. 50 14 5 grown human "being." -J He then asserts that unless medi-cine " s t r i v e s f u l l y i n each of i t s parts to help those in need, i t i s not better than promising sympathy to men." Later he writes that the medical a r t should never be i n -146 jurious to anyone. But Scribonius' insistence that the physician not harm or be injurious to anyone i s just as neutral in respect to the issue of active or passive eu-thanasia as the Hippocratic aphorism "to help, or at lea s t to do no harm." Some physicians may have preferred not to a s s i s t in a suicide, f o r i t could prove to be a messy business, at l e a s t from a leg a l point of view. Under Greek and Roman law the physician could be charged with poisoning h i s pa-t i e n t . Indeed physicians were frequently charged with, or at least suspected of, poisoning t h e i r patients. Other physicians, however, who may have refused to aid a person in committing suicide, perhaps condemned suicide under a l l circumstances f o r philosophical or r e l i g i o u s reasons, but these seem to have l e f t few records of t h e i r s e n t i -ments, much les s professional j u s t i f i c a t i o n for them. Aretaeus, who l i v e d i n the second h a l f of the second century A.D., can perhaps be placed in t h i s l a s t category of physicians. He writes that some patients, while suf-145. Scribonius Largus, Professio medici, p. 24 in Deichgraber's e d i t i o n . 146. Ibid. 51 fering from a particularly painful disease, s t i l l shrink from death while others beg for i t . In these cases, he writes, i t s t i l l is not proper for the responsible physi-147 cian to cause the patients' death but i t is proper to 147. The subject under discussion here is intestinal obstruction. The Greek original of the phrase underlined in the text - TW apxtrjTpcp &e ou 8EU.IQ 7ipf]cJo'siv is signi-ficant for two reasons: 1) The expression ov 0eu,iQ is roughly equivalent to the Latin ne fas, meaning "morally wrong," "contrary to divine law," "i n violation of what is customarily accepted," or simply "not proper". How strong-l y Aretaeus is here using the word, and what moral overtones are implied, are open to interpretation. Be\xic, without the negative is used in the next clause where he says that i t " i s proper" to drug the patiemt. In another instance he writes that the physician " i s not able to make the i l l (sc., those suffering from atrabiliousness) entirely well. For then the physician would be mightier than God. But i t is proper ( Qe\xiql for the physician to bring about the absence of pain and both regressions and latencies of disea-ses" (Corpus Medicorum Graecorum, 2, p. 158, lines 6 f f . ) . Elsewhere he writes that " i t i s not proper ( ovbe . . . Oeuacj) to drink from a pool or from a river by mouth (ibid., p. 86, line 29, where the subject i s elephantiasis). Thus given Aretaeus* uses of de\iiq , we should hesitate to interpret his statement quoted in the text as an extremely strong moral injunction. 2) This is the only instance wh^ ere Are-taeus uses the term &PXLTITP6Q (Ionic f or . &PXtaTp6<; ) , a word that usually means an o f f i c i a l physician (either a court physician or a community physician). It also appears to have been used generally to mean a "responsible practi-tioner" and indeed, in Liddell and Scott's A Greek-English  Lexicon, this passage in Aretaeus is the only example cited to i llustrate this meaning. In roughly the score of instan-ces where he employs a word for "physician," Aretaeus uses tTj-cpoQ (Ionic for tocTpot; ). in fact he uses t n u p o c j in this same passage when stating what procedures the physician ought to follow when dealing with patients suffering from intestinal obstruction. Thus the clause may be translated " i t is not proper for the responsible physician to do this," and would then not be nearly as condemnatory as might ap-pear at f i r s t sight. Indeed he probably is merely saying that a responsible physician should not perform euthanasia, at least when dealing with the ailment under consideration, while the less responsible and average physician might very well do so. 52 148 drug such patients m order to relieve their anguish. In another passage Aretaeus, when discussing the treatment of inflammation of the lungs, writes that " i f [the patient] is in the height [or at the point] of choking [or suffoca-ting] and you give him a drug to cause death, you would be responsible for his death in the opinion of the common 149 people." 7 Aretaeus' concern here seems to be less with the ethical issues than with reputation and possible legal im-plications. On the basis of the paucity of statements such as the f i r s t quoted from Aretaeus and the plethora of evi-dence of opposite sentiments, i t is safe to conclude that the author of the Oath and perhaps Aretaeus as well rep-resented a minority opinion on the question of active eu-thanasia. 1^ 0 148. Corpus Medicorum Graecorum, 2, p. 133, lines 10 f f . 149. Ibid., p. 120, lines 8 f. 150. There are three other sources sometimes cited as evidence for the opposition to active euthanasia in classical antiquity. 1) There is a passage in the Oxy-rhynchus Papyri (nr. 437, third century A.D.) where the Oath is quoted as the basis for the rejection of giving poison. 2) The following problematic passage occurs in a metrical oath of unknown date: OUTS T i c^oy 6ojpoi£ \ie 6ouvca \uypa. A possible translation is "nor would anyone bribe me to alleviate a painful condition by giving baneful drugs (i.e., poison) to a man (sc., a patient)" (Corpus Me-dicorum Graecorum, 1, 1, pp. 5 f-« lines 15 f f . ) . Owing to some ambiguity in the Greek, the exact relationship between TLQ and ocvept is uncertain. If TIQ refers to a third party, then the swearer of this oath i s refusing to give poison to a patient when asked by someone other than the patient. If cVvepi, has a pronominal force, to which TIC; is antecedent, then he is refusing to give poison to the 53 Did the Greco-Roman physician, qua physician, feel ob-ligated by any sense of duty to prolong l i f e ? The answer person requesting i t for himself. It is ambiguous and may well have been intended to be ambiguous. (I wish to thank Dr. Ronald Kotrc of the College of Physicians of Philadelphia for discussing this passage with me.) 3) In the Metamorpho-ses, a novel written by Apuleius in the second century A.D., a woman sent her slave to obtain from a physician a poison to be used for murdering her stepson. Her own son drank the potion unwittingly. She then charged her stepson with mur-der. The physician was one of the judges at the t r i a l . He described how the slave had come to him to buy a quick and efficient poison to give to a friend who wished to escape from an incurable illn e s s . The physician had suspected that i t was really intended for murder. His description continues: "When this fiend came bothering me for a poi-sonous drug, I decided that i t would be a betrayal of my profession to supply anybody with the means of murder, since medicine was meant to be used for the preservation, not the destruction, of mankind. Yet I feared that an untimely re-fusal would provoke him to devise some other way of carrying out the nefarious project on which he was so obviously set — either by buying poison elsewhere, or by having recourse in desperation to the knife or some such weapon. So I gave him a drug, but a sleeping drug compounded of mandragora, an herb valued for i t s numbing effect that can hardly be distinguished from the repose of death** (10, 11). On this episode I have elsewhere commented, "If Apuleius' physician had in fact sold poison to the slave and had been identi-fied later as the supplier of the drug, he would have been liable for prosecution under the provisions of the lex Cor-nelia de s i c a r i i s et veneficis for homicide. Then the bur-den would have been on his shoulders to prove that he had no knowledge that the drug was to be used for murder. It was partially this enlightened self-interest that prompted him to substitute a soporific, for i t is clear from his speech that, i f he had been certain the drug was in fact intended for use in a suicide, he would not have hesitated to supply i t ("Romanticizing the Ancient Medical Profession: The Characterization of the Physician in the Graeco-Roman Novel," Bulletin of the History of Medicine. 1974, 48: 325). Owsei Temkin, however, writes that this physician "did not believe that his profession allowed poisoning even for the sake of suicidal euthanasia" ("Respect for Life," p. 4). See also Danielle Gourevitch, "Suicide among the Sick," pp. 506 f., and Ludwig Edelstein, "The Hippocratic Oath," pp. 13 f. and nn. 23 and 24. 54 to this question must be a qualified "no". The only duty common to probably a l l Greco-Roman physicians was "to help, or at least to do no harm." Taking on a hopeless case was entirely the prerogative of the individual physician and few voices would condemn a refusal, particularly i f such a decision were based on the conviction that the patient's unhealthy l i f e would only be temporarily extended. Pro-longing the l i f e of a patient who did not want to live would probably have been considered as harming the patient and therefore as unethical by a l l , or nearly a l l , classical physicians, even by those constituting that minority that would not assist actively in terminating a patient's l i f e . While a sense of duty to prolong l i f e is not present in any strains of classical medicine, the idea of "res-pect for l i f e " is quite a different matter. Owsei Temkin writes, concerning the so-called Hippocratic Oath and sources expressing compatible attitudes, that "sufficient material has now been gathered to prove the existence of a tradition which, in i t s uncompromising form, did not sanction any limit to the respect for l i f e , not even thera-1 51 peutic abortion. . . ." J This tradition that would sanc-tion no limit to the respect for l i f e appears, in i t s em-phasis, to have been entirely negative: the physician would not actively terminate l i f e by abortion or euthanasia. But i t laid no stress, apparently, on the positive correlate 151. Owsei Temkin, "Respect for Life," p. 5. 55 that would require the physician actively to prolong l i f e . This negative tradition did, indeed, become stronger with the rise of Christianity: abortion, suicide and eu-thanasia became sins. Additionally, charity became a v i r -tue, one of the highest virtues in fact, and the love of man and Christian compassion became central to the Chris-tian ideal of medical practice. These themes, among others, w i l l be considered in the next chapter. CHAPTER II EARLY CHRISTIAN AND EARLY MEDIEVAL MEDICAL ETHICS: DUTY TO GOD AND TO TRADITION We have seen in the preceding chapter that the Greco-Roman physician was entirely a free agent, bound by no clearly-defined duty to his patient, to his art, or to his community. In the medical literature advice on general etiquette or decorum appears. These principles of etiquette are noteworthy for their practicality and seem to have been motivated primarily by concern for enhancing and preserving the individual physician's re-putation and the honor of the art. These rules of e t i -quette are often collectively referred to as "Hippocratic ideals," especially when supplemented by the prohibitions of abortion and euthanasia which appear in the so-called Hippocratic Oath. These prohibitions, as we have ob-served, do not reflect the ethical values of the vast majority of physicians represented in the sources. For the most part, however, the values expressed in the so-called Hippocratic Oath, although many were atypical of the Greco-Roman scene, were f u l l y compatible with Christian morality. Although certain aspects of pagan medical ethics were in harmony with Christian thought, Christianity was fundamentally different in i t s most basic tenets and 56 57 principles from the most common features of the pl u r a l i s t i c society in which i t took root. Thus i t is imperative that we examine certain aspects of early Christian thought that have a direct hearing on the development of Christian medi-cal deontology. This is particularly important since the issues addressed here either are, as resolved in early Christian thought, fundamental to our understanding of later medieval attitudes, or continue to be raised periodi-cally throughout the Middle Ages. We should f i r s t see what early Christian sources say about the place of illness in the Christian's l i f e and in God's purposes. We must then consider early Christian con-cern with whether the use and practice of medicine are compatible with God's purposes. It should be noted that the two questions raised thus far, even though wrestled with and generally resolved in the early centuries of Christianity, are s t i l l very much alive as points of dis-agreement among Christians today, and were so throughout the Middle Ages as well. If physicians and their art have a place within the Christian community, what should their goals and limitations be? If they are instruments of God to succor the i l l and to extend compassion and care to the sufferer, are they bound by any duty to attempt to prolong a patient's l i f e ? In considering this question i t w i l l be necessary to determine early Christian attitudes toward death, suicide, and clinging to l i f e . Once a f a i r l y clear picture emerges of the physician's basic role and limita-58 tions, we shall consider the character and qualities of the ideal physician in early Christian thought and the effect of Christian philanthropy on medical practice and ethics, in both secular and monastic medicine. This chapter w i l l close with an evaluation of the blending of "Hippocratic ideals" with Christian ethics in the deontological l i t e r a -ture of the early Middle Ages. Numerous passages can be adduced from the Old Testa-ment that imply that in Jewish thought both sickness and health were held to be within God's purview, the former visited on people as punishment or as discipline, and the i latter given as a reward. It is perhaps revealing that 1. The problem of suffering in Jewish thought is exceedingly complex. Sickness i s only one aspect of suf-fering and the Hebrew words used for sorrows, a f f l i c t i o n s , griefs, can also sometimes yield the translation disease or sickness. In Isaiah 53 "A man of sorrows and acquainted with grief" can be translated "A man of suffering, familiar with disease." (vs. 3) "Surely he hath borne our griefs and carried our sorrows. Yet we did esteem him stricken" can be rendered "Yet i t was our sickness that he was bearing, our suffering that he endured. We accounted him plagued . . . ." (vs. 4) "Yet i t pleased the Lord to bruise him . . . ." can also yield "But the Lord chose to crush him by disease . . . ." (vs. 10) Jewish, attitudes toward i l l -ness often hinge upon the interpretation of the "Suffering Servant" of Isaiah 52 and 53* For a brief discussion of the various Jewish interpretations, see Christopher R. North, The Suffering Servant in Deutero-Isaiah: An Historical and  C r i t i c a l Study^ (London; Oxford University Press, 1955), 6-22, especially 6-9 dealing with pre-Christian times. For Jewish attitudes toward sickness in the Old Testament and at the time of Christ, see Victor G. Dawe, The Attitude of  the Ancient Church Toward Sickness and Healing (unpublished doctoral dissertation, Boston University School of Theology, 1955), 67; Evelyn Frost, Christian Healing; A Consideration  of the Place of Spiritual Healing in the Church of Today in"  the Light of the Doctrine and Practice of the Ante-Nicene  Church^ (London: A. R. Mowbray, 1949), 206; and Albrecht Oepke, "VOOOQ, K . X . X . in Theological Dictionary of the 59 the question posed by Jesus' disciples when they encountered a person who was blind from birth was, "Who sinned, this man or his parents, that he should be born blind?" Jesus' an-swer was that neither sinned, "but i t was in order that the works of God might be displayed in him." Unfortunately, this does not answer a question posed in various ways by Christians ever since then, namely did the a f f l i c t i o n come from God, from the devil, or from some theologically neut-r a l source, and, regardless of the source, why are Chris-tians a f f l i c t e d by disease and suffering? This is a ques-tion with which the early Christians often wrestled and the attitudes represented in the literature are diverse and con-tradictory. Generally three different sources of suffering are identified in the literature of the f i r s t several centuries of Christianity, namely a divine, an e v i l , and a natural source. More often than not, there was a hesitancy to attribute disease directly to Godj^rather he was typically viewed as the regulator of i t , ^ whether i t came from natu-New Testament, ed. by Gerhard K i t t e l , et a l . , trans, by Geoffrey W. Bromiley (Grand Rapids: Eerdmans, I967), vol. k, pp. 1091 f f . 2. John 9: 2-3. 3. Frost, Christian Healing, pp. 20k f. 4. Dawe, Attitudes of the Ancient Church, p. 130. 5. Frost, Christian Healing, p. 2C4. 6o r a l or e v i l sources. Tertullian, in the late second and early third centuries, held that any particular suffering, at one and the same time, was intended as a warning for Christians and as punishment for the heathen. Indeed, Lactantius, writing in the early fourth century, described with un-Christian delight the excruciating agonies accom-panying the death of Galerius, an emperor who had perse-cuted the Christians quite viciously. Cyprian, in the third century, f e l t that God sometimes used sickness to Q draw the unbelieving to himself, while the author of the second-century Shepherd of Hermas saw sickness and other misfortunes as punishment for those who had wandered from God. Irenaeus, writing m the second century, recogni-zed in infirmities a schooling for endurance. 1 0 His con-temporary, Clement of Alexandria, in several places in his writings, asserts that by a f f l i c t i o n s the Christian acquires moderation both in pain and pleasure, and he loses the fear 11 of poverty, disease and death. He says that "penury and disease, and such t r i a l s , are often sent for admonition, for the correction of the past, and for care for the future. 6. Tertullian, On Flight in Persecution, 1 f. 7. Lactantius, De mortibus persecutorum, 33-8. Cyprian, On Psalm 68, 18. 9. Shepherd of Hermas, 6, 3 . 10. Irenaeus, Against Heresies, 5, 3 . 1 • 11. Clement of Alexandria, Paedagogus, 1, 8 f f . 12. Clement of Alexandria, Stromata, 7, 13s cf., 4 , k Around the middle of the third century the Empire was af f l i c t e d by a series of plagues. After the city of Alexan-dria was hit by a particularly devastating assault, the city's bishop, Dionysius, wrote that while i t was an object of ex-I treme fear to the pagans, "to us i t was not so, but . . . 13 a source of^discipline and testing." ^ When the same plague was ravishing Carthage, Cyprian remarked that some of his brethren were distressed that the pestilence did not strike only the pagans, "as i f the Christian believed in order that he might have the enjoyment of the world and this l i f e free from the contact of i l l s . " But the plague was a blessing because the things they were experiencing "are trainings for us, not deaths; they give the mind the glory of fortitude; by contempt for death they prepare for the crown." v Slightly later, during the f i r s t decade of the fourth century, Lactantius writes that the relationship between the soul and the body is that between master and servant. The flesh must share in the campaign against e v i l and be ready 16 to be despoiled or sacrificed in the service of i t s master. In this spiritual warfare the soul sometimes can be refined through suffering, a point developed at some length by Church Fathers during the fourth century. Ambrose, writing to a friend suffering from a non-fatal illness, maintains that 13. Eusebius, Ecclesiastical History, 7, 22. 14. Cyprian, De mortalitate, 8. 15. Ibid., 16. 16. Lactantius, The Divine Institutes, 5, 22. ! 62 "this sickness was intended for your health and brought you more pain than p e r i l . . . . . He struck you with illness; he healed you with faith. . . . He chose to admonish you in such a way as not to harm your health and yet to incite ' 1 7 your devotion." ' Gregory Nazianzen, delivering his father's eulogy, ruminates thus of suffering: "But why should i t be i surprising that holy men suffer i l l s , either for the puri-fication of some small stain, or for proving their virtue, or testing their philosophy, or for the instruction of the weaker, who|learn from their example to be brave instead of faint-hearted in misfortune?" Gregory's close friend, Basil the Great of Caesarea, discusses six reasons why Chris-tians are a f f l i c t e d with il l n e s s . F i r s t , some diseases are 19 contracted "for our correction." 7 He includes as part of the corrective process both the suffering involved in the disease i t s e l f and the pain incurred in the treatment of the ailment. Our real objective in such suffering "should be our spiritual benefit, in as much as the care of the soul is being taught in the guise of an analogy." Secondly, i l l -ness is often a punishment for sin and should be distinguished from a third category, namely those infirmities that "arise from faulty diet or from any other physical origin." Four-thly, some illness comes at the E v i l One's request, for exam-ple the case of Job, where God confounded Satan's boasts by 17. Ambrose, Epistles, 79. 18. Gregory Nazianzen, On His Father, 28. 19. This and the following quotations from Basil are f rom The Long Rule, 55. the heroic patience of His servants. Fifthly, "God places those who are able to endure tribulation even unto death before the weak as their model." And last is the instance of any greatjsaint, for example the apostle Paul, a f f l i c t e d with physical suffering "in order that he might not seem to exceed the limits of human nature and that no one might think him to possess anything exceptional in his nature." It was in Basil's mind extremely important that "when we suffer the blows of calamity at the hands of God, who directs our l i f e with goodness and wisdom, we f i r s t ask of him understanding of the reason he has in f l i c t e d the blows; second, deliverance from our pains or patient endurance of them." This was important for a variety of reasons but especially so that the a f f l i c t e d would know whether or not to employ a physician. Only in two of the six categories should a physician be summoned, namely for illnesses arising from natural causes and those which are for the Christian's correction. When we are i l l as a pu-nishment for sin and have "recognized our transgressions, we should bear in silence and without recourse to medicine a l l the a f f l i c t i o n s which come to us." Of those in the three remaining categories, Basil says, "What profit would there be for such men in having recourse to medicine? Would there not rather be danger that in their solicitude for the body they would be led astray from right reason?" Throughout the history of Christianity there has a l -I 64 ways been a degree of tension, sometimes only latent, bet-ween theology and secular medicine, between the medicine of the soul and the medicine of the body. If God sends disease, either to punish or test man, then i t i s God to whom one must turn for care and for healing. If God is considered to be both the source and the cure of man's i l l s , then in some minds, the use of human medicine i s an attempt to c i r -cumvent the spiritual framework, to deviate from divine w i l l , to resort to worldly wisdom, which may be considered as in-herently in conflict with the spiritual realm. But, some reasoned, i f God i s the source of disease, or i f disease comes by his leave, and i f he i s the ultimate healer, his w i l l can be f u l f i l l e d through his human agents, and these human agents can be those who, through divine grace, have acquired the a b i l i t y to aid in the curative process. On the other hand, i f i t is not God but rather a diabolic force that causes suffering and disease in man, then the f i r s t , and to some minds, the only source of aid to which one may turn i s God. Within this framework some asserted that the human agent of care, the physician, is the instru-ment of God, used by him in bringing succor to man, and others maintained, on the contrary, that any use of human medicine i s a manifestation of a lack of fai t h . This am-bivalence in the Christian attitude, both among theologians and laymen, has always been present to some degree. During the Church's f i r s t centuries we hear l i t t l e of Christian physicians. Paul refers to his companion Luke 65 20 as "the beloved physician," but aside from him we en-counter no Christian physician until there is record of a Phrygian physician martyred at Lyons under Marcus Aurelius. Some scholars argue that in the early centuries of Chris-tianity the level of faith or the commitment to divine healing was so v i t a l that, owing to the frequency of what believers would c a l l miraculous cures and unbelievers would discount or explain differently, there was l i t t l e 21 need of or room for secular medicine. But as the v i -t a l i t y of early Christianity began to diminish, or as the age of miracles drew to a close, a place for the secular healing art in Christianity was more and more recognized as not discordant with God's purposes. In the second century Tatian spoke out emphatically against the use of medicine, as employing the bad to attain the good. Such a person would be punished by God. He main-tained that " i f anyone is healed by matter, through trusting in i t , much more w i l l he be healed by having recourse to the power of God. . . . Why i s he who trusts in the system of matter not willing to trust in God? . . . Why do you deify the objects of nature? And why, when you cure your neigh-bor, are you called a benefactor? Yield to the power of the 22 Logos!" Tatian*s contemporary, Hippolytus, although he is 20. Colossians 4:14. 21. See, e.g., Frost, Christian Healing; Dawe, A t t i -tudes of the Ancient Church, and Morton T. Kelsey, Healing and Christianity in Ancient Thought and Modern Times (New York: Harper and Row, 1973), passim^ — 22. Tatian, Oratio ad Graecos. 18. I 66 not nearly as outspoken, seems to have shared his opinion, commending the perhaps apocryphal account of King Heze-23 kiah's "ban on medicine. J But this view certainly was not shared by allj Christians of the second century. Clement of Alexandria writes that "health by medicine, and soundness of body through gymnastics . . . have their origin and exis-tence in consequence of human cooperation. Understanding 24 also is from God." Clement's disciple, Origen, followed his teacher in his attitude toward medicine, saying that i t 2 5 is "beneficial and essential to mankind."' J He held that i a man seeking to recover from a disease had two alterna-tives, either "to follow the more ordinary and simple method and have recourse to the medical art," or "he must rise to the higher and better way of seeking the blessing of him who is God over a l l , through piety and prayers." This either-or approach, giving the higher place to divine healing was probably not uncommon. SometimesChristian writers cite a passage from Eccle-siasticus, or the Wisdom of Jesus the Son of Sirach, a book that was part 1of the Septuagint, the Old Testament of the 23. Hippolytus, Commentary on Song of Songs, 2. 24. Clement of Alexandria, Strornata, 6, 1?. 25. Origen, Contra Celsum. 2, 67. 26. Ibid.. 7. 60. I 67 Early Church * but not included in the Jewish canon. The passage from this book, written by a second-century B.C. Jew, reads: Honor the physician with the honor due him according to your need of him for the Lord created him; for healing comes from the Most High, and he w i l l receive a g i f t from the king. The s k i l l of the physician l i f t s up his head, and in the presence of great men he i s ad-mired. The Lord created medicines from the earth, and a sensible man w i l l not despise them. . . . My son, when you are sick do not be negligent, but pray to the Lord, and he w i l l heal you. Give up your faults and direct your hands aright, and cleanse your heart from a l l sin. Offer a sweet-smelling sacrifice. . . . And give the physician his place for the Lord created him; l e t him not leave you, for there is need of him. There i s a time when success l i e s in the hands of phy-sicians for they too w i l l pray to the Lord that he should grant them success in diagnosis and in healing, for the sake of preserving l i f e . He who sins before 2 7 his Maker, may he f a l l into the hands of a physician. ' Note that here healing comes from God, whether directly or through a physician, for the.Lord created both him and his medicines. But man i s advised f i r s t to pray for healing, cleanse his heart from a l l sin, offer a sacrifice and then to give the physician his place. And the physician himself also must depend upon God for his success. This essentially sets the tone for the most articulate and balanced sources in Christendom from the fourth century on. There were s t i l l occasional voices raised condemning medicine, for example, in the early fourth century, Arnobius writes that the phy-sician is "an earth-born creature, not relying on true science, but founded on a system of conjecture, and wavering ?8 in estimating p o s s i b i l i t i e s . " But this was a minority 27. Ecclesiasticus, 38: 1-4, 9-I5. 28. Arnobius, Adversus Gentes. 1, 48. 68 opinion for that period. Gregory Nazianzen, whose brother 29 was a physician, refers to "the marvelous art of medicine" 7 and Gregory of Nyssa speaks of the healing art as a g i f t of 30 God which human nature has gradually discovered how to use. We have already seen the caution with which Basil the Great approached secular medicine, advising i t s employment only in two of his six categories of illness. But when writing to his physician he says ". . . in my opinion, to put your science at the head and front of l i f e ' s pursuits 31 is to decide reasonably and rightly."-^ Most important, in Basil's mind, in regard to medicine were two considera-tions: 1 ) That God created the medical art so as to pro-vide an analogy for Christians, "a model for the cure of the soul," "a parallel to the care given the soul," "an example for the proper care of the soul." That, in his opinion, is medicine's chief end and purpose. 2 ) That i t should be employed in only two of his six categories of physical a f f l i c t i o n s . But yet he writes, since "each of the arts is God's g i f t to us, remedying the deficiencies of nature to reject entirely the benefits to be derived from this art is the sign of a pettish na-t u r e . " 3 2 2 9 . Gregory Nazianzen, On St. Caesarius, ?. 30 Thomas Aquinas Goggin, The Times of Saint Gregory of  Nyssa as Reflected in the Letters and the Contra Eunomium (Patristic Studies, vol. 7 9 , Washington, D.C.: Catholic Uni-versity of America Press, I 9 4 7 ) , 2 0 1 . 31. Basil of Caesarea, Epistles, I89. 3 2 . Idem, The Long Rule, 55. 69 Now Basil's nature was not pettish nor was he as re-luctant as i t might appear to provide medical care for the sick. Indeed he is often indicated as an exemplar of Chris-tian charity for his founding, in 372, of a vast charitable institution, called "New Town," which included, among other f a c i l i t i e s , separate hospitals for those a f f l i c t e d by un-contagious and contagious diseases. Gregory Nazianzen re-fers to this institution as a place where illness became a school of wisdom, where disease is regarded in a r e l i -gious light, where misery is changed to happiness, and where Christian charity shows i t s most striking proof. Medical f a c i l i t i e s were amply staffed by priests, physicians, and nurses. It would be easy to be diverted here into a dis-cussion of the history of the foundation and development of Christian hospitals. It must suffice to mention that in 33.. Gregory Nazianzen, On St. Basil, 63. 34. The early history of hospitals i s r i f e with semantic confusion. The sundry charitable institutions that existed from the fourth century that are called "hos-pitals" include xenodochia (hospices for travelers), bre-photrophia (foundling homes), orphanotrophia (orphanages), gerocomia or gerontochia (homes for the aged) and nosocomia (infirmaries). Although these designations continued in the Greek East, the term xenodochium gained currency in the Latin West, where i t was generously applied to nearly any charitable house or institution. In the early Middle Ages, more often than not these institutions' raison d'etre was simply to provide charitable assistance to the destitute and shelter for the pilgrim. Only seldom does one encounter a xenodochium in the early Middle Ages that had any medical personnel. On the history of early hospitals, see, e.g., George E. Gask and John Tood, "The Origin of Hospitals," in Science, Medicine and History. Essays on the Evolution of  Scientific Thought and Medical Practice, Written in Honour  of Charles Singer (London: Oxford University Press, 1953), 325, at the Council of Nicaea, a l l "bishops in attendance were instructed to set up hospitals in every cathedral city. J A very well-known story is Jerome's account, in the late fourth century, of his friend, a lady named Fabiola, establishing a hospital or infirmary in Rome. He t e l l s , in much detail, the devotion with which she gathered the sick from the public squares of the city and nursed the most wretched cases with her own h a n d s . T h e foundation of Christian hospitals was a logical develop-ment of Christian charity. Regardless of the abuses pro-pagated under the name of Christianity, i t cannot be denied that the most central theme of Christianity is love, both in i t s soteriological and philanthropic emphases. The gospel did not limit i t s e l f to the salvation of souls for eternity, but was also directed to salvation within the world. It was a gospel not only of God's love to men but also of God's love through men. Christ's commandment to 3? love your neighbor as yourself^' was not simply a piece of 122 f f . j A. C. Stuart-Clark, "Early Hospital History," Hos-p i t a l , 1959. 55: 274-278, 379-383, 474-4785 and, although concentrating on a later period, containing an excellent survey of the history of and secondary literature on early hospital development, Timothy S, Miller, "The Knights of St. John and the Hospitals of the West," Speculum, I978, 53: 709 f f . 35. Council of Nicaea, Canon 7 0 . 36. Jerome, Epistles, 77, 6, 1 f. 37. Matthew 19:19, 22:39J Mark 12:31-33} Luke 10:27; cf., Romans 13:9; Galatians 5:19; James 2:8. 71 advice, i t was a categorical imperative. Love for one's neighbor can manifest i t s e l f in quite a variety of ways. But spiritual concern was never to take precedence over immediate material or physical help for those in need. This is bluntly stated in the Epistle of James: "This i s pure and undefiled religion in the sight of our God and Father, to v i s i t orphans and widows in their distress. . . , n J Indeed, Christ's examples of charity include the following: I was hungry, and you gave me something to eat; I was thirsty, and you gave me drink; I was a stranger, and you invited me in; naked, and you clothed me; I was sick, and you visited me; I was in prison, and you came to me. . . . To the extent that you did i t to one of these brothers of mine, even the least of them, you did i t to me.39 "I was sick and you visited me." The verb here rendered "visited" also yields the meanings "to care for," "to be concerned about," "to succor," and is sometimes used in late classical Greek to refer to a physician's medical 40 visitation of a patient. The visitation, care and com-forting of the sick became early a duty incumbent upon a l l believers. Adolf Harnack, a leading- Church historian of a pre-38. James 1:2?. 39. Matthew 25 s 35-46. 40. . ~ a i - - - • p > g 0 1 ™ 0 -i • fee Hermann Beyer, " knlaH^TtTOLiou, H.T.\ » I N Theological Dictionary of the New T ^ t a m p n t , vol. 2, p 72 vious generation, writes regarding the visitation and care of the sick that "to quote passages would be superfluous, for the duty is repeatedly inculcated." It is f i t t i n g , however, to give some representative examples. In the Apostolic Tradition of Hippolytus, dating from the second century, i t is stipulated that before candidates for bap-tism w i l l be approved, they are to be examined as to "whe-ther they have lived soberly, whether they have honored the widows, whether they have visited the sick, whether they 42 have been active in well-doing." Two other second-century documents, one falsely attributed to Justin Martyr and the other to Clement of Alexandria, stress that "to 43 imitate Christ is to minister to the sick" J and that no one should plead such excuses as squeamishness or being 4a unaccustomed to such activity. Early Christian l i t e r a -ture is indeed r i f e with such admonitions. Although in the early church the care of the sick was required of and urged upon a l l believers, in the course of time i t became more and more the specific duty of deacons, deaconesses 41. Adolf Harnack, The Expansion of Christianity in  the F i r s t Three Centuries, trans, by James Moffatt (1904-I 9 0 5 , reprinted, Freeport, N.Y.s Books for Libraries Press, 1 9 7 2 ) , 1 9 9 . 42. Hippolytus, Apostolic Tradition, canon 2 0 . 4 3 . Pseudo-Clement, De virginitate. 44. Pseudo-Justin, Epistles, 17. 73 and widows. J It e s p e c i a l l y became the mark of the very devout. Many examples are given of those who were p a r t i -c u l a r l y zealous in p r a c t i s i n g such ch a r i t y . A t y p i c a l biography of a saint describes him as "the eye of the b l i n d , the feet of the lame, the clothes of the naked, the roof of 46 the homeless, and the physician of the sick." During the outbreaks of plague in the 5Qs of the t h i r d century, the Christians responded with a spectacular degree of a c t i v i t y on behalf of those s u f f e r i n g from the p e s t i -lence, both fellow Christians and pagans a l i k e . Their zeal was nearly s u i c i d a l , as death incurred i n such a fashion 47 was considered to rank with martyrdom. ' Dionysius, Bishop of Alexandria, describes h i s f l o c k ' s a c t i v i t i e s thus: v i s i -t i n g the sick without a thought as to the danger, assiduously ministering to them, tending them i n C h r i s t , and so most 48 gladly departing t h i s l i f e along with them." Their a c t i -v i t y was placed in stark contrast with that of the pagans who deserted the sick or threw the bodies of the a f f l i c t e d out into the s t r e e t s . Cyprian, i n Carthage, saw the plague 45. See Dawe, Attitudes of the Ancient Church, p. 186. 46. Demetrios J . Constantelos, Byzantine Philanthropy  and S o c i a l Welfare (New Brunswick, N.J.: Rutgers University Press, 1968), 93. See also Eusebius (De mart. Pal., 11, 22) who bears testimony to the character of Seleucus, that l i k e a father and guardian, he had shown himself a bishop and patron of orphans and destitute widows, of the poor and of the sick. 47. Eusebius, E c c l e s i a s t i c a l History. 7, 22, 8. 48. Ibid., 7, 22, 7. -? 4 as beneficial as i t "searches out the righteousness of each one, and examines the minds of the human race, to see whether they who are in health tend the sick, . . . whether physicians do not forsake their beseeching patients; . . . whether the haughty bend their neck; whether the wicked soften their boldness. . . " y Cyprian's own heroism during the plague is ably described by his biographer, Pontius.^ 0 Mention should also be made of the Parabolani, a little-known group in the fourth century, whose name means the "reckless ones" because of their primary duty of assisting: the i l l during epidemics.''1 Christianity had quite drastically altered attitudes and actions toward the sick. In the words of Henry Sige-r i s t , Christianity introduced the most revolutionary and decisive change in the at-titude of society toward the sick. Christianity came into the world as the religion of healing, as the joy-f u l Gospel of the Redeemer and of Redemption. It add-ressed i t s e l f to the disinherited, to the sick and af-f l i c t e d , and promised them healing, a restoration both spiritual and physical. . . . It became the duty of the Christian to attend to the sick and poor of the community. . . . The social position of the sick man thus became fundamentally different from what i t had been before. He assumed a preferential position which has been his ever since.52 The question now can be asked whether this new, pre-4 9 . Cyprian, De mortalitate. 16. 5 0 . Pontius, The Life and Passion of Cyprian. 9 f. 5 1 . See "Parabolani" in The Oxford Dictionary of the  Christian Church, ed. by F. L. Cross (London: Oxford Univer-sit y Press, 1 9 5 8 ) , 1 0 1 2 f. 5 2 . Henry Sigerist, C i v i l i z a t i o n and Disease (Ithaca: Cornell University Press, 19*4-3), 6 9 f. 75 ferential position of the sick had, as its correlate, the development of an imposition of any sense of obligation on the part of those tending the sick to make every effort to attempt to prolong the l i f e of the a f f l i c t e d . The Christian attitude toward death that is expressed in the literature of early Christianity is generally con-sonant with Paul's statement that "for me to live is Christ 53 and to die i s gain."-^ Death was not to be sought. Some Christians actively courted martyrdom but more balanced minds condemned such activity as being tantamount to' sui-cide. Clement of Alexandria, writing in the second century quotes Jesus' words "When they persecute you in this city, flee to the other,"- and comments as follows: He does not advise f l i g h t , as i f persecution were an an e v i l thing; nor does he enjoin them by fl i g h t to avoid death, as i f in dread of i t , but wishes us neither to be the authors nor abettors of any e v i l to anyone, either to ourselves or the persecutor and murderer. For he, in a way, bids us take care for ourselves. But he who disobeys i s rash and foolhardy. If he who k i l l s a man of God sins against God, he also who presents himself before the judgment seat becomes guilty of his own death.55 Sometimes comments or at least intimations are made both by scholars and popularizers that early Christians were, i f not sympathetic toward suicide, at least neutral toward the act and that i t was Augustine who, as i t were, imposed on 53. Philippians 1:21. 54. Matthew 10:23. 55. Clement of Alexandria, Stromata, 4, 10. 76 Christians a negative position on suicide. It can be argued that Clement's statement is ambiguous on suicide since i t really is addressed to courting martyrdom. But elsewhere he f l a t l y states that the Christian "does not withdraw him-56 self from l i f e . For that is not permitted him."-' In the same century, Justin Martyr anticipates the hypothetical suggestion: "Go then a l l of you and k i l l yourselves, and pass even now to God, and do not trouble us." To this he responds, ". . .we shall, i f we so act, be ourselves 5 7 acting in opposition to the w i l l of God." S t i l l in the second century the author of the Shepherd of Hermas states that whoever does not save someone who is driven to suicide by calamities "commits a great sin, and becomes guilty of his blood." It was Augustine, in the late fourth and early f i f t h centuries, who was the f i r s t Christian author to dis-co cuss suicide systematically. 7 He does not, in that con-text, however, deal specifically with the question of sui-cide to escape illness or physical disabil i t y , but he does 56. Ibid., 6 , 9 . 57- Justin Martyr, Second Apology, 2, 4. 58. Shepherd of Hermas, 4. Cp. Polycarp, Epistle to  the Philippians, 10, 3« "When i t is in your power to do good, withhold not, because alms deliver from death." Lac-tantius, a l i t t l e over a century later, implies a condem-nation of suicide when he writes, "For i f death were ap-pointed for a fixed age, man would become most arrogant" (On the Workmanship of God, 4 ) . 59. Augustine, City of God, 1, 20-27. 77 elsewhere saying, "For we are among evils which we ought patiently to endure until we arrive among those goods where nothing w i l l be lacking to provide us ineffable delight, nor w i l l there then be anything that we are obliged to endure."^0 Augustine's contrast of the ineffable delights of heaven with the evils of this world partakes of a theme dear to the heart of Christian authors during the early centuries of Christianity. The Christian is placed in juxtaposition with the pagan on the question of his a t t i -tude toward death. While pagans were thought of as fearing death, sad and trembling, the Christian rejoices at the death of his loved ones and anticipates with eagerness his 61 own day of "homegoing." The joys of heaven are often emphasized to show the f o l l y of clinging to this l i f e . Cyprian, in the third century, during a severe outbreak of plague, writes: So many persecutions the soul suffers daily . . . and yet i t delights to abide here . . . although i t should rather be our craving and wish to hasten to Christ by the aid of a quicker death. . . . What blindness of mind or what f o l l y is i t to love the world's a f f l i c -tions, and punishments, and tears, and not rather to hasten to the joy which can never be taken away! . . . How preposterous and absurd i t i s , that while we ask that the w i l l of God should be done, yet when God call s and summons us from this world, we should not at once obey the command of his w i l l ! . . . with a sound mind, with a firm faith, with a robust virtue, l e t us be pre-pared for the whole w i l l of God, laying aside the fear of death, let us think on the immortality which follows." 60. Ibid., 19, 4. „ ^ A 1 ' , ^ 6 e ' f o r e x a m P l e » Cyprian, De mortalitate. 2, 7, 14 and 26 (written while Carthage was being beseiged by plague). 62. Ibid., 5, 18 and 19. 78 Augustine points to the irony that so many, when faced with troubles, cry out, " ' 0 God, send me death; hasten my days.' And when sickness comes they hasten to the physi-cian, promising him money and rewards." ^ Augustine l a -ments at what things men do that they may live a few days. . . . If, on account of bodily disease, they should come into the hands of the physician and their health should be despaired of by a l l who examine them; i f some physician capable of curing them should free them from this des-perate state, how much do they promise? How much is given for an altogether uncertain result? To liv e a l i t t l e while now, they w i l l give up the sustenance of life.°4 But this was not what Christians were to do. They were to put their faith in God,leave the results in his hands, and not cling to l i f e with desperation. Basil, as was his wont, expresses succinctly what seems to be a quite balanced posi-tion, probably representative of the mainstream of Christian thought of his time. He writes: Whatever requires an undue amount of thought or trouble or involves a large expenditure of effort and causes our whole l i f e to revolve, as i t were, around s o l i c i -tude for the flesh must be avoided by Christians. Con-sequently, we must take great care to employ this me-dical art, i f i t should be necessary, not as making i t wholly accountable for our state of health or illness, but as redounding to the glory of God. . . .°5 While i t seems certain that the idea of a duty to at-tempt to prolong l i f e was not a correlate of the very strongly 63. 64. 65. Augustine, Sermones, 84, 1 . Ibid., 3^4, 5. Basil of Caesarea, The Long Rule. 55. 79 f e l t obligation to succor and comfort the sick and, gene-r a l l y , to preserve l i f e until God should choose to end i t , nevertheless i t remains an indisputable fact that compas-sion for the i l l was a central feature of early Christianity. Christian love, kyoJir\ , the God Shepherd's love for his sheep, could be more graphically expressed in a more common meta-phor. Christ became the Great Physician, the verus medicus, solus medicus, verus archiater, ipse et medicus et medica-mentum — himself both the physician and the medication.^ Early Christian authors thus adopted and adapted a strong tradition in classical literature that employed, in simile or metaphor, the idea of the physician as a compassionate, selfless and philanthropic healer of i l l s , soother of dis-6? tress and, sometimes, i n f l i c t e r of health-givinff pain. While seldom concerned directly with actual conditions of medical practice, the church fathers frequently availed themselves of the rich potential that illustrations from the practice of medicine afford for medical-spiritual ana-logies. Their illustrations provide us with some interesting 66. There is a f a i r l y extensive literature on the mo-t i f of Christus Medicus. See, e.g., Arthur Stanley Pease, "Medical Allusions in the Works of St. Jerome," Harvard  Studies in Classical Philology. I9I4, 25: 73 f f . ; Rudolph Arbesmann, "The Concept of 'Christus Medicus' in St. Augus-tine," Traditio. 1952+, 10: 1 f f . ; and Heinrich Schipperges, "Zur Tradition des 'Christus Medicus' im fru'hen Christentum und in der alteren Heilkunde," Arzt und Christ, 1965, 2: 12 f f . 67. Discussed above in Chapter I. 80 insights into standards that they considered ideal. Origen writes that he followed "the method of a philanthropic phy-sician who seeks the sick so that he may bring r e l i e f to 68 them and strengthen them." He apparently held that a phy sician ought to attempt to help as many people as possible. In demonstrating the superiority of Christianity to pagan philosophy, he says that "Plato and the other wise men of Greece, with their fine sayings, are like the physicians who confine their attention to the better classes and des-pise the common man while the disciples of Jesus carefully 70 study to make provision for the great mass of men."' It was in his care for the common man, for the destitute, for the poor, that the physician evinced a Christ-like compas-sion. Augustine points to his friend, the physician Gen-nadius, as "a man of devout mind, kind and generous heart 9 68. Origen, Contra Celsum, 3 . 74. 6 9 . Ibid., 7, 59: "It i s obvious that humanity i t s e l f and the interest of mankind as a whole suggest that the phy sician who has cared for the health of the majority helps his fellow-men more than the physician who has cared for the health of only a few." 70. Ibid. , 7 , 60. Origen apparently did not feel that physicians were obligated to attempt to extend care in a l l cases, for earlier in the same work ( 3 i 35) he writes: "Many instances may be adduced of people being healed [sc. at pagan healing shrines] who did not deserve to l i v e , people who were so corrupt and led a l i f e of such wicked-ness that no sensible physician would have troubled to cure them." 81 71 and untiring compassion, as shown by his care of the poor."' Zenobius, a fourth-century physician, i s lauded by his bio-grapher for not only serving his poor patients free of charge, 72 but also helping them financially when necessary. Augus-tine, with some frequency, speaks of the hypothetical phy-sician who, motivated by charity, asks no remuneration for his services, but undertakes the most desperate cases among 73 the poor with no thought for receiving any recompense.{J Without any condemnation, Augustine acknowledges that often the physician, when coming to a new community, w i l l take on desperate cases among the poor gratis so that, in addi-tion to exercising benevolence, he may also increase his 74 reputation. With greater renown, the physcian w i l l be able to inspire greater confidence, which Augustine seems to have considered as an important aspect of the physician/ 7 5 patient relationship.'-^ 71. Augustine, Epistles, 159. 72. Constantelos, Byzantine Philanthropy, p. 182, in the same place also mentions the sixth-(or perhaps f i f t h - ) century physician Sampson who "transformed his home into a free public c l i n i c . Not only did he treat poor patients free of charge, but also offered them food and lodging." 73. Augustine, Sermones, 175, 8 f. 74 . Ibid., I 7 6 , 4 . 75. Ibid., 9, 10; 80, 30; 84, 1; I37, 3; 3kk, 5; De bapt., 1, 8, 11; In Psalm. 45, 11; Enchiridion. 16. 82 According to Peter Chrysologus (early f i f t h century), i t i s "to the praise of his virtue, the glory of his s k i l l , and the increase of his reputation,* i f the physician exer-cises patience."^ Peter goes on to describe how the phy-sician must sometimes endure bites and "pains by no means 77 light in order to free his patients from suffering."'' Augustine marvels at the mildness of physicians who do not return insult for insult when irrational patients treat 78 them with sharpness and abuse.' The physician, in caring for the i l l , encounters un-pleasant things. Eusebius writes that Christ, "like some excellent physician, in order to cure the sick, examines what is repulsive, handles sores, and reaps pain himself 79 for the sufferings of others."' 7 Origen employs the same comparisons It is relevant to observe that a physician also, who n Q "sees terrible things and touches unpleasant wounds," in order to heal the sick, does not pass from good to bad, or from beautiful to shameful, or from happiness to misfortune, although the physician who sees the terrible things and touches the unpleasant wounds does not wholly avoid.the possibility that he may f a l l into the same plight. ° 1 76. Peter Chrysologus, Sermones, 38. 77. Ibid. 7 8 . Augustine. Sermones, 1 7 5 , 2; I 7 6 , 4: 3 5 7 , 4; Epistles, 104, 7 ; De tract. Joh., 7 , 1 2 . 7 9 . Eusebius, Ecclesiastical History, 1 0 , 4, 1 1 . 8 0 . This appears to be a loose quotation from De f l a -tibus, 1 , in the Hippocratic corpus. 81. Origen, Contra Celsum, 4, 1 5 . Origen also uses 8 3 A good physician, however, w i l l not be deterred by the pos-s i b i l i t y of contagion for by very definition he is moti-82 vated by philanthropy. Indeed the physician, according to Augustine, should always have his patient's cure at heart,^ for the practice of medicine would be cruelty i f the physician were only concerned about engaging in his 84 art. Indeed his concern for his patients manifests i t -self in his refusal to give them those things that they ask for that would be harmful for them.^ Further, in an effort to keep the patient's mind free from care and worry, the physician should not inform him of any disturbing mat-R6 ters, in spite of his questionings. Augustine saw as worthy of praise the action of his friend, the physician Gennadius, who had been called in as a consultant on an extremely d i f f i c u l t case. When Gen-this example in Horn, in Jerem., 14, 1 . On i t s employment by classical authors as well, see Ernst Nachmanson, "Hip-pocratea: Aus Aufzechnungen und Vorarbeiten," in Symbo-lae Philologicae 0 . A. Danielsson Octogenario Dicatae (Upsala: A.-B. Lundequistska, 1 9 3 2 ) , 1 8 7 f f • 82. See Basil of Caesarea, Epistles, 189, written to the physician Eustathius. 8 3 . Augustine, Sermones, 9, 1 0 . 84. Idem. In Psalm.. 1 2 5 , 1^.. 8 5 - Ibid., 8 5 , 9 . 8 6 . Ibid., 1 0 2 , 6 , and De mendacio, 5 . 6 . Jerome (Adv. Ruf., 1, 18) maintains that the physician may resort to justifiable falsehoods as to the patient's condition. 84 nadius had examined the procedures being employed by the physicians in charge, he refused to take over in their place. "He commended their s k i l l , and declared that to win the credit of the cure by doing the l i t t l e that re-mained to be done would be most inconsistent with his na-ture." This may t e l l us something about rjenna,dius' na-ture as a man, but i t does not necessarily imply that such magnanimity was an essential quality of the practitioner of the "Hippocratic art." It was, however, not uncommon for the term "Hippocratic art" to be used in early Chris-tian literature as a metonymous expression for the medi-cal art and we occasionally encounter the name Hippocrates used as an ethical ideal for the medical practitioner. In-deed Christ is himself spoken of quasi s p i r i t u a l i s Hippo-crates.-- "as i t were, a spiritual Hippocrates" — and i t is to Hippocrates as the type of physician that Jerome 89 compares the Christian healer. 7 In a passage well known to medical historians, Jerome refers to the so-called Hippocratic Oath. He is writing to Nepotian on a pastor's duties: It is part of your duty to v i s i t the sick, to be acquainted with people's households, with matrons, and with their children, and to be entrusted with the secrets of the great. Let i t therefore be your 87. Augustine, City of Ood, 22, 8. 88. Pease, "Medical Allusions in Jerome," p. 75. 89. Jerome, C. loan. Hier.. 38 f. Cf., Epistles, 125, 16. 8 5 duty to keep your tongue chaste as well as your eyes. Never discuss a woman's looks, nor let one house know what is going on in another. Hippocrates, before he w i l l instruct his pupils, makes them take an oath and compels them to swear obedience to him. That oath exacts from them silence, and prescribes for them their language, gait, dress, and manners. How much greater an obligation i s l a i d on us who have been entrusted with the healing of souls 190 Those well-acquainted with the so-called Hippocratic Oath shall have immediately recognized that there i s nothing in the pagan oath bearing on "language, gait, dress, and man-ners," although there is an injunction to confidentiality 91 or silence. But in the Hippocratic works Precepts and Decorum these matters are dealt with and i t appears that the general principles of etiquette associated with the name Hippocrates were at least vaguely identified with the Oath bearing his name. 9 0 . Jerome, Epistles, 5 2 , 15* Not only was Christ referred to as #a physician but by extension Origen applied the term taxpoC to the prophets. Although in the passage quoted, Jerome does not directly c a l l the clergy physicians of the soul or spi r i t u a l physicians, he certainly does so by im-plication. Augustine has one reference to the pastor as a spiritual physician (Epistles, 2 5 , 3 ) , a figure that there-after became extremely common, particularly in the Middle Ages. 9 1 . W. H. S. Jones, The Doctor's Oath, comments that "there is nothing in the extent forms [of the Oath] which touches on either incessus or habitus. We are forced to the conclusion that either Jerome has inadvertently included under the term sacramentum rules of conduct which appear, not in Oath, but in Precepts or in Decorum, the two works of the Hippocratic Collection which, after Oath, give us most information about ancient medical etiquette, or else that in early Christian times there were forms of Oath which include references to incessus and habitus. Of the two suppositions the second is perhaps the more likely" (pp. 41 f . ) . 86 A l l these guidelines for conduct are basically the product of commonsense, both for physicians and clergy-men. Since there is much in common between the two pro-fessions, both would be reduced substantially in efficiency by significant deviation from these basic principles of decorum. In a collection of letters falsely attributed to Clement of Alexandria there appears a passage that reads in part s For such is the manner in which we are to v i s i t the sick . . . without guile or covetousness or noise or talkativeness or pride or any behavior alien to piety . . . instead of using elegant phrases, neatly arran-ged and ordered . . . act frankly like men who have received the g i f t of healing from God, to God's glory. This excellent advice for physicians was actually written for exorcists dealing with the demon-possessed. Every detail enunciated here, save reference to piety and to God, is also mentioned in the Hippocratic literature, but we need not assume that the anonymous author of this letter was adopting principles of medical etiquette. Although in early Christian literature a reasonably clear i f not exhaustive picture of the ideal physician emerges, i t t e l l s us l i t t l e , i f anything, directly about the ethics of the early Christian physician, except insofar as individual physicians may have agreed with and attempted to conform to such an ideal. Few references to Christian physicians are found from the period when Christians were 92. Pseudo-Clement, De virginitate. 1, 112. 87 93 a persecuted minority. As mentioned above, J Luke is said to have been a physician, and there is occasional mention 9 4 of martyred Christian physicians. 7 But as Christianity became more widespread, encompassing an ever broadening spectrum of society, physicians became Christians and Christians became physicians on a much larger scale. Christianity f i n a l l y displaced paganism, becoming the o f f i c i a l and then the only tolerated religion. While Christianity remained a religion of conviction for some, i t became a religion of convenience for many, and the social amalgam that resulted in the late Empire was a not entirely harmonious marriage of the new religion with the extremely varied cultural and intellectual strains that in the aggregate comprised late classical Mediterranean so-ciety. ^ While the physician as an ideal, convenient for homiletics, and the ideal physician as an exemplar, ap-pear in the literature, we know next to nothing about the effect of such ideals on actual medical practice. The 93. At n. 20. 94. E.g., Alexander, martyred at Lyons under Marcus Aurelius (W. H. C. Frend, Martyrdom and Persecution in the  Early Church: A Study of a Conflict from the Maccabees to  Donatus [Oxford: Blackwell. 19651. 9) and Zenobius. a priest who was also a physician, martyred in Sidon under Diocletian (Eusebius, Ecclesiastical History, 8, 13). 95- Voluminous discussion has been devoted to the inter-pretive problems central to an understanding of the social milieu of the Roman Empire of the fourth through sixth cen-turies. As a preliminary, one should see E. R~. Dodds, Pagan  and Christian in an Age of Anxiety: Some Aspects of Religious  Experience from Marcus Aurelius to Constantine (Cambridge: 88 Christian who also happened to be a physician may well have f e l t bound to apply fervently to his practice the philanth-ropic and moral precepts of his religion. On the other hand, the physician who also happened to he a Christian may have found his principles of conduct and responsibi-l i t y much less tempered by his religion. Both, however, would have shared a tradition of classical medical e t i -quette that was in many ways consonant with Christianity, as is easily demonstrated by a comparison of the ideal physician of classical thought with that of Christian thought. Although i t is certain that many of the stipu-lations in the so-called Hippocratic Oath were discordant with the re a l i t i e s of classical medical practice, yet, under the Empire, owing to a growing philanthropic emphasis and an increasing reaction against such practices as abor-96 tion and euthanasia, this oath and probably a wide variety 97 modelled on i t , increased in popularity in some quarters and was easily adapted to Christian ideals. Several manu-scripts are extant of the "Oath of Hippocrates insofar as a Christian may swear i t . " There is doubt as to how early Cambridge University Press, 1965). See The Conflict between  Paganism and Christianity in the Fourth Century, ed. by Ar-naldo Momigliano (Oxford: Clarendon Press, 1 9 6 3 ) 5 and A. H. M. Jones, The Later Roman Empire: A Social, Economic and Ad-ministrative Survey (Oxford: Blackwell. 1964). 9 6 . See above, Chapter I. 9 7 . See, e.g., Roger Pack, "Note on a''Progymnasma* of Libanius," American Journal of Philology, 1948, 6 9 : 3 0 0 f f . 89 the Christian Oath was composed. W. H. S. Jones writes that " a l l the evidence, without "being conclusive, points 98 to a date anterior to Galen." 7 Even i f Jones' dating is too early, there is no reason to doubt that the Christian Oath was in existence at least by the end of the second century A.D. A comparison of the Christian Oath with the pagan Oath reveals these differences: The Christian Oath omits the enigmatic prohibition of cutting for stone, makes more specific and definite the anti-abortion statement, and, or course, eliminates the references to pagan deities. The clauses promising preferential treatment to his instructor and his instructor's family, his own sons and other physi-cians "who have sworn allegiance to the physicians' law" 99 are dropped. On this last point Jones remarks: The sentences which encourage an inner cir c l e of practitioners show an aristocratic exclusiveness, which i s in sharp contrast with the universal bro-therhood of Christianity. The r e l i e f of pain and suffering, thought the writer, should be tied by no fetters and hindered by no trade-union rules. Chris-tian benevolence should.be universal.1 0 0 It is further interesting to note that where the pagan Oath reads, "Into whatsoever houses I enter, I shall do so to help the sick, keeping myself free from a l l intentional wrong-doing and harm," the Christian Oath has, "Into whatsoever houses I enter, I w i l l do so to help the sick, 98. W. H. S. Jones, The Doctor's Oath, p. 55. 99. Also the reference to instruction aveu u-ioeoO (with-out fee) i s changed to aveu cp06vou (without jealousy). 100. W. H. S. Jones, The Doctor's Oath, pp. 54 f.• 9 0 k e e p i n g m y s e l f f r e e from a l l w r o n g - d o i n g , both i n t e n t i o n a l and u n i n t e n t i o n a l , t e n d i n g to death o r to i n j u r y . " How much can be made o f i n c l u d i n g a promise to keep o n e s e l f f r e e from u n i n t e n t i o n a l i n a d d i t i o n to i n t e n t i o n a l wrong-101 d o i n g ? I t c o u l d be argued t h a t the f a c t t h a t the C h r i s -t i a n Oath was composed l a t e r t h a n the pagan Oath s i m p l y r e f l e c t s i n t h i s passage a p r a g m a t i c awareness o f a c o n -t i n u a l l y d e v e l o p i n g c o n c e p t o f t o r t i o u s l i a b i l i t y i n Roman l a w , c o n s i d e r a b l y more s o p h i s t i c a t e d and t h u s more w o r r i -102 some to the n e g l i g e n t p h y s i c i a n than t h a t of Greek l a w . But i t i s perhaps more l i k e l y t h a t an a r t i c u l a t i o n o f c o n -c e r n to a v o i d even u n i n t e n t i o n a l harm i s l e s s consonant w i t h pagan m e d i c a l e t h i c s than w i t h t h e u n d e r l y i n g d e o n t o l o g i c a l b a s i s o f C h r i s t i a n p h i l a n t h r o p y and c h a r i t y m a n i f e s t i n g i t -s e l f i n a sense o f o b l i g a t i o n to extend compassion and c a r e t o the d e s t i t u t e and the i l l . 103 There i s a w e l l - k n o w n and f r e q u e n t l y - c i t e d document J penned by C a s s i o d o r u s i n the s e r v i c e of the O s t r o g o t h i c k i n g T h e o d o r i c i n the e a r l y s i x t h c e n t u r y . T h i s document r e i n s t i -t u t e s the o f f i c e of the comes a r c h i a t r o r u m , who a p p e a r s to have been b o t h the p r e s i d e n t o f the c o l l e g i u m o f a r c h i a t r i 1 Q i 1 0 1 . One m a n u s c r i p t o f the pagan O a t h , p e c u l i a r on many a c c o u n t s , i n c l u d e s the same p h r a s i n g here as i s found i n the C h r i s t i a n O a t h . See i b i d . , p . 2 3 , n . 4 . 1 0 2 . See D a r r e l W. Amundsen, " T h e L i a b i l i t y o f the P h y s i c i a n i n C l a s s i c a l Greek L e g a l T h e o r y and P r a c t i c e , " p p . 172 f f ; and idem, "The L i a b i l i t y o f the P h y s i c i a n i n Roman L a w , " p p . 17 f f . 1 0 3 - C a s s i o d o r u s , V a r i a e , 6 , 1 9 . 104. The term a r c h i a t e r and i t s Greek e q u i v a l e n t 91 ( p r o b a b l y c i v i c p h y s i c i a n s i n Rome) and p e r s o n a l p h y s i c i a n to the k i n g and the r o y a l h o u s e h o l d . The t e x t b e g i n s w i t h an encomium on the u s e f u l n e s s o f the a r t o f m e d i c i n e . C a s -s i o d o r u s h e r e p l a c e s m e d i c i n e among the most u s e f u l a r t s t o w h i c h "none seems s u p e r i o r , even e q u a l " i n terms o f i t s b e n e f i t s to m a n k i n d . " I t endeavors to s u s t a i n us when no w e a l t h and no d i g n i t y can h e l p . Those s k i l l e d i n law are h e l d to be e x c e l l e n t when they d e f e n d i n d i v i d u a l s ' a f f a i r s . But how much more g l o r i o u s i s i t to d r i v e out t h a t which c a u s e s death and to r e s t o r e h e a l t h to one endangered , who has d e s p a i r e d o f r e c o v e r y ? " He l a u d s the n e a r l y uncanny p r o g n o s t i c s k i l l o f the e x p e r i e n c e d p h y s i c i a n w h i c h , to the i g n o r a n t man, seems n e a r l y s u p e r n a t u r a l . He emphasizes t h a t the a r t o f m e d i c i n e i s worthy of r e s p e c t and i s " c o n -s e c r a t e d not because i t has p r o v e d u s e f u l i n t imes o f p e r i l , b u t because i t i s a l e a r n e d d i s c i p l i n e . O t h e r w i s e we are s i m p l y exposed t o dangers i f we a r e s u b j e c t e d t o p h y s i c i a n s ' f i c k l e w h i m s . " He then b r i e f l y t o u c h e s on the humoral t h e o r y , d i e t and d r u g s , e s s e n t i a l t h e o r e t i c a l knowledge f o r the p h y - . s i c i a n . " T h e r e f o r e , f o r the s a f e t y of a l l and a f t e r t h e i r t r a i n i n g , l e t p h y s i c i a n s have a m a s t e r , l e t them spend t ime mean b a s i c a l l y " c h i e f " - a r c h - " p h y s i c i a n " - l a t e r . R e f e r e n -ces to a r c h i a t r i a re f r e q u e n t l y e n c o u n t e r e d , e s p e c i a l l y from the t h i r d c e n t u r y A . D . o n . There has been much debate over the o f f i c e and f u n c t i o n s o f a r c h i a t r i . The most r e c e n t t r e a t m e n t i s by V i v i a n N u t t o n , " A r c h i a t r i and the M e d i c a l P r o f e s s i o n , " who c o n c l u d e s t h a t a l t h o u g h t h e r e were s h i f t s i n the meaning and use o f the t e r m , i t g e n e r a l l y comprised b o t h r o y a l and c i v i c p h y s i c i a n s . Of t h e d e f i n i t i o n , f u n c -t i o n s and r e s p o n s i b i l i t i e s o f the l a t t e r we know v e r y l i t t l e . w i t h "books, l e t them d e l i g h t i n a n c i e n t w r i t i n g s . No one more j u s t l y r e a d s c o p i o u s l y t h a n he who d e a l s w i t h human h e a l t h . " The " m a s t e r " whom p h y s i c i a n s s h o u l d h a v e , a t l e a s t those w i t h i n the c o l l e g i u m of a r c h i a t r i , i s the comes a r c h i a t r o r u m to whom t h i s t e x t i s a d d r e s s e d . The comes i s d i r e c t e d to "be an " a r b i t e r o f t h i s d i s t i n g u i s h e d art," to " j u d g e p h y s i c i a n s * d i s p u t e s w h i c h the outcome a l o n e was accustomed to j u d g e . " C a s s i o d o r u s commands p h y s i c i a n s i n g e n e r a l to " l a y a s i d e c o n t e n t i o n s t h a t a re h a r m f u l to the i l l " and he urges them to y i e l d to each o t h e r and share t h e i r t e c h n i q u e s m u t u a l l y . Then t h e y can q u e s t i o n each o t h e r w i t h o u t envy f o r " e v e r y man seeks a d v i c e . " T h i s problem o f b e d s i d e b i c k e r i n g seems to have weighed h e a v i l y on C a s s i o d o r u s ' mind f o r l a t e r he reminds p h y s i c i a n s t h a t " a t the v e r y b e g i n n i n g o f y o u r c a r e e r i n t h i s a r t y o u are c o n s e c r a t e d by oa ths l i k e t h o s e of p r i e s t s ; you p r o m i s e to y o u r i n s t r u c t o r s to hate i n i q u i t y and to l o v e p u r i t y . " I t i s on t h a t a c c o u n t t h a t p h y s i c i a n s a r e not f r e e o f t h e i r own v o l i t i o n to be d e r e l i c t . They must put the h e a l t h of t h e i r p a t i e n t s b e f o r e the m i n u t i a e of m e d i c a l s c i e n c e . "So more d i l i g e n t l y s e a r c h out what t h i n g s cure the s i c k and s t r e n g t h e n the f e e b l e . " C a s s i o d o r u s t h e n s t a t e s t h a t a l -though the p h y s i c i a n ' s f a u l t i s not l e g a l l y c u l p a b l e , 1 0 ^ 105. The p h y s i c i a n s , as Romans, n o t O s t r o g o t h s , would have s t i l l been s u b j e c t to Roman law w h i c h had a p o o r l y d e f i n e d concept o f t o r t t h a t c o u l d be a p p l i e d to the n e g -l i g e n t or incompetent p h y s i c i a n o n l y i f the i n j u r e d p a r t y was a s l a v e . In the case o f the d e a t h o f a p a t i e n t who 93 y e t , as f a r as he was c o n c e r n e d , " t o s i n a g a i n s t the h e a l t h of a p e r s o n c o n s t i t u t e s the c r ime of h o m i c i d e . " T h i s document i s i n t e r e s t i n g f o r a v a r i e t y o f r e a s o n s . I t demonstra tes an acute awareness o f the r e s p o n s i b i l i t y o f the p h y s i c i a n to h i s t e c h n e . But i t i s not by any means a d i s t i n c t l y C h r i s t i a n document and much o f i t c o u l d j u s t as e a s i l y have been composed c e n t u r i e s e a r l i e r and a d d r e s s e d to any group o f p h y s i c i a n s who d i d b i n d them-s e l v e s by oa th to a b i d e by those p r i n c i p l e s t h a t they c o n s i d e r e d as f o u n d a t i o n a l to the p r a c t i c e o f t h e i r a r t . C a s s i o d o r u s * r e m i n d e r t h a t p h y s i c i a n s swear to hate i n i -q u i t y and l o v e p u r i t y i s consonant w i t h the tone of b o t h the s o - c a l l e d H i p p o c r a t i c Oath and the C h r i s t i a n v e r s i o n such as t h a t mentioned a b o v e . I t i s i m p o r t a n t to b e a r i n mind t h a t t h e r e was s t i l l no system o f m e d i c a l l i c e n s u r e and t h a t t h i s document was a d d r e s s e d t o the head o f some k i n d o f p u b l i c h e a l t h s e r v i c e about which we know v e r y l i t t l e and one w h i c h v e r y l i k e l y encompassed o n l y a m i n o r i t y o f the p r a c t i s i n g p h y s i c i a n s . The p r a c t i c e of m e d i c i n e was s t i l l f r e e e n t e r p r i s e , a r i g h t and not a p r i v i l e g e . W i t h -out a m e d i c a l o r g a n i z a t i o n , s o c i e t y , o r g u i l d t h a t would i n c l u d e a l l r e c o g n i z e d p r a c t i t i o n e r s , e n f o r c e a b l e s t a n d a r d s of conduct and a d e f i n e d and g e n e r a l l y a c c e p t e d d e o n t o l o g i c a l b a s i s f o r m e d i c a l p r a c t i c e s h a l l not have been g e n e r a t e d from w i t h i n the p r o f e s s i o n . W i t h o u t a s t a t e - c o n t r o l l e d and s t a t e -was n o t a s l a v e , no means o f r e d r e s s were a v a i l a b l e u n l e s s i n t e n t c o u l d be p r o v e d . See Amundsen, " L i a b i l i t y of the P h y -s i c i a n i n Roman L a w , " p a s s i m . 94 enforced system of medical licensure, a cogent and well-de-fined code of ethics shall not have been imposed upon the profession as a whole from the outside. Neither internal nor external regulation developed for several more cen-turies. The biographer of Hypatios, a monk and physician l i v i n g in the late f i f t h and early sixth centuries, men-tions his treating patients a f f l i c t e d with various sores. These individuals had come to him because, being poor, they had been refused treatment by other physicians. This introduces an important point. The extent of a phy-sician's conformity to the Christian ideal may well have been, on the whole, in converse ratio to his Christian conviction and commitment. We cannot expect the average physician of the period after the Christianization of the Empire to act significantly differently from his pagan counterpart of a few generations earlier, except that the religious pressures against abortion and active euthanasia may have deterred many nominally Christian physicians from such practices. But the physician who was also a fervent Christian in late antiquity might well have found his p r i -mary commitment to be to Christ and his secondary commit-ment to be to the medical art and practice of the latter to 1 0 6 . Constantelos, Byzantine Philanthropy, pp. 9 5 f. Ambrose, a century and a half earlier, had commented that physicians l e f t the care of lower-class patients to their slaves or servants (medicorum pueri and ministri). He writes: "Let the rich man c a l l the master, the poor man the servant" (Enarratio in Psalmum, 3 6 , 3 ) . 9 5 be a vehicle for presenting the former. Gennadius, men-tioned above, as a secular physician seems to have been of that kind. But more and more w i l l such men be o f the nature of Zenobius and Hypatios, both already mentioned, the former a priest and the latter a monk, physicians whose spiritual and medical interests blended into a common con-cern for the spiritually and physically i l l . Around- 3 7 5 Basil wrote a letter to the secular (but Christian) phy-sician Eustathius extolling him for his combination of the medical and sp i r i t u a l . The author writes, "And your pro-fession i s the supply vein of health. But, in your case, especially, the science is ambidextrous, and you set for yourself higher standards of humanity, not limiting the benefit of your profession to bodily i l l s , but also con-. . 107 trivmg the correction of spiritual i l l s . " ' The extent to which secular physicians set for them-selves these "higher standards of humanity" simply cannot 108 be determined. But there is f a i r l y ample evidence for a growing number of Christian physicians who were also priests or monks in late antiquity and by the early Middle 1 0 7 . Basil of Caesarea, Epistles, I 8 9 . 108. Aside from the early Christian Oath, which was probably written by a physician, there is l i t t l e direct evidence from medical sources for the ethics of the early Christian physician. My attempts to c u l l from the late Roman and early Byzantine medical compilers, e.g., Alexander Trallianus and Paulus Aegineta, matters of etiquette or ethics, other than repetitions of classical principles, have proved fr u i t l e s s . 96 Ages our sources, which by then are almost entirely c l e r i -cal, reveal a strong emphasis on the practice of medical charity by the clergy, especially by monks. A clear dis-tinction must be made here between monastic medical care for monks and for the l a i t y . Sometimes a chapter from the Rule of Saint Benedict is cited as evidence for an ob l i -gation to care for the sick l a i t y . The passage reads in part: Before a l l things and above a l l things care must be taken of the sick, so that they may be served in very deed as Christ himself; for he said: "I was sick and you visited me;" and "what you did to one of these least ones, you did unto me." But let the sick on their part consider that they are being served for the honor of God, and not provoke by their unrea-sonable demands the brethren who are serving them. Yet they should be patiently borne with, because from such as these is gained a more abundant reward. There-fore l et the abbot take the greatest care that they suf-fer no neglect. Let there be assigned for these sick brethren a special room and an attendant who is God-fearing, diligent, and careful. . . . Let the abbot take the greatest care that the sick be not neglected by the cellarers and attendants; for he must answer for a l l the misdeeds of his disciples.1°9 The concern here is clearly with the care of sick monks and nothing is said or even implied about any obligation to the general populace. However the cellarer, who is in great part responsible in the above passage for the care of his sick brothers, is admonished elsewhere in the Rule to "take the greatest care of the sick, of children, of guests, and of the poor, knowing without doubt that he w i l l have to 110 render an account for a l l these on the Day of Judgement." 109. Benedict of Nursia, Rule, Ch. 36. 110. Ibid., Ch. 31. 97 The "children, guests, and poor" in this context certainly would not apply to monks, nor should "the sick" here be limited to them. S t i l l this is far from a concise articu-lation of a monastic obligation to succor the i l l of the lay community at large. Cassiodorus, after retiring from the court of the Ostrogothic kings of Italy for the pursuit of a religious l i f e , founded a monastery, naming i t Vivarium. In his Introduction to Divine and Human Readings, Cassiodorus writes to those of his monks who were also physicians: I salute you, distinguished brothers, who with sedu-lous care look after the health of the human body and perform the functions of blessed piety for those who flee to the shrines of holy men -- you who are sad at the sufferings of others, sorrowful for those who are in danger, grieved at the pain of those who are received, and always distressed with personal sorrow at the misfortunes of others, so that, as ex-perience of your art teaches, you help the sick with genuine zeal; you w i l l receive your reward from him by whom eternal rewards may be paid for temporal acts. Learn, therefore, the properties of herbs and perform the compounding of drugs punctiliously; but do not place your hope in herbs and do not trust health to human counsels. For although the art of medicine is found to be established by the Lord, he who without doubt grants l i f e to men makes them sound. For i t is written: "And whatsoever you do in word or deed, do a l l in the name of the Lord Jesus, giving thanks to God and the Father by him." He then goes on to point out to them various medical authors whose works he had "stored away in the recesses of our l i b -„1U rary It is worthwhile to compare this exhortation of Cas-siodorus to his monk/physicians with that which he had directed 111. Cassiodorus, Institutiones, 1, 31. 98 toward the comes a r c h i a t r o r u m a n d , by e x t e n s i o n , to a r c h -i a t r i i n the p u b l i c m e d i c a l s e r v i c e . In b o t h he l a u d s the m e d i c a l a r t . A s i d e from t h i s t h e r e i s l i t t l e s i m i -l a r i t y between the two p i e c e s . The s e c u l a r p h y s i c i a n i s urged to p l a c e h i s c o n f i d e n c e i n h i s techne ( s i n c e the m e d i c a l a r t i s a l e a r n e d d i s c i p l i n e ) and not i n e x p e r i e n c e and s u c c e s s e s . On the o t h e r h a n d , the m o n k / p h y s i c i a n i s t o p l a c e h i s hope i n the L o r d ( " f o r he who . . . g r a n t s l i f e to men makes them sound") and n o t i n the m e d i c a l a r t i t s e l f . A l t h o u g h C a s s i o d o r u s s t r e s s e s t h a t the s e c u l a r p h y s i c i a n i s to be d e d i c a t e d to h i s l e a r n e d techne and m i n d -f u l o f the o a t h by which he was c o n s e c r a t e d , s w e a r i n g " t o hate i n i q u i t y and to l o v e p u r i t y , " n e v e r t h e l e s s , s t r e s s i s p l a c e d on a n e g a t i v e a s p e c t o f m e d i c a l p r a c t i c e : p r o f e s -s i o n a l j e a l o u s i e s , e n v y , and an u n w i l l i n g n e s s to share t e c h n i q u e s w i t h c o l l e a g u e s , a l l m a n i f e s t i n g themselves i n b e d s i d e b i c k e r i n g . T h i s document a d d r e s s e d to the comes a r c h i a t r o r u m i s not p a r t i c u l a r l y concerned w i t h the c a l l i n g , m o t i v a t i o n , or q u a l i t i e s o f the s e c u l a r p h y s i c i a n . Q u i t e d i f f e r e n t i n d e e d i s t h a t d i r e c t e d toward the m o n k / p h y s i c i a n . He i s to be a man o f deep c o m p a s s i o n , d i s t r e s s e d w i t h p e r -s o n a l sorrow a t the m i s f o r t u n e s o f o t h e r s , g r i e v e d by t h e i r p a i n , sad a t t h e i r s u f f e r i n g , and s o r r o w f u l f o r those who a r e i n d a n g e r . H i s m e d i c a l s e r v i c e , m o t i v a t e d by compas-s i o n , w i l l t h u s " p e r f o r m the f u n c t i o n s o f b l e s s e d p i e t y " and h i s reward w i l l be r e c e i v e d from the L o r d . W h i l e t h e i m p r e s s i o n o f the e t h i c a l base o f C a s s i o d o r u s ' s e c u l a r p h y -99 sician is identical to classical descriptions, the peculiar qualities of the monk/physician constitute a picture of the physician as an ideal and the ideal physician of earlier Christian thought. But no longer is this an ideal posited for Christian physicians generally, hut for the relatively new breed known as the monastic or c l e r i c a l physicians. There i s abundant and irrefutable evidence that, in the early Middle Ages, both in the Latin West and in con-112 temporary Byzantine society as well, monasteries became the refuge for the sick, the poor, and the persecuted, and our primary sources supply many examples of monastic medi-cal care of the l a i t y . Although the monastic clergy un-doubtedly took the lead in the administration of medical assistance and in the establishment and maintenance of charitable institutions, such as xenodochia and hospices, 113 nevertheless the secular clergy ^ also were sometimes knowledgeable of medicine and extended medical care to the destitute as a good work. A commonly-cited example is Bishop Masona of Merida who, in the sixth century, founded a xenodochium, staffed i t with physicians, and sent his clergy out to beat the bushes in an effort to round up 112. Constantelos, Byzantine Philanthropy, p. 95. 113. To avoid any semantic confusion, one should note that secular clergy were those who were in orders but not l i v i n g under a rule, thus not monks. A member of the secu-la r clergy who practised medicine would not be a secular physician (i.e., a physician who was not a member of the clergy) but rather a c l e r i c a l physician who was a cleric but not a monk. 100 patients, making, as our source t e l l s us, no distinction 114 between Christians and Jews, slaves and free. Citing illu s t r a t i o n after i l l u s t r a t i o n now would add bulk but not substance to our awareness of the existence of monastic and c l e r i c a l medicine and i t s underlying philanthropic basis. While there i s , in some genres of early medieval l i -terature, particularly from the Merovingian era, a strong . l i s anti-medical, pro-miraculous sentiment, throughout the period there continued to be an active interest in and use of what we may c a l l a sanctified secular medical prac-tice by the monastic and secular clergy, motivated by cha-r i t y and accomplished, ideally, for the glory of God. A l -though secular (i.e., non-clerical, non-monastic) physi-cians are known to have continued to exist throughout the early Middle Ages, we learn of them only by occasional and then oblique references, and these references are usually in c l e r i c a l literature. Unless new and significantly different types of sources for the early Middle Ages should come to light, we simply can only conjecture as to the ethics of these secular physicians and can surmise that there would have been l i t t l e uniformity either in ideals or practice. The differences between the occasional western physician trained in Constantinople, the Germanic wound specialist, 114. Paulus Diaconus, De v i t i i s patrum Emeritensium, 4. 115. E.g., in the writing of Gregory of Tours and Pope Gregory the Great. See Loren C. MacKinney, Early Medieval  Medicine with Special Reference to France and Chartres (Bal-timore: Johns Hopkins University Press, 1937), 23 f f ; 56 f; 61 f. 101 and the p e r i p a t e t i c l i t h o t o m i s t would be extreme and e x t e n -s i v e , i n t r a i n i n g , t r a d i t i o n , and p r o b a b l y m o r a l p e r s p e c -t i v e s as w e l l . The o n l y t h i n g t h a t they d e f i n i t e l y have i n common i s t h a t we can now l o o k back a t them a n d , h o p e f u l l y aware of our semantic s l o p p i n e s s , l a b e l them p h y s i c i a n s . Even i f we uncover a n e c d o t e s about them t h a t seem to r e v e a l , i n some i n s t a n c e s , a h i g h e t h i c a l s t a n d a r d o r , i n o t h e r s , a low e t h i c a l s t a n d a r d i n d i v i d u a l l y , i t t e l l s us l i t t l e or n o t h i n g about the e t h i c s of t h a t amorphous and n e b u l o u s c a t e g o r y c o n v e n i e n t l y grouped t o g e t h e r as the s e c u l a r p h y s i c i a n s o f the e a r l y M i d d l e A g e s . Not o n l y d i d t h e y not l e a v e any d e o n t o l o g i c a l l i t e r a t u r e , but t h e y d i d not even produce any s i g n i f i c a n t e x t a n t m e d i c a l l i t e r a t u r e from which we c o u l d perhaps g l e e n a few t i d b i t s on e t i -q u e t t e , and maybe even a few gems on e t h i c s p r o p e r . We must not lament the absence of such l i t e r a t u r e but t u r n to what we do h a v e . The m e d i c a l l i t e r a t u r e t h a t has s u r v i v e d f rom the e a r l y M i d d l e Ages i s e x t e n s i v e and d i v e r s e . The m e d i c a l l i t e r a -t u r e ranges from s u r v e y s of m e d i c a l knowledge i n the e n c y c -116 l o p e d i c t r a d i t i o n to t r e a t i s e s d e a l i n g w i t h s p e c i f i c a r e a s of m e d i c a l knowledge . Some e x t e n s i v e m a n u s c r i p t s a re e x t a n t c o n t a i n i n g many d i f f e r e n t t r e a t i s e s o f the l a t t e r c a t e g o r y and among these are o c c a s i o n a l l y found t r e a t i s e s d e a l i n g w i t h m e d i c a l e t i q u e t t e and e t h i c s . About f i f t y y e a r s 116. E . g . , I s i d o r e of S e v i l l e , Rabanus Maurus . 102 ago , E r n s t H i r s c h f e l d p u b l i s h e d the L a t i n t e x t s o f s e v e r a l 117 o f t h e s e . T w e n t y - f o u r y e a r s l a t e r L o r e n C . MacKinney p u b l i s h e d an a r t i c l e on e a r l y m e d i e v a l m e d i c a l e t h i c s . In t h i s paper he g i v e s t r a n s l a t i o n s o f t r e a t i s e s i n c l u d e d and o t h e r s not i n c l u d e d i n H i r s c h f e l d ' s a r t i c l e . In a l l i n s t a n c e s where he t r a n s l a t e s s o u r c e s p r i n t e d by H i r s c h -f e l d he t r a n s l a t e s from m a n u s c r i p t s b o t h o l d e r and more r e l i a b l e t h a n t h o s e w h i c h H i r s c h f e l d e d i t e d . B e f o r e c o n -s i d e r i n g t h e purpose f o r which these d e o n t o l o g i c a l t r e a -t i s e s were w r i t t e n and the a u d i e n c e f o r which t h e y were i n t e n d e d , i t would be w e l l t o s u r v e y t h e i r scope and c o n t e n t The i n t r o d u c t i o n to a m a n u s c r i p t handbook p r o b a b l y com-p i l e d i n a German monastery i n the l a t e e i g h t h c e n t u r y , ex -h o r t s p h y s i c i a n s to serve the r i c h and the poor a l i k e , l o o -. H Q k i n g f o r e t e r n a l r a t h e r than m a t e r i a l r e w a r d s . The mu-t u a l o b l i g a t i o n between p a t i e n t and p h y s i c i a n i s m e n t i o n e d : " S i c k one, pay the p h y s i c i a n what you owe l e s t when i l l s r e t u r n no one w i l l v i s i t y o u . P h y s i c i a n , c a r e f o r the poor as w e l l as the p o w e r f u l . I f the p a t i e n t i s r i c h you have 1 1 7 . E r n s t H i r s c h f e l d , " D e o n t p l o g i s c h e Texte des f r u h e n M i t t e l a l t e r s , " A r c h i v f u r G e s c h i c h t e d e r M e d i z i n und der N a t u r w i s s e n s c h a f t e n , 1928, 20: 3 5 3 ff. ~ 118. L o r e n G . MacKinney , " M e d i c a l E t h i c s and E t i -q u e t t e i n the E a r l y M i d d l e A g e s : The P e r s i s t e n c e o f H i p -p o c r a t i c I d e a l s , " B u l l e t i n o f t h e H i s t o r y o f M e d i c i n e , 1952, 26: 1 f f . 1 1 9 . I b i d . . p . 6 and n . 7 . 103 a j u s t o c c a s i o n f o r p r o f i t ; i f p o o r , l e t one reward s u f -120 f i c e . " T h i s " one r e w a r d , " o f c o u r s e , wou ld he s p i r i t u a l . The t r e a t i s e ends w i t h t he e x h o r t a t i o n : " A i d t h e s i c k , y o u r r eward coming f r o m C h r i s t , f o r whoever g i v e s a cup o f c o l d w a t e r i n H i s name i s a s s u r e d o f the e t e r n a l k i n g -dom where w i t h F a t h e r and H o l y S p i r i t He l i v e s and r e i g n s f o r e t e r n i t y . " The hu lk o f M a c K i n n e y ' s m a t e r i a l f r om the e a r l y M i d d l e Ages comes f r om a d e t a i l e d m e d i c a l handbook, com-p i l e d p r o b a b l y b e f o r e t he n i n t h c e n t u r y i n C e n t r a l F r a n c e . T h i s handbook c o n t a i n s , among o t h e r t h i n g s , e p i s t o l a r y t r e a t i s e s , t h e f i r s t seven c o n c e r n e d w i t h m e d i c a l t r a i n i n g , e t h i c s , and e t i q u e t t e . MacK inney c o n s u l t e d a v a r i e t y o f 121 m a n u s c r i p t s o f t h i s handbook, and u sed a n i n t h - c e n t u r y P a r i s m a n u s c r i p t as a s o r t o f ma s t e r copy . S i n c e t h e P a r i s m a n u s c r i p t i s i t s e l f a c o m p i l a t i o n o f a l r e a d y e x i s t i n g me-d i c a l t r e a t i s e s , many, i f n o t a l l , o f t h e t r e a t i s e s p r o -b a b l y were composed p r i o r t o t h e n i n t h c e n t u r y . M u c h ' i s w r i t t e n i n t h e s e d e o n t o l o g i c a l t r e a t i s e s c o n -c e r n i n g the i d e a l c h a r a c t e r o f the p h y s i c i a n . Tn one t r e a t i s e i t i s s a i d t h a t t he p h y s i c i a n s h o u l d b e : 120. C p . , I s i d o r e o f S e v i l l e ' s V e r s u s : P a u p e r i s a t -t e n d e , m e d i c e , censum a tque p o t e n t i s . D i s p a r c o n d i t i o d i s -p a r i habenda modo e s t . S i f u e r i t d i v e s , s i t i u s t a o c c a s i o l u c r i ; s i p a u p e r , merces s u f f i c i t una t i b i . V e r s u s I s i d o r i , i n I s i d o r S t u d i e n , e d . by C h a r l e s H. Beeson (Mun i ch : C. H. Beck , 1913), 164. 121. A c h r o n o l o g i c a l l i s t o f m a n u s c r i p t s c o n t a i n i n g t h e t r e a t i s e s under c o n s i d e r a t i o n i s g i v e n on p. 8 o f Mac-K i n n e y ' s " M e d i c a l E t h i c s . " 104 . . . of a gracious and innately good character, apt and inclined to learn, sober and modest; a good conversationalist, charming, conscientious, intelli-gent, vigilant and affable, in all detailed affairs adept and skillful. Our art also requires that one be amiable, humble, and benevolent . . . not be hesi-tant or timid, turbulent or proud, scornful or lasci-vious, or garrulous, a publican, or a woman-lover; but rather full of counsel, learned, and chaste. Ke should not be drunken or lewd, fraudulent, vulgar, criminal or disgraceful; it is not right for a phy-sician to be taken in a fault or to blush for shame in the presence of his people. . . . Inasmuch as the physician has high honors he should not have faults, but instead discretion, taciturnity, patience, tran-quility, and refinement; not greed but more of res-traint and subtilty, rationality, diligence, and dig-nity. One of the virtues of this art is zeal in the acquisition of wisdom, long sufferance, and mild-ness. . . .122 In the same collection a treatise entitled "Concerning those who are starting in the art of medicine," begins: "In character and spirit let him be zealous and talented, indeed keen so that he may understand readily and be teachable; also strong so that he may be able to endure the recurring labor and the terrible sights that he en-counters." It closes with the statement that "he who takes up the art . . . should be well endowed and wise, 121 indeed adorned with all good characteristics." J Another treatise in this collection contains the ad-monition for the physician to be "very chaste, sober, not 124 a. winebibber." And yet another says "you ought always to read, and to shun indolence . . . cherish modesty, f o l -125 low chastity." 'J It was felt that good character should 122. Ibid., pp. 11 f. 123. Ibid., p. 14. 124. Ibid., p. 18. 125. Ibid., p. 23. 105 m a n i f e s t i t s e l f i n good manners : The p h y s i c i a n " s h o u l d be g e n t l e i n manners and modest , w i t h the p r o p e r amount of r e l i a b i l i t y . He s h o u l d be n e i t h e r l a c k i n g i n knowledge , n o r p r o u d . . . . He s h o u l d be unassuming i n manners so t h a t b o t h p e r f e c t i o n i n the a r t and good manners may be 126 harmonized i n s o f a r as i s p o s s i b l e . " The same theme i s t a k e n up i n a n o t h e r t r e a t i s e i n the same c o l l e c t i o n : The p h y s i c i a n s h o u l d be c a r e f u l about h i s manners . A c c o r d i n g t o E r a s i s t r a t u s , the g r e a t e s t f e l i c i t y i s to keep t h i n g s i n b a l a n c e so t h a t one i s b o t h a c c o m p l i s h e d i n the a r t and a l s o e n -dowed w i t h the b e s t o f manners . I f e i t h e r one i s l a c k -i n g , b e t t e r to be a good man w i t h o u t l e a r n i n g t h a n a s k i l l f u l p r a c t i t i o n e r w i t h depraved manners . I f i n -deed the l a c k of good manners i n the a r t seems to be compensated by r e p u t a t i o n , g r e a t i s the blame, f o r p r o f e s s i o n a l knowledge can be c o r r u p t e d by b l a m e f u l manners . But i f b o t h o f these are f a u l t y , I a d j u r e y o u . . . t o withdraw from the a r t .127 Under the r u b r i c o f manners or e t i q u e t t e , much i s s a i d i n t h i s c o l l e c t i o n . There i s c o n c e r n o v e r a p p e a r a n c e : "The p h y s i c i a n s h o u l d have s l e n d e r , f i n e f i n g e r s so as to be a g -r e e a b l e to a l l and to be s u b t l e i n h i s t o u c h . H i p p o c r a t e s 12P h i m s e l f s a i d t h i s . . . ." ~J A l t h o u g h t h e p h y s i c i a n , or p o t e n t i a l p h y s i c i a n , has l i t t l e c o n t r o l o v e r the l e n g t h of. h i s f i n g e r s , he can r e g u l a t e h i s d r e s s and demeanor. On t h i mat ter one o f these d e o n t o l o g i c a l t r e a t i s e s i s q u i t e s p e c i f i The p h y s i c i a n : 126. 127. 128. I b i d . , p . 12. I b i d . , p . 14. I b i d . , p . 12. 106 ought n o t to be f a s t i d i o u s i n e v e r y t h i n g , f o r t h i s i s what the p r o f e s s i o n demands. He ought to have an a p -pearance and approach t h a t i s d i s t i n g u i s h e d . In h i s d r e s s t h e r e s h o u l d n o t be an abundance o f p u r p l e , n o r s h o u l d he be too f a s t i d i o u s w i t h f r e q u e n t c u t t i n g s of the h a i r . E v e r y t h i n g ought t o be i n m o d e r a t i o n , f o r these t h i n g s are a d v a n t a g e o u s , so i t i s s a i d . Be s o -l i c i t o u s i n y o u r a p p r o a c h to the p a t i e n t , not w i t h head thrown back or h e s i t a n t l y w i t h lowered g l a n c e , but w i t h head i n c l i n e d s l i g h t l y as t h e a r t demands 1 2 9 • • • • ' Bedside manner and duty to the p a t i e n t are v a r i o u s l y p r e s e n t e d i n these t r e a t i s e s . One recommends t h a t the p h y s i c i a n " v i s i t w i t h c a r e " the p a t i e n t s whom he " a c c e p t s 130 . f o r t r e a t m e n t , and s a f e g u a r d t h e m . " ^ A n o t h e r i s more s p e c i f i c : " F o r those who are i l l , you ought to get up e a r l y so as to i n q u i r e about the p r e c e d i n g n i g h t . . . . A t midday p l a n a n o t h e r v i s i t . . . . F o r a t h i r d t i m e , 11 v i s i t a t about n i g h t f a l l , s t a y i n g f o r about an h o u r . . . . " ^ # A c c o r d i n g to a n o t h e r t r e a t i s e , when g o i n g to see the p a t i e n t , " e n t e r the homes you v i s i t i n such a manner as to have eyes o n l y f o r the h e a l i n g of the s i c k . Be m i n d f u l of the H i p -p o c r a t i c Oath and a b s t a i n from a l l g u i l t and e s p e c i a l l y f rom i m m o r a l i t y and a c t s o f s e d u c t i o n . Keep s e c r e t e v e r y -112 t h i n g t h a t goes on o r i s spoken i n the homes . " J Ye t a n o t h e r t r e a t i s e c o n t a i n s a p a r a g r a p h i n t r o d u c e d by the s tatement t h a t what f o l l o w s " c o n s t i t u t e d the s a c r e d m e d i -c a l oath a c c o r d i n g to the p r e c e p t s of H i p p o c r a t e s . " T h i s i s f o l l o w e d by a d v i c e to a b s t a i n from s e x u a l r e l a t i o n s w i t h 1 2 9 . I i d . , p . 1 8 . 1 3 0 . I b i d . , p . 2 3 . 1 3 1 . I b i d . , p . 2 2 . 1 3 2 . I b i d . , p . 1 2 . 107 maid-servants, children, married women, virgins, or widows, and to maintain confidentiality. It also contains the only mention in these treatises of abortion and, perhaps, eu-thanasia: "Enter a home without injuring or corrupting i t . Beware lest your medicines bring death to anyone. Do not allow women to persuade you to give abortives, and do not be a part to any such counsel, but keep yourself immacu-133 late and sacred." J J These concerns, which are consonant with those ex-pressed in the Hippocratic Oath, are also articulated in some of the other treatises in this collection. One trea-tise reads in part: " I warn you, physician, even as I was warned by my master . . . guard the secrets of the homes [you v i s i t 1. If you know anything derogatory concerning 134 a patient, keep quiet about i t . " J Another treatise con-tains the admonition that the physician "ought not to be a deceiver. Like a friend he should maintain silence. . . . 135 The physician ought also to be confidential." J J The physician should take his calling seriously and uphold his oath. One of these deontological treatises en-t i t l e d "On giving the sacred Oath and what sort of books one should read" includes the admonition that "he who wishes to begin the art of medicine and the science of nature ought to take the oath and not shrink in any way whatsoever from 136 the consequences." D His duty to his art and to his fellow 133. Ibid. , p. 19.' 13^. Tbid., p. 23. 135- Ibid., p. 18. 136. Ibid., p. 15. 108 practitioners is urged upon him. In one treatise the phy-sician is advised not "to spread abroad his private cures or the secrets of the art, excepting only data on cases 137 already cured." And in another of these treatises appears this admonition: "Do not detract from other [phy-sicians]; If you praise the character and cures of others you yourself w i l l have a better reputation. You w i l l win more thanks i f you do a l l these things, and no physician 138 w i l l be greater than you [in reputation]." J The concern with preserving one's reputation is rea-sonably strong. Indeed one treatise, after giving advice on character, basic etiquette, and demeanor, reads, "thus the physician himself, and the art, w i l l acquire greater 139 praise." J 7 There is l i t t l e that I have extracted to this point from this collection of deontological treatises that is not completely consistent with the etiquette of Greco-Romans (and the peculiarities of the so-called Hippocratic Oath) as summarized in Chapter I. But there are also ele-ments that, i f not distinctly Christian, are much more com-patible with the Christian emphasis on compassion and cha-r i t y than with pagan medical ethics generally. One trea-tise states that the physician "should make the cases of 140 others his own sorrow." Motivated by a sorrowful com-137. Ibid.. p. 18. 1 38. Ibid., pp. 23 f. 139. Ibid., p. 12. 140. Ibid., p. 14. 109 passion, a cheerful physician turns sorrow and sadness into joy, and comforts a l l the members of his patient, and restores his s p i r i t s . According to the secret teachings which should be pursued in medical inst-ruction, let the physician be cheerful because he is the gentle helper. . . . The physician is said to be the preceptor of healing, the liberator, the opportune worker who renders aid in time of need.141 And the Christian physician must exercise charity: . . . he should take care of rich and poor, slave and free, equally for among a l l such people medicines are needed. Moreover, i f certain compensation is offered, do not demand i t because, however much each one pays, the compensation for medical services cannot be equa-ted with the benefits.142 MacKinney correctly sees in these early medieval deon-tological treatises a fusion of classical thought with Christian principles. He writes, "To be sure, the monastic s p i r i t dominated the compiling of the medical handbooks of the period, but . . . the result was classical as well as 143 pious, and secular as well as ascetic." J But MacKinney does not address the question of the purpose for which these treatises were originally written, the types of people who may have composed them, and the audience for which they were intended. On paleographical grounds the earliest, manuscripts of the treatises under consideration can be dated, in the f i r s t instance, to the eighth century, and the rest to the ninth. But these dates provide only a terminus ante quern 141. Ibid., p. 12. 142. ibid. 143. Ibid., p. 5. 110 and do not n e c e s s a r i l y r e f l e c t a c o m p o s i t i o n d a t e . Whether the o r i g i n a l s were w r i t t e n i n m o n a s t e r i e s o r o u t s i d e , t h e r e a r e a t l e a s t t h r e e d i f f e r e n t p o s s i b l e p u r p o s e s b e h i n d t h e i r c o m p o s i t i o n : 1) As p u r e l y l i t e r a r y e f f o r t s . 2) To be used i n g e n e r a l or advanced c l e r i c a l e d u c a t i o n . 3) To be used i n the t r a i n i n g o f p h y s i c i a n s . 1) L i t e r a t u r e d e a l i n g w i t h m e d i c a l e t h i c s and e t i -q u e t t e appears to have b e e n , i n c l a s s i c a l a n t i q u i t y , a d i s -t i n c t s u b - g e n r e of m e d i c a l l i t e r a t u r e . And i t was a s u b -genre w i t h a s t r o n g t r a d i t i o n a l component. I t i s w e l l known t h a t the m o n a s t e r i e s o f the e a r l y M i d d l e Ages were r e s p o n s i b l e f o r the p r e s e r v a t i o n and t r a n s c r i p t i o n of much c l a s s i c a l and e a r l y C h r i s t i a n - l i t e r a t u r e . The m o n a s t e r i e s were not w i t h o u t o r i g i n a l l i t e r a r y output as w e l l , and i n -deed these t r e a t i s e s under c o n s i d e r a t i o n may have been com-posed i n a m o n a s t i c s e t t i n g as c o n s c i o u s e f f o r t s to C h r i s -t i a n i z e t h i s p a r t i c u l a r g e n r e . O n l y two o f these t r e a t i s e s are a t t r i b u t e d to s p e c i f i c a u t h o r s . One i s an " E p i s t l e of 144 A r s e n i u s to N e p o t i a n , h i s sweetest s o n . " W h i l e t h e r e i s no c l u e as to why the name A r s e n i u s was c h o s e n , N e p o t i a n i s the name of the p r i e s t to whom Jerome had a d d r e s s e d a s i m i l a r e p i s t l e , the l a t t e r on p a s t o r a l d u t i e s , i n which r e f e r e n c e i s made to the e t h i c s and e t i q u e t t e of p h y s i c i a n s as e x p r e s s e d m the H i p p o c r a t i c O a t h . J G i v e n the l a t e 144. I b i d . , p p . 11 f . 145. See a b o v e , a t n . 90. I l l c l a s s i c a l and m e d i e v a l p r a c t i c e o f w r i t i n g h o r t a t o r y t r e a -t i s e s i n the form of l e t t e r s , o f t e n a t t r i b u t e d to a famous o r i n some way a p p r o p r i a t e p e r s o n o f the p a s t as w r i t t e n to some s i m i l a r p e r s o n , i t i s v e r y p o s s i b l e t h a t t h i s p a r t i c u l a r t r e a t i s e i s s i m p l y such an e x e r c i s e . A n o t h e r t r e a t i s e i n the same c o l l e c t i o n i s v a r i o u s l y g i v e n the t i t l e " E p i s t l e o f H i p p o c r a t e s " o r " E p i s t l e o f G a l e n " i n 146 v a r i o u s m a n u s c r i p t s . Even i f some or a l l the t r e a t i s e s i n q u e s t i o n were w r i t t e n s i m p l y as l i t e r a r y e x e r c i s e s , t h e y may s t i l l have been used f o r an e d u c a t i o n a l purpose f o r w h i c h t h e y had not been e n v i s a g e d . 2) G e n e r a l e d u c a t i o n i n the e a r l y M i d d l e Ages c o n -s i s t e d o f the t r i v i u m and the q u a d r i v i u m , t h a t i s , the seven l i b e r a l a r t s . A l t h o u g h m e d i c i n e was not one o f t h e s e , i t was v a r i o u s l y i n c l u d e d as a s u b - d i v i s i o n o f the l i b e r a l a r t s i n the d i f f e r e n t c l a s s i f i c a t o r y systems of the 147 M i d d l e A g e s . A g e n e r a l a c q u a i n t a n c e w i t h , a t l e a s t , the t h e o r e t i c a l a s p e c t s of m e d i c i n e was e x p e c t e d of e v e r y man who c o u l d be c o n s i d e r e d as e d u c a t e d . Thus s u r v e y s o f m e d i -c i n e were i n c l u d e d i n e n c y c l o p e d i a s r a n g i n g from V a r r o ' s 146. MacKinney , " M e d i c a l E t h i c s , " p . 2.3. 14?. F o r a s h o r t d i s c u s s i o n o f the p l a c e of m e d i c i n e (and l a t e r , s u r g e r y ) i n the schemat ic l i t e r a t u r e of the M i d d l e A g e s , see D a r r e l W. Amundsen, " M e d i c i n e and S u r g e r y as A r t or C r a f t s The R o l e o f Schemat ic L i t e r a t u r e i n the S e p a r a t i o n o f M e d i c i n e and S u r g e r y i n the L a t e M i d d l e A g e s , " T r a n s a c t i o n s and S t u d i e s o f the C o l l e g e of P h y s i c i a n s o f  P h i l a d e l p h i a , 1979. n . s . Is 43 f f . 112 D i s c i p l i n a e ( f i r s t c e n t u r y B.C.) to I s i d o r e o f . S e v i l l e ' s S t y m o l o g i a e s i v e O r i g i n e s ( s i x t h / s e v e n t h c e n t u r y ) and Raba-nus Maurus* s l i g h t l y l a t e r De rerum n a t u r a . G e n e r a l l y t h e s e d e a l t w i t h such s u b j e c t s a s , f o r example , i n I s i -d o r e ' s work, the d e f i n i t i o n o f m e d i c i n a and m e d i c u s , the f o u n d e r s of m e d i c i n e , the d i f f e r e n t m e d i c a l s e c t s , the f o u r humors, acute d i s e a s e , c h r o n i c d i s e a s e , m e d i c a l b o o k s , p h y s i c i a n s ' i n s t r u m e n t s , and so f o r t h , a l l t r e a t e d i n a p e r f u n c t o r y f a s h i o n . S t u d e n t s who wished to pursue a t l e a s t a t h e o r e t i c a l s t u d y o f m e d i c i n e f u r t h e r c o u l d do so by r e a d i n g under a s p e c i a l i s t . The s p e c i a l i s t h i m s e l f would u s u a l l y have been s i m p l y one who had advanced f u r t h e r i n m e d i c a l t h e o r y . There are many examples of c l e r i c s who had a s t r o n g t h e o r e t i c a l background i n m e d i c i n e , a c q u i r e d p a r t l y d u r i n g f o r m a l e d u c a t i o n and supplemented by s u b -sequent p r i v a t e r e a d i n g . An example i s G e r b e r t , l a t e r Pope S y l v e s t e r I I , who l i v e d i n the t e n t h c e n t u r y . H i s c o r r e s p o n d e n c e i n c l u d e s o c c a s i o n a l m e d i c a l r e f e r e n c e s . One l e t t e r i l l u s t r a t e s an a t t i t u d e toward m e d i c i n e t h a t p r o b a b l y was q u i t e common among educated c l e r i c s * "Do n o t ask me to d i s c u s s what i s the p r o v i n c e o f p h y s i c i a n s , e s p e c i a l l y because I have always a v o i d e d the p r a c t i c e o f m e d i c i n e , even though I have s t r i v e n f o r a knowledge of 1^ ' 8 i t . " r~ Even those who had d e v o t e d much o f t h e i r advanced 1 2 | f i * The L e t t e r s o f G e r b e r t w i t h H i s P a p a l P r i v i l e g e s  a s ^ S y l v e s t e r I I . t r a n s , by H. P . L a t t i n (New Y o r k : C o l u m b i a U n i v e r s i t y P r e s s , I 9 6 I ) , 188. 113 e d u c a t i o n to the s tudy o f m e d i c i n e might never p r a c t i s e . R i c h e r of Rheims, a l s o l i v i n g i n the t e n t h c e n t u r y , d e -v o t e d g r e a t a t t e n t i o n to the s tudy o f m e d i c i n e , f i r s t a t Rheims and t h e n a t C h a r t r e s . H i s s t u d i e s i n c l u d e d p h a r -macology , pharmacy, b o t a n y , and s u r g e r y . There i s no e v i -dence t h a t he e v e r p r a c t i s e d m e d i c i n e , and i t i s o b v i o u s t h a t h i s major c o n c e r n was w i t h the t h e o r e t i c a l r a t h e r t h a n li+q the p r a c t i c a l . '' R e g a r d l e s s of the purpose f o r which our d e o n t o l o g i c a l t r e a t i s e s were w r i t t e n , i t i s l i k e l y t h a t t h e y may have been perused as an i n t e g r a l p a r t o f t h a t body of m e d i c a l l i t e r a t u r e w i t h which the educated c l e r i c , who had a s p e c i a l i n t e r e s t i n m e d i c i n e , would have had an a c q u a i n t a n c e . 3) There were t h r e e b a s i c c a t e g o r i e s o f p h y s i c i a n s d u r i n g the e a r l y M i d d l e A g e s : m o n a s t i c p h y s i c i a n s , c l e r i -c a l p h y s i c i a n s ( s e c u l a r c l e r g y ) , and s e c u l a r ( l a y ) p h y s i -c i a n s . I t i s l i k e l y t h a t n e a r l y a l l i n the f i r s t two c a -t e g o r i e s would have had a t l e a s t a g e n e r a l , t h e o r e t i c a l t r a i n i n g i n the l i b e r a l a r t s and m e d i c i n e , a l o n g w i t h p r a c -t i c a l e d u c a t i o n under a p r a c t i s i n g p h y s i c i a n . The l a s t c a t e g o r y would have to i n c l u d e the wide v a r i e t y of i l l i -t e r a t e e m p i r i c s as w e l l as the laymen who were educated i n 149. See L o r e n C . MacKinney , " T e n t h - C e n t u r y M e d i c i n e as Seen i n the H i s t o r i a o f R i c h e r o f R h e i m s , " B u l l e t i n o f  the I n s t i t u t e of the H i s t o r y of M e d i c i n e , 1934, 2: 349. 114 m o n a s t i c o r c a t h e d r a l s c h o o l s , t h e n p u r s u e d advanced t h e o -r e t i c a l s t u d y o f m e d i c i n e , and f i n a l l y worked d i r e c t l y under an e d u c a t e d , p r a c t i s i n g p h y s i c i a n . I t i s t o t h e s e f i r s t two c a t e g o r i e s and the e d u c a t e d p h y s i c i a n s o f the t h i r d c a t e g o r y t h a t we s h o u l d now d i r e c t our a t t e n t i o n . The t h e o r e t i c a l e d u c a t i o n t h a t t h e s e p h y s i c i a n s r e c e i v e d would p r o b a b l y have been the same as t h a t o f t h o s e who p u r s u e d a g e n e r a l and more a d v a n c e d m e d i c a l e d u c a t i o n w i t h no i n t e n t i o n o f e v e r p r a c t i s i n g . The o n l y d i f f e r e n c e would have been i n the s t u d e n t ' s r e s p o n s e t o t h e p u r p o s e b e h i n d h i s s t u d y o f m e d i c i n e . The s t u d e n t s e e k i n g o n l y a t h e o r e -t i c a l background i n m e d i c i n e may have found t h e d e o n t o -l o g i c a l t r e a t i s e s as m e r e l y p r o v i d i n g some i n t e r e s t i n g p r i n c i p l e s o f t h e a n c i e n t a r t o f m e d i c i n e and the i d e a l c h a r a c t e r , e t i q u e t t e , and m o r a l r e s p o n s i b i l i t i e s o f i t s p r a c t i t i o n e r s . F o r the s t u d e n t o f m e d i c i n e who i n t e n d e d t o p r a c t i s e t h e a r t , even t h e most t h e o r e t i c a l a s p e c t s o f h i s t r a i n i n g would l i k e l y have been viewed w i t h an eye t o -ward t h e i r u l t i m a t e p r a c t i c a l i t y and u t i l i t y . I t s h o u l d a l s o be n o t e d t h a t t h e s e t r e a t i s e s a r e d i r e c t e d toward t h o s e who were about t o b e g i n t h e i r m e d i -c a l s t u d i e s . C h a r l e s T a l b o t , a r e s p e c t e d h i s t o r i a n o f m e d i e v a l m e d i c i n e , w r i t e s c o n c e r n i n g t h e s e d e o n t o l o g i c a l t e x t s t h a t t h e y " n o t o n l y e v i n c e a g r a v e c o n c e r n f o r the e t h i c a l s t a n d a r d s o f t h o s e who a r e t o p r a c t i s e m e d i c i n e , b u t a l s o draw up i n some d e t a i l the p r e l i m i n a r y s t u d i e s 115 w h i c h a c a n d i d a t e was assumed to have completed b e f o r e 1 50 embarking on the s tudy o f m e d i c i n e . " J I t s t i l l remains t h a t we cannot determine w i t h any c e r t a i n t y the purpose b e h i n d the c o m p o s i t i o n of these t r e a t i s e s o r the a c t u a l use to w h i c h t h e y may have been p u t . Even i f they were s t u d i e d by those p r e p a r i n g f o r m e d i c a l p r a c t i c e , the e x t e n t o f t h e i r i n f l u e n c e cannot be a s s e s s e d . And f u r t h e r , i t must be remembered t h a t the p h y s i c i a n s o f the e a r l y M i d d l e Ages were , i n r e s p e c t to t h e i r m e d i c a l p r a c t i c e , f r e e a g e n t s , bound t o no r e g u l a -t i n g a u t h o r i t y and thus not bound by any code of conduct or promulgated d e l i n e a t i o n o f m o r a l r e s p o n s i b i l i t i e s . Such developments w i l l be d i s c u s s e d i n the next c h a p t e r . 150. C h a r l e s T a l b o t , " M e d i c a l E d u c a t i o n i n the M i d d l e A g e s , " i n The H i s t o r y o f M e d i c a l E d u c a t i o n , e d . by C , D . O ' M a l l e y ( B e r k e l e y : U n i v e r s i t y o f C a l i f o r n i a P r e s s , 1970), 75-CHAPTER III LICENSURE, UNIVERSITIES AND GUILDS: DUTY TO THE STATE AND TO THE PROFESSION If one development were to be identified as the single most significant element in the history of medical deonto-logy, i t might well be the change from the practice of me-dicine as a right to the practice of medicine as a p r i v i -lege. This occurred in the late Middle Ages, brought about by movements both from outside and within the medical pro-fession, namely the imposition of licensure requirements by secular or ecclesiastical authorities in an attempt to protect the public from charlatans, and the organization of medical and surgical guilds (to include universities) by practitioners in an effort to secure and protect a mono-poly in providing medical and surgical service. In this chapter I shall f i r s t discuss the occasional attempts in secular law of regulating medical practice prior to the advent of licensure and guilds. Next to be treated w i l l be the developing concern of the state to protect the people and of medical practitioners to establish a monoply in health care delivery. The result of these developments was a fundamental change in the basis for practising medi-cine, a change from a right to practise to a privilege to practise. We shall see a resulting reciprocity of o b l i -gations where, in exchange for the privilege of practising 116 117 and exercising a monopoly, the profession assumed certain obligations both to the state and to the people, that i s , a responsibility to the community. In the early Middle Ages there i s l i t t l e evidence of attempts made in secular law to regulate medical practice. Of the sundry codes of early medieval law, known collec-tively as the Leges Barbarorum, there are several that mention physicians. The Pactus Legis Alamannorum, promul-gated around 613, contains a provision that, in the event that one strikes another's head and a dispute arises over the severity of the wound, " l e t the physician take a solemn i oath with his iron tools." In the Leges Alamannorum, writ-ten between 7 1 7 and 7 l 9 » and in the Lex Baiwariorum, dating from 7*+^-7^8, a somewhat similar forensic role is assigned to physicians in cases of head wounds. Of the Lombard Laws, Rothair's Edict, promulgated in 643, contains seve-r a l laws specifying that in the case of injury to another's slave, the offending party must pay a fine for damage, com-pensation for work lost, and the physician's fee.^ It is 1. Pactus Legis Alamannorum, I, 2, in Laws of the  Alamans and Bavarians, trans, with an introduction by Theo-dore John Rivers (Philadelphia: University of Pennsylvania Press, 1977), -+7. 2. Leges Alamannorum, LVII, 5-7» ibid., p. 865 Lex  Baiwariorum, V, 3 i ibid., p. 135« 3 . Rothair's Edict, 82-84, 87, 89, 9^, 9 6 , 101-103, 106-107, ilO - 1 1 2 , and 118 in The Lombard Laws, trans, with an introduction by Katherine Fischer Drew,(Philadelphia: University of Pennsylvania Press, 1973). These involve treatment of blows in general, blows to the head resulting 118 s p e c i f i e d that he who struck the blow should seek the phy-. . 4 s i c i a n . Pierre Riche, i n h i s masterful study of education and culture in the early Middle Ages, writes: "From the time they came into the Empire, the Barbarians showed great i n -t e r e s t i n medicine and protected those who devoted them-selves to i t . " ^ The absence of measures i n most early me-diev a l codes r e s t r i c t i n g medical practice would seem to lend support to h i s assertion. One notable exception i s V i s i -gothic law which has one section containing several laws devoted to regulating medical p r a c t i c e . ^ These laws have been severely c r i t i c i z e d i n surveys of medical h i s t o r y , f o r example by F i e l d i n g H. Garrison and Max Neuburger: "Under the Visigoths i n Spain, the a c t i v i t i e s of the medi-7 c a l profession were crushed by a Draconic code of laws."' i n breakage, breaking arms, breaking hip bone or shin bone, blows to chest with a sharp or blunt instrument, puncturing of arm or l e g , cutting o f f nose, ears, l i p s , b ig toe, thumb, or f i f t h f i n g e r . 4. Rothair's E d i c t . 128. 5. Pierre Riche, Education and Culture i n the Bar-barian West: Sixth through Eighth Centuries * trans, from the t h i r d French e d i t i o n by J . J . Contreni (Columbia: Uni-v e r s i t y of South Carolina Press, 1976), 70. 6. In Monumenta Germaniae H i s t o r i c a , Legum Sectio I, 1. For a recent treatment of V i s i g o t h i c law, see P. D. King, Law and Society i n the V i s i g o t h i c Kingdom (Cambridge: Cambridge University Press, 1972). 7. F i e l d i n g H. Garrison, An Introduction to_the His-tory of Medicine (Philadelphia: Saunders, 1929), 146. 119 In Spain . . . the schools of the Imperial era dege-nerated , . . and with them also the medical status, the profession declining to the level of a trade. The small esteem in which i t was held is shown by the l e -gal enactments of the Visigoths. . . . Limitations of medical activity, such as are found amongst the V i s i -goths, are not known in the legal systems of other nations. . . . Such draconic enactments naturally hin-dered medical action, for none but itinerant quacks could escape the criminal dangers threatening treat-ment . 8 o I have previously 7 argued that Garrison and Neuburger and many other medical historians have greatly exaggerated the severity of Visigothic medical legislation; that, in V i s i -gothic law, the laws governing physicians did provide cer-tain safeguards both to the physician and the patient; were not, considering the absence of medical licensure regula-tions, unduly harsh; did not excessively hinder medical action; did not limit the medical profession to none but itinerant quacks; nor necessarily indicate that the medi-cal profession was held in small esteem or that medical practice and medical ethics were at a low level. The laws in question appear as T i t l e I of Book XI of the Lex Visigothorum under the rubric De medicis et egro-t i s ("Concerning physicians and sick persons"). The Lex  Visigothorum was promulgated in 654 by Reccesswinth. Over half of i t s laws are labeled Antiquae, ancient laws, that i s , from codes promulgated by Euric (475) or Leovigild 8. Max Neuburger, History of Medicine, trans, by E. Playfair (London- Oxford University Press, 1925), vol. 2, part 1, pp. 10 f. 9. Darrel W. Amundsen, "Visigothic Medical Legisla-tion," Bulletin of the History of Medicine. 1971, 45: 553 f f . 120 (between 572 and 586) . There are eight laws in the sec-tion dealing with physicians. One law demonstrates that there was continuation of the Greco-Roman medici-discipuli educational system in Visigothic Spain: Lex VII. Antigua: "Concerning an ap-prentice's fee. If any physician should take an atten-dant into his instruction, l e t him receive twelve s o l i d i for his services." As in classical times, the level of medical education for physicians would depend in great part on the proficiency and philosophy of the individual instructor. In the education of Visigothic physicians we cannot ascertain the curricular ratio of precepts and oral instruction to that of observation and experience. Since the practice of medicine probably was for most Visigothic medici a craft, l i k e l y for the majority, as was the case in Greece and Rome,, the practical aspects of apprentice-ship played the dominant i f not the exclusive role. Lex V. Antigua: "If a physician should remove cata-racts from the eyes. If any physician should remove a cataract from an eye and restore the patient to his former condition of health, l e t him receive five s o l i d i for his services." Since the stipulation in this law concerns the fee for successful operation and since there i s no mention of penalty for the physician i f damage to the patient re-sults, in light of the concern which we shall see in V i s i -gothic law for the welfare of the patient, i t is probably 121 reasonable to conclude that in this particular area of practice there were at least some physicians whose com-petence was relatively high. This is the only law that specifies a fixed fee for a particular medical procedure. The physician's receiving his fee was made contingent upon the success'of his treatment apparently only in the case of cataract removal. Lex III. Antigua: If a physician should be sought under contract on account of i l l n e s s . If anyone should request that a physician treat him for a dis-ease or cure his wound under contract, when the phy-sician has seen the wound or diagnosed the illness, immediately he may undertake the treatment of the sick person under conditions agreed upon and set forth in writing. This law provides for the possibility of the physician/ patient relationship being contractual. It does not make a written contract mandatory, nor does i t in any way spe-ci f y content or form of contract, should one be drawn up, but leaves these up to the discretion of the individuals involved. This law i s not inherently prejudicial either to physician or patient. If a physician should guarantee the results of an operation or treatment or sign any con-tract that he could not f u l f i l l , i f i t were specified that the payment of his fee was contingent upon success, this would be the result of his own poor judgment, not the product of unfair legislation. Lex IV. Antigua: If a sick person who has been treated under contract should die. If any physician should undertake the care of a sick person under con-tract reduced to written obligation, let him restore the patient to health. Assuredly, i f the patient 122 should die, the physician shall definitely not re-quire the fee specified in the contract; thereafter no malicious suit shall be brought against either party. A physician, of course, i s judged to a degree by the re-covery or death of his patient, although the apparent re-sults of treatment may be due to many causes other than the a b i l i t y or incompetence of the physician. Obviously, a physician cannot be liable to criminal investigation for every instance in which a patient does not recover. Visigothic law alleviated the threat of malpractice suits to a great extent in the case of a patient's death by the promulgation of this law under which a physician could not be charged with homicide after unfortunate termination of a case following his treatment. Of course, forfeiting a fee after one has conscientiously tried every possible means to help a patient i s unfortunate, but immunity from criminal action brought by vindictive relatives of the de-ceased i s some compensation. The only law in the Lex Visigothorum which deals spe-c i f i c a l l y with the punishment for what we could c a l l mal-practice pertains to phlebotomy. In Recceswinth*s code (654)J Lex VI. Antigua: "If a free man or a slave should die due to phlebotomy. If any physician, while he bleeds a patient, should debilitate a free man, let him be com-pelled to pay 150 s o l i d i ; i f , however, the patient is a slave, let him replace the slave with one of equal value." One often associates with medieval medicine the "barber 1 2 3 surgeon" whose "surgical" panacea was phlebotomy. Dis-cussing the popularity of this type of treatment in early medieval times, Loren C. MacKinney writes: Most prominent was the process of cupping or blood-letting. It was employed constantly for a l l sorts of ailments, especially fevers. Sometimes the re-sults were admittedly precarious? early medieval l i -terature contains references to the dangerous swel-lings that followed the operation. Many a person in medieval times must have been bled to death.1° The Visigoths, not borrowing this law from earlier known codes, indeed must have been cognizant of the possibly harmful results of this manner of treatment to have en-acted legislation of this nature. Such a law, i f enforced, ought to have discouraged the indiscriminate practice of phlebotomy; yet a need to enlarge i t s scope was apparently f e l t , as shown by the revision promulgated by Erwig ( 6 8 0 -6 8 7 ) : Lex VI. Antigua > If a free man or a slave should die due to phlebotomy. If any physician, while he bleeds a patient, should debilitate a free man, let him be compelled to pay 1 5 0 s o l i d i . If, however, the patient should die, the physician must immediately be handed over to the relatives of the patient so that they would have the power to do with him whatever they wish. If, however, he should debilitate or k i l l a slave, l et him replace the slave with one of equal value. The provision for a physician being turned over for ven-geance to the relatives of the patient whom he had bled to death may seem to be extremely harsh. The degree of the harshness of a law can be evaluated in different terms. 1 0 . Loren C. MacKinney, Early Medieval Medicine, p. 3 9 . 124 It can be compared to present standards of justice, in which case this law would seem most severe; i t can also be analyzed in respect to i t s degree of severity in com-parison with the concepts of justice and punishment in-herent in the code in which the law is found. In the Lex Visigothorum punishments were relatively mild for the times and the extent of employment of the lex talionis, i.e., retribution in kind, was limited. There were cer-tain crimes for which the principle of "an eye for an eye and a tooth for a tooth" was imposed and in some cases more severe punishment exacted so as to act as a deter-rent: "The savage temerity of some persons must be legally punished by more severe penalties, so that, when anyone fears to suffer for what he has done, at least unwillingly 11 he would abstain from the commission of crime." The in-jured party could opt in certain cases for pecuniary com-pensation from his oppressor (wergeld), in l i e u of r e t r i -bution in kind, with the amount at his discretion. In many instances, though, a fine was stipulated to be paid to the injured party, for example 50 s o l i d i for the loss of a thumb, 100 s o l i d i for the loss of a nose. The seve-r i t y of the punishment of the physician who bleeds a free man to death is probably indicative of the extent of de-bilit a t i o n s and deaths resulting from the indiscriminate 1 1 . Lex Visigothorum XI, 4 , 3 . 125 practice of phlebotomy. After the enactment of Erwig's revision, i t is very probable that the practice of phle-botomy decreased to the mutual benefit of patients' health and physicians' reputations. Another law dealing with phlebotomy is Lex I. Antiguas A physician shall not presume to bleed a woman in the absence of her relatives. No physician shall presume to perform a phlebotomy on a free woman without the presence of her father, mother, brother, son, or uncle or any other relative, unless the exigency of the i l l -ness demands i t . Now, when the above named persons  are not present, then, in the presence of respectable  neighbors or in the presence of suitable male and fe-male slaves, let him apply what he knows according to  the nature of the il l n e s s . If he should presume other-wise, let him be convpelled to pay ten s o l i d i to her relatives or husband, because i t i s not very d i f f i c u l t , on such an occasion, for wantonness occasionally to oc-c u r . ^ Some medical historians wax exceedingly indignant about this law, as i f i t were an insult to the integrity of the medical profession as a whole. Perhaps they do so justly; but let us consider the practical implications of this piece of legislation. It is reasonable to assume that the enactment of this law, unprecedented in other, earlier l e -gal codes, was brought about by circumstances that made i t at least seem to i t s enactor to be warranted. We cannot assume that the unlicensed medici of Visigothic Spain were one and a l l of extremely high moral fiber. Neither, on the basis of this law, can we relegate the Visigothic physicians as a whole to the unsavory category of wanton violators of debilitated women, nor can we interpret this as an indica-12. Sections in i t a l i c s were added by Erwig's revision. 126 tion that members of the medical profession were held in a position of deepest distrust by the Visigothic legislators. Even i f there had not been one case in which a physician had actually abused a woman weakened by phlebotomy, i t is not unlikely that there were some physicians accused of doing so. The debilitating and sometimes syncopic effect of phlebotomy could make i t in some ways, although certainly not in a l l respects, analogous to anesthetization. George R. Fowler stresses the importance of a physician not ad-ministering an anesthetic to a woman without a witness being presenti The necessity of always having witnesses at hand when anaesthetics are administered to female patients has been more than once insisted upon. Experience shows that young women often have voluptuous sensations while under the influence of an anaesthetic, during which time their clothing may become soiled with mucus. Upon awakening they w i l l affirm, with the greatest positiveness, that they have been violated sexually during the anaesthesia. This may arise in part from the fact that women fear that the person administering the anaesthetic might take advantage of their helplessness. The impression may continue after awakening, the fear being changed into a belief of the impression as a reality. The importance of observations upon this point is apparent when the fact is borne in mind that more than a few persons thus accused have suffered punishment, although in the light of subsequent events i t was deemed more than probable that they were innocent.!3 Even though the law under consideration was probably in-tended more for the protection of the patient than the physician, i t undoubtedly served to benefit both. 13. George R. Fowler, "Surgical Malpractice," in A. M. Hamilton and L. Godkin, A System of Legal Medicine 2 (New Yorks E. B. Treat and Co., 1906), vol. 2, p. 595- I assume that 127 Another prohibitive law i s Lex II. Antiguas A physician shall not presume to v i s i t those confined in prison. No physician shall presume to enter where governors* tribunes, or deputies are held in custody, without the keeper of the prison, so that those through fear of their crime would not seek from him a means of death for themselves. For i f anything deadly should  be furnished or administered to these by the physicians  themselves, the course of justice would be greatly ob-structed. If any physician should presume to do this, let him receive judgment along with punishment.!^ We cannot assume the ethical standards of a l l who would c a l l themselves medici and undertake to practise medicine were compatible with those expressed in the so-called Hip-1 5 pocratic Oath J or with Christian attitudes toward suicide 16 and euthanasia. It is l i k e l y that at least the educated physicians practising in Visigothic Spain were Romans, i.e., Hispani, rather than Visigoths, and some indeed may have f e l t no qualms about following the strong Greco-Roman tra-17 dition amenable to euthanasia. ' For the state to guard against activity of this nature and to punish those guilty of such action does not seem to be either unduly repressive nor necessarily an adverse reflection on the ethical level of physicians of that time and place. Fowler is here thinking specifically of the effect of ether. Such physiological effects would not necessarily occur in a woman rendered syncopic by phlebotomy, but nevertheless the psychological effects could be analogous. 14. Sections in i t a l i c s were added by Erwig's revision. 15. As discussed in Chapter I, above. 16. As discussed in Chapter II, above. 17. See above, Chapter I. 128 The last law dealing with physicians is indeed favor-able to members of the medical profession: Lex VIII. Anti-gua : "A physician shall not be imprisoned without a hearing. No one shall confine a physician in prison without a hearing, except in the ease of homicide. Nevertheless, when charged with debt, he must provide a surety." This places the medici in an almost unique position in Visigothic law and raises the question of how legislators and judges determined who was and who was not a medicus. There is no evidence at a l l of any state-supported medical f a c i l i t i e s ; indeed, the evi-dence available i s most conclusively indicative of their absence. Criteria used probably were somewhat arbitrary: those who had established practice in the community would l i k e l y qualify for this exemption whereas itinerants would 18 not. It appears, then, that a physician charged with malpractice would be entitled to a formal hearing and would not be subject to retention pending t r i a l in the event of an accusation having been f i l e d against him. The clause excepting cases of homicide would not apply to cases of alleged malpractice resulting in the death of a patient since, as we have seen, in the event of a patient's death, the physician was contractually protected against suit by virtue of the forfeiture of his fee, except, as noted, in the case of death resulting from phlebotomy. 18. John M. Riddle cites this definition with appro-val in his a r t i c l e "Theory and Practice in Medieval Medi-cine," Viator, 1974, 5 : 166, n. 3 6 . 129 These laws are relevant to a discussion of medieval medical ethics for a variety of reasons. Their promulga-tors appear to have been motivated by a desire to protect the public from certain kinds of at least potential abuse by physicians and to protect physicians from vindictive patients or the latters' relatives. The law makers ap-parently considered i t to be in the best interest of the state to regulate the fees that a physician could receive for training an apprentice and for successfully performing cataract surgery, and to extend to them certain legal p r i -vileges as well. While such legislation was designed to regulate medical activity for the benefit of patient and physician alike, to check abuses and encourage responsible practice, i t f a l l s far short of that most significant step in regulating medical practice for the common good, namely limiting the practice of medicine to those who meet a set standard of training and competence. Additionally these laws are anomalous. There i s , to the best of my knowledge, nothing similar in Western medico-legal history. They also seem to represent a possible groping toward medical licen-sure. But owing to the fate of Visigothic c i v i l i z a t i o n , these laws are only a cul-de-sac in the history of the ex-ternal regulation of medical practice. As far as I have been able to determine, i t is not u n t i l the twelfth century that another attempt to regulate medical practice appears in Western law and that is in the 130 Latin (Crusader) Kingdom of Jerusalem.1*7 After Jerusalem was conquered by the crusaders in 1099, Godfrey of Bouillon, as Baron and Defender of the Holy Sepulchre, created two courts: the high court (Haute 20 Cour) and the lower court (Cour des Bourgeois). Cases between members of the nobility were judged in the high court and those between the free non-nobles in the lower 21 court. Litigation between noble and non-noble was held 22 in the lower court. Local tradition in the Latin King-dom of Jerusalem held that Godfrey had also ordered a compilation of the existing usage of his day, the so-called Lettres du Sepulcre. These were not a formal code of laws but consisted of provisions drawn up to meet the immediate contingencies of the newly created kingdom. They were re-19. Much of this section is drawn from Darrel W. Amundsen, "The Medical Legislation of the Assizes of Jeru-salem," in Proceedings of the XXIII International Congress  of the History of Medicine. London, 2-9 September 1972 (London: Wellcome Institute of the History of Medicine, 1974), vol. 1, pp. 517 ..ff. 20. Livre de Jean d'Ibelin, I, 2, in A. A. Beugnot, Les Assises de Jerusalem (Paris: Imprimerie royale, 1841-1843), vol. 1, p. 23. 21. It should be noted that the high court did not stand in appellate relation to the lower court. 22. J. L. LaMonte, Feudal Monarchy in the Latin King-dom of Jerusalem 1100-1291 (Cambridge, Mass.: Harvard Uni-versity Press, 1932), 106. 131 v i sed, amended and added to as the occasion arose hut the ent i re code was l o s t when Jerusalem f e l l to Saladin i n 23 1187. J Oral t r a d i t i o n "based on f a m i l i a r i t y with the Let t res du Sepulcre was that upon which the customary law was founded that governed the kingdom u n t i l the compila-t i o n of the two major d i v i s i on s of law of the kingdom that are extant: the Assises de l a Haute Cour and the Assises oh. de l a Cour des Bourgeois. In the l a t t e r are contained various regulat ions governing the medical p ro fe s s i on . 2 ^ There has been considerable debate as to the date of the w r i t i n g of the Ass izes of the lower court. They were, however, compiled during the f i r s t ha l f of the t h i r -26 teenth century. Much of the Ass izes of the lower court 23. I t has become fashionable to deny the very ex i s -tence of the Lett res du Sepulcre; however, f o r a defence of t h e i r h i s t o r i c i t y , see J . L. LaMonte, "Three Questions con-cerning the Ass ises de Jerusalem," Byzantina-Metabyzantina, 1946, 1: 204 f f . 24. These are published in Beugnot, Les Ass ises, vo l s . 1 and 2 respect i ve ly . 25. There are i n the Ass ises de l a Haute Cour a few references per ta in ing to forens ic medicine. For these see R. P. B r i t t a i n , "The History of Legal Medicine: The Assizes of Jerusalem," Medico-Legal Journal , I 9 6 6 , 34: 72 f . B r i t -t a i n ' s concern here i s s t r i c t l y l im i t ed to forens ic medicine i n the Haute Cour. 26. M. Grandclaude, i n h i s exce l lent study of the As-s i zes (E*tude Cr i t i que sur l e s L i v re s des Assises de Je ru - salem (Paris: Jouve, I923 ], 66 f f . ) sets the date of com-pos i t i on between 1229 and 1244; J . Prawer (L 'etablissement des coutumes du marche a Saint-Jean d'Acre et l a date de composition du l i v r e des Assises des Bourgeois," Revue  h i s tor ique Dro i t Francais et Etranger, 1951, 28: 346 f f . ) argues for a more l im i t ed per iod, 1240-1244. 132 seems to be case law, that i s specific law based upon pre-cedent. Whether any particular section was based on the transcript of an actual adjudication or on oral tradition is usually impossible to determine. Nor can we assume that this code gives a picture of conditions in the Latin King-dom of Jerusalem for any specific point in time. These were not r i g i d laws but were subject to change. Accor-dingly, the extent to which any part represents customary law and procedure of the early Latin Kingdom of Jerusalem i s highly debatable. Chapters 236 and 238 of the Assises de la Cour des 27 Bourgeois are devoted to medical regulations. Although the text does not divide the chapters into individual rub-r i c s , chapter 236 contains eleven different laws and chap-ter 238, twelve. Eighteen of these twenty-three laws are concerned with the l i a b i l i t y of the physician for what we would term negligent or ignorant malpractice. The making of a physician's l i a b i l i t y dependent upon the unfavorable results of specific types of treatment was employed exten-sively by the Cour des Bourgeois. In chapter 236 there are three laws dealing with the improper treatment of wounds, one with the improper treatment of a b o i l , a l l resulting in the death of the patient. In each of these the patient was a slave. In a l l of these instances the physician is ordered to pay to the slave's owner as much as the slave was worth while in good health. In chapter 27. In Beugnot, Les Assises, vol. 2, pp. 164-169. 133 238 there are eight cases of improper treatment of ailment resulting in the death of a slave. These range from admi-nistering laxatives to a patient with dysentery to burning out the intestine in an attempt to cauterize hemorrhoids with a hot iron. In these also the physician must indem-nify the owner for the death of his slave. There is in chapter 236 one case where a physician poorly set a slave* broken arm or leg causing him to be crippled. The court ordered the physician to buy the slave for the sum he was worth before his injury or, i f he lacked the means, to pay to the slave's owner the amount of the slave's diminution of value. Roman law indirectly provided the basis for a great part of the Assises de l a Cour des Bourgeois. Jurists in the Latin Kingdom of Jerusalem could easily have found legal' precedents in Roman law for making the physician, who by negligence or incompetence caused the injury or death of a slave, responsible for indemnification of the 29 slave's owner. 7 Not so, however, when the patient who 28. LaMonte, Feudal Monarchy, p. 101, n. 5. Accor-ding to J. Prawer ("FJtude preliminaire sur les sources et l a composition du 'Livre des Assises de Bourgeois, "'Revue  historique Droit Francais et Etranger, 195^, 31> 210 f . ) , the section in which the medical regulations appear was not influenced extensively by Roman legal principles nor is there any indication in that section of borrowing from earlier or contemporary codes. 29. The law that detailed procedures for claims re-sulting from damage to property was the Lex Aquilia, for which see F. H. Lawson, Negligence in the C i v i l Law (Oxford Clarendon Press, I950). 134 was injured or k i l l e d by the negligent or incompetent phy-sician happened to be a free man or a free woman. There was no penalty in Roman law for the negligent injuring or k i l l i n g of a free man. Intent was a necessary factor in homicide. Also, since there was in Roman law no appli-cable concept of tortious l i a b i l i t y , at the most the neg-ligent or incompetent physician would be liable only for expenses. The Cour des Bourgeois, in dealing with the k i l l i n g or injuring of a free man or a free woman by a negligent or incompetent physician, made the matter of in-tent irrelevant. In chapter 2 3 6 there are three laws dealing with the treatment of wounds, one with the treat-of a bo i l , a l l resulting in the death of the slave-patient. After these appears the following provision: And i f this physician has thus, as i s stated above, badly treated any free man or free woman and he dies from i t , reason judges that this physician ought to be hanged and as much as he owns ought to be the lord's by right. But i f the physician has received something from the dead man, this ought to be given to the relatives of the diseased from the possessions of the physician, for this is right and reason. Also in chapter 236 i t is ordered that, i f a physician so badly sets a free person's broken arm or leg that he is crippled on that account, he ought to have his right hand cut off and be compelled to return any fee that he had received. In chapter 238, following those treatments lis t e d that had proved fatal to patients who were slaves, appears this stipulation: Likewise, i f any physician has thus treated any 135 free man or free woman, reason judges and commands that this physician ought to he hanged and that a l l that he owns be given to the lord. But before he i s hanged, he ought to be whipped through the city with a urinal in his hand, for this is right and reason to frighten the others from this malpractice, for this is right and reason by the assizes. The concern of the court here was not directed toward the compensation of the victim or his relatives seeking redress. Nor is this an instance of the application of the lex t a l i o -nis as was the case in Visigothic law that provided for the physician who bled a free man to death be turned over to the deceased's relatives. The severity of the punish-ment of physicians in cases such as these in the Latin Kingdom of Jerusalem, indeed the very necessity of judg-ments of this nature, l i s t i n g a wide variety of specific treatments considered blatantly improper for specific a i l -ments, i s surely an indication that a f a i r l y sizeable seg-ment of the medical profession was of a low calibre. This was not an attempt on the part of the promulgators of law to establish a fixed body of proper and improper medical procedures. The Assises de l a Cour des Bourgeois are, after a l l , case law. As individual cases were judged, pre-cedents would be established based on the peculiarities of the case at hand. It had to be "proved" that the accused physician had in fact followed improper procedures i f he was to be found guilty of responsibility for a patient's death. In chapter 238 one law specifies that in the event of a patient's death owing to the physician's malpractice, "there must be due witness by law." If the physician denies 136 that he followed the procedure that was thought to have ki l l e d the patient, witnesses must "swear on the saints that they saw him prescribe such medicines and such syrups for the patient, and that because of this he died . . . and that they heard the patient say that because the phy-sician had given him such things he f e l t within his body that he was dying." It is reasoned that such witnesses are necessary, for the physician "must not be accused simply on the word of people or of the patient alone with-out anything more." In chapter 236 there appears the pro-vision that i f the physician can demonstrate in court, through a good witness, that the person whom he treated either had lain with women, drunk wine, or consumed any bad food that the physician had forbidden him, or did any-thing that he was not supposed to do . . . even i f the physician had treated him otherwise than he should have, he is not l i a b l e , because i t is better reason to understand that he died because he should not have done what was forbidden rather than by bad doc-toring. . . . While most of the laws in this collection specify im-proper procedures for which a physician is liable, l i t t l e is said about the physician's active responsibilities or omissions for which he is li a b l e . In chapter 236 one sec-tion readsJ "But i f the misfortune happens to the physician that, after he has taken a patient under his care, he be captured by the Saracens or is himself taken i l l , or otherwise cannot care for the patient and the patient dies, reason judges that the physician not be held liable." This implies that the physician who through negligence failed to 137 attend his patient was legally culpable in the event of the patient's death. There i s , indeed, only one law that specifically states an active responsibility incumbent upon the medical practitioner. In the event that a physician had not forbidden the patient certain a c t i v i t i e s or foods and he died on account of such a c t i v i t i e s or foods, "reason judges that the physician be held liable because he i s re-quired by law to command the patient, as soon as he has seen him, as to what he i s to eat and what he ought not to eat, and i f the physician does not do this and i l l results, this must be the responsibility of the physician." The responsibility of the promulgators of law to pro-tect the general public from quacks, charlatans and pseudo-physicians reaches i t s highest realization in the estab-lishment of an enforceable system of medical licensure. And the Assises de l a Cour des Bourgeois did create a sys-tem of medical licensure of sorts. No foreign physician, whether he came from Christian Europe or from pagan coun-30 t r i e s ^ was allowed to practise medicine "by means of urine" 30. William of Tyre asserts that the nobility of the Latin Kingdom, through the influence of their women, pre-ferred the services of Jewish, Samaritan, Syrian, and Saca-cen physicians to Latin physicians (Rerum in partibus trans-mar in is gestarum, 18, 34). The Synodicum Nicosiense in March 1252, under Hugh of Fagiano, Archbishop of Nicosia, whose area of jurisdiction included the Latin Kingdom of Jerusalem, contains the following prohibition: "Prohibemus etiam dis-t r i c t e , ne quis Christianus sanus aut infirmus medicum ad-vocet infidelem, Judaeum videlicet aut Saracenum: sed nec ab eo, vel de eius consilio medicinam aliquam recipiat, quia hoc pia confideratione in sacris canonibus prohibetur. Nam 138 u n t i l he had been tested by other physicians, the best in 31 the land, in the presence of the bishop. If found com-petent, he would be given letters from the bishop certifying 32 that he could legally doctor by means of urine. The law goes on to say that i f he is not found to be a good physi-cian, the bishop and court must command that he leave the city or remain in the city without practising medicine. It does not state, however, that he would be allowed to con-tinue practising medicine but without the right to use urine analysis (i.e., uroscopy) as a diagnostic and prog-nostic method. Further, i t says that i f any physician practises medicine in the city without leave of the court and the bishop, he must be seized and thrown out of the city. ex hoc contingit nostram fidem haberi despectuis cum ip s i Judaei vel Saraceni, huiusmodi Christianorum u t i ministerio dedignentur, et reputent propter hoc offendere suam legem" (in J. D. Mansi, Sacrorum conciliorum nova et amplissima  collectio, vol. 26, col. 314). This prohibition is repeated in the Constitutio instruens Graecos, ibid., col. 328 f. It was apparently ignored: e.g., shortly after this, Hugh III, King of Jerusalem and Cyprus, is known to have had a Jewish court physician. 3 1 . A. F. Woodings, "The Medical Resources and Prac-tice of the Crusader States in Syria and Palestine 1096-1 1 9 3 , " Medical History. 1 9 7 1 , 1 5 : 269, errs in ascribing to the bishop, on the basis of this law, either the right or the a b i l i t y to judge the competence of the candidate. 32 . Chapter 238, Beugnot, Les Assises, vol. 2, p. I 6 9 . 33- Ibid. 139 Once again there is no mention of practising medicine by means of urine. Accordingly, i t seems that any physician who wished to engage in any type of medical practice would f i r s t have to submit to an examination of his a b i l i t y to 34 diagnose through urine analysis. What was the source of their policy of medical licen-sure? We shall be turning presently to a discussion of the medical licensure legislation of S i c i l y , f i r s t by Roger II in 1140 and then by Frederick II in 1231. If we knew the date of the in i t i a t i o n of the system of medical licensure in the Latin Kingdom of Jerusalem, i t might prove helpful in determining whether or not any relationship existed be-tween i t s institution and the developments in S i c i l y during the twelfth and thirteenth centuries. It is very possible that the medical licensure provisions of the Assizes of Jerusalem antedate the legislation of Roger II. It would then be the f i r s t known provision for medical licensure in 35 the western world. Since the arrangement of the Assises 34. There is no evidence to indicate that there was any dichotomy between the practice of medicine and surgery. I n i t i a l l y there might seem to be evidence to support such a contention: The cases in chapter 236 deal primarily with what would be under the purvue of the surgeon and those in chapter 238 for the most part involve medicine. In the pu-nishment ordered for the guilty physician, the major d i f f e -rence between the two chapters is that in chapter 238 there is the additional stipulation that the physician, before being hanged, is to be whipped through the city carrying a urinal in his hand. The same word, however, is used to de-signate the medical practitioner in both instances. 35. Unfortunately, the evidence i s scanty and incon-140 de la Cour des Bourgeois i s topical and not chronological, the fact that the provisions for licensure occupy the last part of the sections devoted to medical practice does not mean, eo ipso, that they were drawn up later than the rest of the same sections. But the provisions for licensure surely are not the product of case law and would not have been based on specific precedent as the other cases at which we have looked were. Yet the medical licensure pro-visions of the Latin Kingdom of Jerusalem were, in some ways, a reasonable consequence of case law. The attempt to define, punish, and curtail medical malpractice led to the creation of a primitive system of medical licensure not designed with the intent of their superseding the mal-practice laws but probably with the hope that need of ap-plication of the malpractice laws would be substantially diminished. The medical licensure regulations of the Kingdom of S i c i l y , mentioned above, are the earliest in the Western world that can be dated with certainty. In 1140, Roger II promulgated his Assizes of Ariano. Many of the statutes in this collection were later included by Frederick II in his elusive for dating these provisions. William of Tyre's story of the fear-motivated refusal of physicians to treat the feverish King Amalric with a purgative in the year 1174 could point to the existence of a precedent for one of the laws found in chapter 238. Although the Assises de la Cour  des Bourgeois were not written down in present form until the f i r s t half of the thirteenth century, many of their pro-visions are from the twelfth century. The medical regulations, of course, could be included among them. 141 Liber Augustalis or Constitutions of Melfi. One of these is entitled "Concerning acceptable experience for physi-cians." Its text reads: Whoever in the future desires to practise medicine must present himself to our o f f i c i a l s and judges to be examined by their judgment. But i f he should dare to practise otherwise, l e t him be incarcerated and a l l his goods confiscated. This is designed so that the subjects in our kingdom be not endangered by the i n c o m p e t e n c e 3 o Q f physicians . 3 7 While in the Assizes of Jerusalem an examination in uroscopy is specified, Roger's legislation simply stipu-lates that the candidate be examined. In the Assizes of Jerusalem the candidate i s examined by the "best physicians of the land, in the presence of the bishop," but in Roger's kingdom the examination is conducted by the king's o f f i c i a l s and judges. While we can assume that a concern with the 36. Imperitia - basically meaning inexperience. It was a technical term in Roman law which signified the i g -norance or incompetence that resulted from inexperience. 37. Two manuscripts of the Assizes of Ariano were found in the last century and have been edited by Francesco Brandileone, II Dirit t o Romano nelle Leggi Normanne e Sveve  del Regno di S i c i l i a (Rome: Frantelli Bocco, 1884). The law in question appears in one of these two manuscripts, the Codex Vaticanus, at t i t l e J6 (p. 115) and, except for a minor difference in the word order of one clause, is identi-cal to the text included by Frederick II in his Liber Augus-t a l i s and as printed in J. L. A. Huillard-Breholles, Historia  Diplomatica F r i d e r i c i II (Paris: H. Plon, 1852-1861), vol. 4 , part 1, p. 149. A translation is available in The Liber Augus-t a l i s or Constitutions of Melfi Promulgated by the Emperor  Frederick II for the Kingdom of S i c i l y in I231 , trans. and with an introduction and notes by James M. Powell (Syracuse: Syracuse University Press, I 9 7 I ) , I 3 0 . See also Edward F. Hartung, "Medical Regulations of Frederick the Second of Hohenstaufen," Medical L i f e . 1934, 41: 595. 1though no examining o f f i c i a l s are mentioned, i t 142 bonum publicum provided much of the motivation behind the licensure requirement in the Latin Kingdom of Jerusalem, in Roger's legislation such a concern i s succinctly a r t i -culated: "This is designed so that the subjects in our kingdom be not endangered by the incompetence of physicians." This difference between these two pieces of legislation is significant. The regulation in the Latin Kingdom of Jeru-salem appears to have been the response of the courts of that kingdom to extreme abuses of medical practice that had come to adjudication.-^ j-t w a s n o t a statute enacted by royal proclamation and was not the product of a philo-sophy of sovereign right and responsibility underlying the promulgation of a monarch's code. Such, however, was the case with Roger's legislation. Roger II, as king of S i c i l y , faced the monumental task of devising royal institutions for a land comprised of Greeks, is reasonable to assume that medical authorities were in-volved in the examination. Possibly the o f f i c i a l s mentioned were medical o f f i c i a l s of some sort. Contrary to the asser-tion made by Henry E. Sigerist ("The History of Medical Licen-sure," Journal of the American Medical Association, 1 9 3 5 , 104 1 0 5 8 ) , no mention i s made of the school of Salerno in Roger's medical legislation. See Paul K r i s t e l l e r , "The School of Salerno, i t s Development and i t s Contribution to the History of Learning," Bulletin of the History of Medicine, 1 9 4 5 , 1 7 : 164 f. 3 9 - It i s , of course, possible that the regulation in question came well after Roger's, perhaps even after that of Frederick II ( I 2 3 I ) . The rulers of the Kingdom of S i c i l y were Norman and the Norman influence in the King-dom of Jerusalem was very strong. Relations between the two kingdoms were close and Frederick II was also King of Jerusalem, at least in name, for eighteen years. 143 Lombards, Arabs, Jews and the newly-arrived Normans, a heterogeneous land that had not been unified under a single authority since Justinian's reconquest of Italy in the sixth century. An examination of Roger's administration demonstra-tes a high degree of success on his part, a success that was the result of an administrative ableness and a legislative brilliance. Although overshadowed in nearly every area by his grandson, Frederick II, Roger II was, in his own right, 40 an exceedingly competent and gifted monarch. It was parti-cularly his view of the monarchy that made him distinct and provided the basis for the scope of his legislation? and Roger indeed held a lofty view of the monarchy. To Roger the royal office was absolute in two particular but comple-mentary aspects: in terms of i t s absolute power and in terms of i t s absolute responsibility. When discussing the exalted view of kingship exemplified in Roger's admi-nistration as embodied in his legislation of 1140 (the Assizes of Ariano), John Norwich asserts that "no other nation, no other legal code in mediaeval Europe conceived 41 of [kingship] in such sweeping terms." Although this may be an overstatement, in essence i t appears true. As A. Marongiu writes: 40. Ernst Kantorowicz, Frederick the Second 1 1 9 4 - 1 2 5 0 , trans, by E. 0 . Lorimer (New York: Ungar, I 9 3 I ) , writes that Roger II "had wrought indeed with great intensity and a wisdom and statesmanship amounting to genius" (p. 1 1 0 ) and refers to his "creative achievements as lawgiver in a newly conquered country" (p. 2 3 6 ) . 41. John J. Norwich, The Kingdom in the Sun 1 1 3 0 - 1 1 9 4 (New York: Harper and Row, I 9 7 O ) , 8 3 . 144 The Norman State was so coherently organized that a l l powers converged in the King. An introductory passage . . . of a Rogerian document of 1143 approp-riately expresses this ideas "as the rays of the sun illuminate everything, as the river f i l l s i t s bed, so the power of my majesty distributes grace to a l l sub-jects."^ 2 In distributing "grace to a l l subjects," Roger viewed himself then as the source of a l l justice and, as sovereign, his very prestige "rested in his defense of justice and pre-vention of abuse of power by o f f i c i a l s , prelates, and feudal 43 lords. . . ." J While Roger's attempted curtailing of abuses of power by o f f i c i a l s , prelates, and feudal lords may have been motivated both by self-interest as monarch and by a con-cern for the general welfare of his subjects, his medical licensure legislation seems to have been motivated by a royal altruism directed toward the benefit of his subjects and is f u l l y consonant with his apparent philosophy of regal responsibility. Holding an even more exalted view of royal right and responsibility than Roger II, his grandson Frederick II has been described by Ernst Kantorowicz as the only monarch of the thirteenth century who l i t e r a l l y acted in accord with 44 the new maxim Rex est imperator in regno suo. Describing 42. A. Marongiu, "A Model State in the Middle Agess The Norman and Swabian Kingdom of S i c i l y , " Comparative  Studies in Society and History, 1964, 6s 314. 43. Ibid. 44. Ernst H. Kantorowicz, The King's Two Bodiess A  Study in Mediaeval P o l i t i c a l Theology (Princetons Princeton University Press, 1957), 97 f f . See also Thomas Curtis van 145 himself as the "fountain of justice" and pater et f i l i u s  Iustitiae, J Frederick sought m his legislation to f u l -f i l l the role which he enunciates in the Prooemium to his Liber Augustalis as inhering upon a monarch: " . . . prin-ces of nature were created through whom the license of crimes might be corrected. And these judges of l i f e and death for mankind might decide, as executors in some way of Divine Providence, how each man should have fortune, 46 estate, and status." Frederick was, by any standards, a genius and w i l l probably always remain a fascinating enigma. He was a sensitive man of letters, an inordina-tely inquisitive and enlightened student of science, an able but ruthless administrator, called by some of his contemporaries (among quite a variety of other things) stupor mundi ("the wonder of the world") and immutator 47 mundi ("transformer of the world"). If much of Roger's legislation was motivated by a sense of responsibility for the welfare of his subjects, Cleve, The Emperor Frederick II of Hohenstaufen: Immuta-tor Mundi (Oxford: Clarendon Press. 1972). 100 f f . , 162 f., and 241. 45. Kantorowicz, The King's Two Bodies, pp. 97 f f . 46. Powell's translation, p. 4. 4 7 . For an assessment of Frederick's genius and personality, see Kantorowicz, Frederick the Second, near-ly passim but especially pp. 3 0 7 - 3 6 8 5 and van Cleve, The  Emperor Frederick II. also nearly passim, but especially his "Epilogue," pp. 531-5^0. 146 so also was Frederick's, assuming a consistency between the philosophy of government expressed in the Prooemium and the force of the laws in the Liber Augustalis. A. Marongiu comments that Frederick's state was not only an aesthetic creation, but above a l l , the fr u i t and the result of calculation and reflection . . . . One can discern in i t the man, the univer-sal student, the poet . . . enlightened and guided by the importance of his own mission, by the i n c i -siveness of his reasoning and by the firm temper of a constans v i r . Viewing Frederick's legislation in this light, Marongiu holds that his concern for the welfare of his people was not "from any sense of obligation toward his subjects" but was "because he f e l t such activity to be useful and reasonable." Further he asserts that Frederick "sought the maximum possible results, through distributive justice, order, and discipline, through the common dependence of a l l 48 on the law and on the sovereign." In 1231 Frederick II promulgated the Liber Augustalis or Constitutions of Melfi which contains three books. Between I23I and his death he issued new laws, Novae con-49 stitutiones. 7 A l l the laws with which we shall deal were part of the original Liber Augustalis except for one Nova  constitutio. 48. Marongiu, "A Model State," pp. 3I6 f. 49. These Novae constitutiones were inserted into the manuscripts^of the Liber Augustalis at Frederick's command. Huillard-Breholles, m his edition, separated the Novae con-stitutiones from the original legislation of the Liber Augus-t a l i s , printing them separately. 147 Placed immediately after Roger's medical regulation in the Liber Augustalis i s the following law: That no one should dare to practise unless he has been approved in a public examination by the Masters of Salerno. We take precautions for a special ad-vantage when we provide for the common safety of our fai t h f u l subjects. Therefore, being aware of the serious loss and irreparable damage that can result from the incompetence50 of physicians, we order that henceforth no one alleging the t i t l e of physician shall dare to practise otherwise or to give remedies, unless, f i r s t having been approved in a public exami-nation by the Masters of Salerno, he approach our presence with testimonial letters as to his loyalty- 5 and sufficient knowledge both from the Masters and from those appointed by us, or, i f we are absent, he may approach the presence of him who remains in our place, and obtain from us or from him a license to practise as a physician. The penalty of confiscation of their goods and a year's imprisonment threatens those who dare in the future to practise in defiance of this edict of our serene majesty.52 This law is similar to that of Roger in several ways. For one, a concern for the safety and welfare of the people is enunciated as the incentive behind this legislation. Se-50. See n. 36, above. 51. The word I have translated "loyalty" is fides, a word ranging in meaning from "faith" to "loyalty" to "trust-worthiness" to "safe-conduct." The meaning "loyalty" seems more consonant than other nuances with the tenor of the Liber Augustalis. The subjects of Frederick II were called fideles, about which James Powell, in his translation of the Liber Augustalis. writes: "I prefer to keep this term in the Latin because of i t s special connotations of a l l e -giance that no translation can f u l l y render. It denotes a bond of loyalty between ruler and subject" (p. 12, n. 22). Additionally, the emphasis on the quality of loyalty in the physician that appears in the license i t s e l f (which w i l l be discussed presently) supports the translation of fides as "loyalty." 52. Liber Augustalis, 3, 65? Huillard-Breholles, His-toria Diplomatica, vol. 4, part 1, p. I50. 148 condly, the right to grant the license to practise medicine s t i l l remains with the king. Thirdly, a severe penalty is to be imposed on those who practise without a license. The differences between these two pieces of legislation are the requirements for the candidates to be approved in a public 5 3 examination by the Masters of Salerno-^ and that candidates be able to present, from both the Masters of Salerno and royally appointed o f f i c i a l s , letters attesting their loyalty and knowledge. An example of a physician's license or diploma is con-tained in the correspondence of Petrus de Vineis, chief l e -gal adviser to Frederick, for whom the Emperor created the post of Logothetes. Petrus was probably the actual composer of the Emperor's laws. The text of the license or diploma reads: 53. The origin of the medical school at Salerno has excited a good deal of scholarship, theorizing, and specu-lation for several centuries, both by medical historians and historians of the medieval university. Some scholars have supported the tradition that the school was founded during Roman times. More recent scholars date the origin of the school to the ninth century. Although a vast bib-liography on Salerno exists, the previously-cited study by Kr i s t e l l e r remains s t i l l the most reliable. K r i s t e l l e r demonstrates convincingly that the medical school of Salerno originated toward the end of the tenth century and did not start as a university but simply as a group of practising physicians who taught students who came to Salerno to learn practical medicine. The school gradually developed a re-gular curriculum during the twelfth, and acquired legal status in the thirteenth, century.' 149 54 We make knovm for yourloyal compliance-^ that our loyal subject55 N. . . having approached our court, having been examined and having been found loyal56 and a des-cendent of a family of loyal subjects,57 and being ade-quate for the practice of medicine, is approved by our court. On account of this, having been made confident of his knowledge and legal status, and having received the oath of loyalty58 from him in our court, and an oath that he w i l l practise the art of medicine i t s e l f faithfully59 according to custom, we have given to him a license to practise medicine on these terms; that henceforth he must f a i t h f u l l y ^ 0 exercise the art i t -self for our honor and in loyalty to us, 61 and for the health of those who require him. Therefore we command, for the instruction of your loyal compliance,62 that no one shall hereafter hinder or disturb the above-mentioned N. . ., our loyal subject,"3 in exercising the art of medicine i t s e l f in these lands, as has been decreed.°^ The extent to which loyalty and faithfulness i s emphasized in this document should be noted. Only one direct reference to the welfare of patients i s made and that is subordinated 54. F i d e l i t a t i . 55. Fidelis. 56. F i d e l i s . 57. Fidelium. 58. F i d e l i t a t i s sacramento. 59. Fideliter. 60. F i d e l i t e r. 61. Ad honorem et fidelitatem nostram. 62. F i d e l i t a t i . 63. Fidelem. 64. Huillard-Breholles, Historia Diplomatica. vol. 4, part 1, p. 150,n. 2. 150 to the assertion that the physician "must fa i t h f u l l y exercise the art i t s e l f for our honor and in loyalty to us." But the very institution of medical licensure i t s e l f was, of course, a manifestation of concern for the general welfare, as also was the requirement, as evidenced in the license, that the physician had to swear that he would practise the art "according to custom." Included in the middle of a law dealing with the pre-paration of medicines,^ is the stipulation that "no one in the kingdom shall lecture in medicine or surgery, or take the t i t l e of master, unless he has been thoroughly examined in the presence of our o f f i c i a l s and of the mas-ters of the same a r t . " ^ A century before Frederick's time, Gilles of Corbeil had complained that some medical students at Salerno, who were too young and inexperienced, begin to teach and to practise medicine and, by virtue of the former activity, become masters. He did not indicate that there were any fixed requirements or formal procedures requisite to assuming the t i t l e and responsibilities of a master in medicine or surgery.^ If Gi l l e s is to be trus-ted, i t would seem that Frederick's legislation under dis-cussion here was motivated by a desire to eliminate such 65. To be discussed below. 66. Liber Augustalis, 3, ^7; Huillard-Breholles, His-toria Diplomatica, vol. 4, part 1, p. 151• 67. See K r i s t e l l e r , "The School of Salerno," p. 17^. 151 abuses by laying down, probably for the f i r s t time, fixed regulations governing the appointment of masters at Salerno. While the license to practise medicine was to be granted by the king, the authority to confer the t i t l e of master was to be in the hands of the school of Salerno. The in-terest of the monarch insinuated i t s e l f by the requirement that the examination was to be conducted in the presence of royal o f f i c i a l s . Some years after the promulgation of the Liber Augus-t a l i s , Frederick deemed i t desirable to issue a Nova con-68 stitutio under the rubric "Concerning physicians." The text reads: Because the science of medicine i s never able to be known unless something of logic i s learned before, we order that no one study in medical science unless he f i r s t study for at least three years in the science of logic. After three years, i f he wishes, he may ad-vance to the study of medicine in which he shall study for five years; and this in such a way that, in this period of time, he learn additionally the f i e l d of surgery which is part of medicine. After this and not before let him be granted a license to practise, once he has been examined according to legal formula, and also has received an affidavit from his faculty that he has completed the prescribed time of study. Such a physician shall swear to obey the laws in force up t i l l now, with this added that i f i t comes to his attention that any apothecary i s preparing drugs under standards, he w i l l denounce him to the court, and that he w i l l give advice ° to the poor gratis. 68. The date of this Nova constitutio i s uncertain, but probably by 1241. See Huillard-Breholles' introductory comments to this rubric (Historia Diplomatica, vol. 4, part 1, p. 235). 69. Consilium. The word can mean simply "advice" or "medical attention" in the broadest sense. The former would J 152 Such a physician shall v i s i t his patients at least twice a day, and, at the patient's request, once during the night. He shall receive from the patient per day not more than half a gold tarenus, provided he has not been called beyond the city or village limits. From a patient, however, whom he v i s i t s be-yond the city, he shall not receive per day beyond three tareni, when the patient has covered his own medicinal expenses, or beyond four tareni i f the phy-sician has paid for the medicines himself. He i s not to form an association witJi apothecaries nor is he to receive anyone of them under his patronage for the payment of a fixed sum, nor is he himself also to have his own pharmaceutical shop.? 0 No physician shall practise after completing his five-year period of training, unless he practise for an entire year under the direction of an ex-perienced physician. During the appointed five-year period the masters assuredly shall teach in the schools the authenticated books of both Hippocrates and Galen, in both the theory and practice of medi-cine. Moreover we enact, by a salubrious regulation, that no surgeon be admitted to practice unless he provide testimonial letters from the masters teaching in the medical faculty that for at least one year he has studied in that part of medicine which provides s k i l l in surgery, especially that he has learned the anatomy of human bodies in the schools, and that he is proficient in that part of medicine without which neither incisions can safely be made nor fractures healed.71 not contain the idea of the furnishing of drugs, while the latter would. It is unlikely that Frederick required phy-sicians to furnish the poor with drugs as well at their own expense. 70. The remainder of this paragraph deals with the regulation of apothecaries, a subject we shall consider presently. 71, Liber Augustalis, 3, 46: Huillard-Bre'holles, Historia Diplomatica, vol. 4, part 1, pp. 235 f f -1 5 3 This Nova constitutio, issued, as i t was, as much as a decade after the Liber Augustalis, lays down new regu-lations governing medical (and surgical) education, sets new standards of medical ethics, and provides one new ob-ligation to the state. F i r s t , in the area of medical education: Now three years of logic are required before commencing medical edu-cation proper. Then five years of medical education must be pursued during which the student is to be taught the "authenticated" (i.e., traditionally accepted) books of Hippocrates and Galen, and learn that part of medicine which is surgery. The student i s then to be subjected to an examination in accord with the law followed by a year of internship under a practising physician. Additionally, for the f i r s t time, licensure requirements for surgeons (who were not physicians qua surgeons) were set: One year of study under the medical faculty "of that part of medicine which provides s k i l l in surgery," especially human anatomy. The physician i s reminded of his obligation to obey the laws in force up to that time. It is now specified that he must v i s i t his patients at least twice each day and once during the night i f the patient wishes. The fees for v i s i t s are now fixed by law and depend in part on whether i t is necessary for the physician to travel outside his city or town. For the f i r s t time in secular law i t is required that the physician give his advice free to the poor. The 154 giving of free care to the poor is completely consonant with the emphasis of Christian ethics as we have seen above in Chapter II. But i t had been a matter that was l e f t entirely to the conscience of the individual physi-cian. To make medical charity mandatory was novel. It should be noted that the physician was required to give his advice free. This does not necessarily mean that he would be required to provide medications at his own expense. Further, the physician was forbidden to form an association with any apothecary or to own his own pharmaceutical shop. The potential for abuse when the physician prescribing medications profits from the sale of the drugs he orders is self-evident, as is the wisdom and perspicacity behind the promulgation of such an unprecedented regulation. While the concerns discussed in the preceding para-graph were entirely with the ethics of the profession, there is one requirement in this Nova constitutio that in-volves the physician's obligation to the state: The phy-sician must inform the authorities i f he knows of any apo-thecary who dilutes his drugs. Such a regulation as this makes every licensed physician functionally a potential agent of the state in respect to apothecaries. These laws of Frederick II are, in many respects, re-volutionary and create, at least in areas in which they were in force, a basis for medical practice starkly d i f -ferent from that which had prevailed previously in the 155 Western world. No longer was the practice of medicine a right of which anyone could avail himself, free enterprize without constraints other than those provided by individual conscience and the basic restraints of criminal law; but rather the practice of medicine was now a privilege, a p r i -vilege granted, enforced and protected by the state. These regulations basically were of benefit both to the general public and to the qualified and responsible physician as well, and evince a reciprocity of obligations between the profes-sion and the state. Yet these were regulations that were imposed by an absolute, albeit enlightened, monarch, not the end result of negotiation and agreement between trades-men or professionals and the state or civic authority. They were as unilateral as were regulations governing other oc-cupations in the Liber Augustalis. Reference has already been made to legislation gover-ning apothecaries. One law included in the original pro-mulgation of the Liber Augustalis reads as follows: About the number of loyal subjects to be appointed concerning electuaries and syrups. In every land of our kingdom subject to our jurisdiction, we desire that two circumspect and trustworthy men be appointed and be held by a corporeal oath, and that their names be submitted to our court, and that under their veri-fication electuaries and syrups and other medicines be tested by the Masters of Salerno.? 2 We also desire 72. At this point in the text are introduced the re-gulations governing the appointment of Masters at Salerno, discussed above, at n. 65. 156 that those preparing drugs be obliged by an oath sworn corporeally that they w i l l make them faith-f u l l y according to the arts and capacities of men in the presence of sworn witnesses. But i f they act con-trary, l e t them be condemned by sentence to the confis cation of a l l their goods. Furthermore, i f those ap-pointed, to whose trust the above specified matters have been committed, are proved to have practised fraud in the office entrusted to them, we order that they be put to death.73 A Nova constitutio, already discussed for i t s regu-lations governing physicians and surgeons, contains fur-ther regulations of apothecaries' a c t i v i t i e s : Apothecaries indeed are to make their confections at their own expense and with the prescription of a physician, in accordance with our regulations, nor are they permitted to keep confections unless they have taken an oath. They are to prepare a l l their confections in the prescribed manner without fraud. -Furthermore, the shopkeeper i s to be paid for his confections in the following manner: For compound and simple medicines which are not accustomed to be kept in the shop longer than a year after the time of purchase, for any ounce he w i l l be enabled and empowered to receive three tareni. For others which, owing to the nature of the drugs or owing to some other cause, are kept in the shop beyond a year, for any ounce he w i l l be allowed to receive six tareni. Shops of this kind are not to be allowed everywhere, but in certain c i t i e s throughout the kingdom, as w i l l be described below.7^ These regulations are similar to those governing phy-sicians in three ways. Fi r s t , the motivation behind their 73. Liber Augustalis. 3, *+7» Huillard-Breholles, Historia Diplomatica. vol. k, part 1, p. 151. 7k. Liber Augustalis. 3. 46; Huillard-Breholles, Historia Diplomatica, vol. 4, part 1, p. 236. The promised description of where these shops would be located has not survived in the legislation. .1.57. composition was the public good - although this was not articulated here as i t was in the legislation pertaining to physicians - for the dangers to the health and safety of the general public are as extreme as in the case of in-competent or negligent physicians. Secondly, the regula-tions governing the conduct of the apothecaries (for exam-ple, the prices to be charged), although not as extensive as those on physicians, impinge upon their a c t i v i t i e s in a way that is not as imperative for the public good as are those regulations of drug quality, for instance. Thirdly, these regulations were unilaterally imposed by regal autho-r i t y and were not the result of negotiations where apothe-caries guarantee certain standards in exchange for the right to pursue their trade under municipal, royal, or ecclesias-t i c a l protection. Not only did Frederick regulate occupations that had a great potential for harming the health of his subjects, but he also attempted to set standards for quite a variety of trades. Masters of mechanical arts "whose works are necessary for mankind should exercise their crafts legally and f a i t h f u l l y . " Butchers and fishmongers, "who administer the necessities of l i f e for men and from whose frauds loss can be i n f l i c t e d not merely on property but also on persons, should be trustworthy in their merchandise and their marke-ting." They were not to s e l l diseased flesh or food that had been kept over a day or anything corrupt or infected 158 unless the buyer was f i r s t informed of the condition of the merchandise. The quality of materials for candle makers was set and tavern keepers and wine sellers were forbidden to s e l l watered wine as pure. Goldsmiths, silversmiths, bronze and iron workers, makers of catapults and bows, and a l l artisans were to work with trustworthiness and zeal. Shield and saddle makers were to desire f a i t h f u l l y to make buyers more secure; they were to strengthen saddles and shields with the needed strong ornaments. Gold was not to be worked that contained less than eight ounces of pure gold per pound, or silver known to contain less than eleven ounces of pure silver per pound, regardless of the use to which i t was to be put. "In order that the opportunity and the material for committing frauds may be closed to a l l these artisans, we desire that two trustworthy men should be chosen in each locality, to be appointed by the b a i l i f f s of the d i s t r i c t " and "that these officals should be bound by an oath on the Holy Gospels to exercise loyally and diligently the office committed to them." They were to seize and hold suspect goods as evidence and report the frauds of artisans to the court. B a i l i f f s were to establish workshops of artisans and grape gatherers, reapers and the like at a fixed salary. Such workers were not permitted to leave the limits of 159 their establishment. If they were to leave, they would not only lose the salary they would have received but were then to pay four times that amount to the court. Any artisan caught making works below standards pre-scribed by this law, or any butcher, fishmonger, tavern-keeper or wine-seller found to be selling forbidden or corrupt food or watered wine for pure was to be punished as follows: For a f i r s t offense he was to be fined one pound of purest gold to the royal f i s c . If he lacked the means to pay, he was to be beaten. For a second offence he was to lose a hand. For a third offence he was to die on the forks, "which he has f u l l y merited by committing i l l e g a l acts and not correcting his behavior." If the in-specting o f f i c i a l s were found to have been bribed or other-wise corrupted by those whom they were to supervise, they were to suffer the same penalty. 7^ Merchants' weights and measures and the cutting of cloth for sale were regulated."^ i f a merchant was appre-hended in using false weights, he was to be punished, for a f i r s t offence by a fine of one pound of the purest gold to the royal f i s c . If the culprit could not pay, he was to be publicly beaten through the land "with the weight or measure hung around his neck for a punishment and as an Liber Augustalis. 3, 49. Huillard-Breholles, Historia Diplomatica. vol. 4, part 1, pp. I 5 2 f f . „. ^ 7 6 ' L i b e r Augustalis f 3, 50; Huillard-Breholles, Historia Diplomatica. vol. 4, part 1, pp. 155 f. 160 example to others." For a second offense he was to lose a 77 hand and for a third he was to he hanged. Now these laws are similar to those governing physi-cians and apothecaries in two ways in particulars First, their promulgation was motivated, at least in part, by the bonum publicum, although the potential dangers to people would not have been nearly on the same level as those which incompetent or dishonest physicians or apothecaries offered. Secondly, these regulations were unilaterally imposed on the various trades. A significant difference i s that the tradesmen affected reaped no direct benefits in exchange for the standards now fixed by law, where the phy-sicians and apothecaries gained a legally protected mono-poly in their trades. A. Marongiu enthusiastically compares Frederick with the princely reformers of the eighteenth century and sees the Norman kingdom of S i c i l y as a precursor of the modern state. Joseph Strayer, whose comments on Marongiu's article immediately follow i t , disagrees and sees Frederick's king-dom as an imperial anachronism. Strayer writes that i t is true that the S i c i l i a n kings, and especially Frederick II acted deliberately and consciously as legislators at a time when such acts were rare. But this proves very l i t t l e , since conscious and delibe-77. Liber Augustalis, 3, 51; Huillard-Bre'holles, Historia Diplomatica, vol. 4, part 1, p. 156. When foreig-ners were deceived by merchants, the penalties were to be doubled. "For we desire that our defense and knowledge should take the place of their [sc., the foreigners'] weak-ness and ignorance" (Liber Augustalis, 3, 52; Huillard-Bre'holles, Historia Diplomatica, vol. 4, part 1, pp. I56 f . ) . 161 rate legislation i s as typical of ancient empires as of modern states. . . . i f we have to choose between thinking of the Norman kingdom of S i c i l y as a precursor of the modern state, or as a f i n a l attempt to revive the s p i r i t of the old empires in the medie-val West* there i s not much d i f f i c u l t y in making a de-cision.'" While Frederick's adopting an imperial model for his re-gime was, in many ways, the creation of an anachronistic state, certain aspects of his legislation were exceedingly innovative and without precedent. The laws governing phy-sicians and apothecaries demonstrate that their source was both enlightened and despotic while the laws regulating artisans and merchants, although evincing a concern for the common good, reveal the heavyhandedness of an absolute monarch. The feature that is most striking about the legis-lation we have discussed and that makes i t discordant with developments elsewhere in Europe i s i t s having been uni-la t e r a l l y imposed on the tradesmen involved without nego-tiations. While Frederick's actions in regulating trades were not an anachronism, they were an anomaly. Elsewhere in Europe tradesmen (and I include in their number artisans, merchants, physicians, professors) were organizing into guilds, gaining charters from municipal, royal, or eccle-s i a s t i c a l authorities, and guaranteeing standards of quality of goods or services in exchange for the privilege of holding a monopoly in the particular service or commodity. . I8' -J- Strayer, "Comment," Comparative Studies i n  Society and History. 1954, 6 : 3 2 3 f. 1 6 2 It is to guild development that we must now turn in order to gain some insight into efforts at formal regula-tion made by medical and surgical organizations. One of the most striking features of late medieval urban l i f e was 79 i t s corporative aspect, particularly in i t s gu i l d ' 7 organi-zation. While the early history of guilds is obscure, i t is safe to say that, by the end of the twelfth century, most towns had at least a guild consisting, in the aggre-gate, of several trades. During the course of the twelfth century, many towns had received a charter enabling them to establish a merchant guild (or guild merchant), although in some cases the formation of the merchant guild preceded the granting of a municipal charter. The merchant guild was an association of traders formed for common actions on matters of common interest, "an omnibus in which different an kinds of traders could ride." The common interests of a merchant guild varied from town to town as the economic 7 9 . There are some real semantic problems here. Susan Reynolds* comments bear quoting: "In the Middle Ages almost any voluntary association or club might be called a guild, and i t s members -whether united for trading, p o l i t i c a l , re-ligious, or any other purposes - would bind themselves to-gether by the characteristic methods of feasting, religious ceremonies, and perhaps oath-taking. Guilds were, in G. H. Martin's excellent phrase, 'a form of association as unself-conscious and ubiquitous as the committee is today.'" An  Introduction to the History of English Medieval Towns (Ox-ford: Clarendon Press, 1 9 7 7 ) , 8"4~^  Martin's phrase is found in "The English Borough in the Thirteenth Century," Trans-actions of the Royal Historical Society, I 9 6 3 , 5th series, 13: 1 2 6 . 80. Herbert Heaton, Economic History of Europe (New York: Harper, 1948), 202. ~ 163 character of each town was reflected in i t s merchant guild. In small towns more often than not the economic activity was limited to supplying the needs of the town and adja-cent countryside. In larger towns (or even in some smaller ones in which there was produced one predominant economic commodity) in addition to the local market there was often a strong involvement in foreign trade. In these towns that catered both to the local and foreign market the composi-tion of the merchant guild was usually different from that of towns with only a local market in that the former were typically dominated by an upper echelon of wealthy mer-chants who were active in international trade. This domi-nant group was essentially those who, because of their eco-nomic importance, controlled the city government or, in reality, were the city government. They are frequently referred to as the urban patriciate. In large towns or c i t i e s that had a sufficiently spe-cialized population, there developed, in addition to, or as offshoots of, the merchant guild, a variety of craft guilds or artisan guilds. Before the thirteenth century, craft guilds were of l i t t l e consequence, but they soon pro-liferated rapidly throughout most of Europe. Beginning in the thirteenth century and culminating in the fourteenth, a high degree of intra-urban s t r i f e arose in many c i t i e s between the patriciate or merchant class and the various craft or artisan guilds, with the former attempting to 164 maintain control of municipal goverments and to protect their privileges, and the latter seeking to wrest a cer-tain degree of p o l i t i c a l power from the patriciate or wealthy merchants. Many merchants were also artisans since most artisans were at least part-time traders who sold some of their wares directly to the public. Although these artisans qua merchants were not always merely petty traders or shop-keepers, they were typically masters in their craft. Some were indeed very wealthy and did themselves engage in ex-tensive and mixed enterprise thus being nearly identical with merchants who were not even nominally craftsmen or artisans. This particularly held true in certain industries such as the cloth trade. But even here there were s t i l l variations among different areas of Europe, e.g., Florence where the masters of the Arte della Lana were essentially merchants engaged in extensive international trade but were artisans in the sense that they were masters of a craft, and various c i t i e s of Flanders where the merchants exercising entrepreneurial control over the cloth trade were distinctly members of the patriciate and not masters of a craft. The extent to which a master was wealthy affected the degree to which he could be identified, both functionally and ideolo-gically, as a merchant, even though he might s t i l l be a mem-ber of a trade that was organized into a craft or artisan guild. Furthermore, some guilds appear more, i f not ex-165 clusively, mercantile in scope than others. "There existed, 81 in effect, mixed gilds." When speaking of artisan industry, what is usually implied, are small, individual enterprises and the virtual absence, in most cases, of large-scale capital investment. What is usually involved are one mas-op ter and one or two apprentices. The artisan or craft guild was the aggregate of autonomous workshops "whose owners (the masters) normally made a l l decisions."^ 3 In theory, the artisan guilds joined together, as unequal partners, masters and apprentices, "but strove to ensure 84 for a l l members an equal chance of advancement and success." Not a l l craft or artisan guilds were comprised of men who produced commodities. Those who sold services often were organized into guilds or collegia, the latter not being craft guilds in the s t r i c t sense of the word. The medieval universities were essentially educational guilds or collegia, 81. Sylvia L. Thrupp, "The Gilds," in The Cambridge  Economic History of Europe, vol. 3 (Cambridge: Cambridge University Press, 1963), 266. 82. Harry A. Miskimin, The Economy of Early Renais-sance Europe, 1300-1460 (Englewood C l i f f s : Prentice-Hall, 1969), 82. 83. Robert S. Lopez, The Commercial Revolution of the  Middle Ages. 950-1350 (Englewood C l i f f s : Prentice-Hall, 1971), T2~T. 84. Ibid.. p. 126. 166 corporations either of students (as was the case in Bologna) or of teachers (which was more common). Some universities gained charters, beginning in the late twelfth century, be-coming corporate bodies designed to further educational in-terests and to protect their members. Donald Matthew is probably not overstating when he writes that the teachers or students created the universities by organizing "to de-fend common interests, with forms of association, purposes and procedures similar to those of the guilds which enabled i l l i t e r a t e lay men to protect s k i l l s of value, sought after by many. It was not learning, but corporate professionalism, that created the u n i v e r s i t i e s . " ^ There were guilds of various professions. Medical practitioners were either physicians or surgeons. In great part, although there were significant exceptions, surgeons (or barber-surgeons) were organized in craft guilds and physicians separately formed their own guilds except in c i t i e s having a university, where they were not then members of a craft guild but were part of, a f f i l i a t e d with, or under the supervision of the medical 8 5 . Donald Matthew, The Medieval European Community (New York: St. Martins, 1 9 7 7 ) , 218. George Unwin comments that "the federated gilds of scholars or teachers or both, of which the universities were composed, performed the same functions in regard to higher education of the professional classes as the later gilds performed in regard to the tech-nical education of the merchant and the craftsman" ("Mediaeval Gilds and Education," originally published in 19.12 and reprinted in Studies in Economic History; The Collected Papers of George  Unwin, ed. by R. H. Tawney [London: Frank Cass and Co., 1958], WT7~ 167 faculty of the university.' Also organized into guilds were lawyers and notaries.^ Perhaps originally organized simply as fraternal or-ganizations under the auspices of a patron saint, guilds were overtly concerned with technical ( a r t i s t i c , in the broad sense) and trade interests. There were three major identifiable interests: 1) fraternal, manifesting i t s e l f in charitable efforts, both internal and external, and social l i f e within the guild (banquets, etc.); 2) p o l i t i c a l , both active and passive; and 3) commercial, protection of finan-c i a l and vocational interests. In the matter of commercial interests, the guilds, in obtaining charters, secured the right of exercising a monopoly on their product or service in a particular geographical area. They had the riffht typically to make and enforce standards of quality in their products or services, to control hours and working condi-tions, to limit competition among members, to limit entry into the craft or profession, and to ensure the proper treat-ment of customers. Part of the monopoly was the right to train and, essentially, to license new members, thus e l i -minating competition from outside the guild. Although one 86. See Carlo IV!. Cipolla, "The Professions: The Long View," Journal of European Economic History, 1973, 2: 37 f f . 87. Susan Reynolds writes: "A comparison of English and continental evidence suggest . . . that guilds were o r i -ginally social and religious associations,primarily for drin-king and fellowship, and probably of pagan origin, some of which began to acquire purposes connected with trade and urban government as and when their members' interests developed in these directions" (English Medieval Towns, p. 81). 168 of the major concerns in these measures was economic, yet the claim was frequently made by the guilds that such res-trictions were necessary to maintain a high degree of com-petence and ethics in the trade or profession. It is d i f f i c u l t to compartmentalize the various in-terests of these corporate entities, particularly to se-parate the economic and the p o l i t i c a l concerns. The guilds were associations designed for the safeguarding of personal interests. At the best the organization of guilds was motivated by enlightened self-interest. Donald Matthew comments that "the guilds were intended from the f i r s t to serve the interests of the members. If the public came to benefit by the insistence upon quality or prices, this was incidental. The guilds set out to prevent outsiders from Q Q practising the craft in the town." Guilds were hotly involved in p o l i t i c a l activity and considerable s t r i f e arose on occasion between guilds in their efforts to gain p o l i t i c a l advantages that could be translated into economic gain. Strife also arose between guilds that supplied raw or semi-worked materials and those guilds that created the finished product (as in the textile industry) or between guilds of overlapping interests, e.g., physicians, surgeons, barbers, apothecaries. Throughout the discussion of guilds to follow, i t should be borne in mind that conditions varied considerably at different times and in different places. There has been 88. Donald Matthew, Medieval Community, p. I 6 7 . See also Cipolla, "The Professions," pp. 38 f. 169 no scholarly treatment of guild ethics in general, certainly not of medical and surgical guild ethics in particular. A comprehensive treatment of even the latter would require a massive effort and considerable archival research. So, relying on the limited primary documents available in various published collections, supplemented by occasional relevant secondary material, I shall attempt to provide what I trust w i l l be a representative picture of late me-dieval medical and surgical guild ethics by using available documentation from Montpellier, Paris, and London, with some brief mention of conditions elsewhere. The earliest mention of some kind of medical school O Q at Montpellier is from 1137. The type of organization this medical school had and whether or not i t s masters enjoyed any protected status are unknown. Apparently an effort was made by 1181 to gain a monopoly in the teaching of medicine there, for in that year Guilhem VIII, seigneur of the city„ issued an edict granting the right to anyone who wished, regardless of his country or place of origin, to teach medicine in the city. He promised that, regardless of insistence or offers of bribes, he would not grant to anyone a monopoly in the teaching of medicine at Montpellier 89. Hastings Rashdall, The Universities of Europe in the Middle Ages, ed. by F. M. Powicke and A. B. Emden (Lon-don: Oxford University Press, 1936), vol. 2, p. 119. For a discussion of the medical school at Montpellier, see Vern L. Bullough, The Development of Medicine as a Profession: The  Contribution of the Medieval University of Modern Medicine (New York: Karger, 1966), 52 f f . 170 90 since such a privilege was contrary to equity and justice. As Hastings Rashdall writes: ". . . the masters soon began to imitate the guild-system already established at Bologna and Paris . . . while the bishop claimed that authority over the schools was everywhere enjoyed by the Church north 91 of the Alps.' It was indeed to the church, specifically to the pope, that the masters of Montpellier turned and, in 1220, Pope Honorius III gave to Cardinal Conrad the respon-s i b i l i t y and authority to regulate the teaching of medicine in Montpellier. Conrad, after consulting with the medical masters and students, and in concert with the Bishops of Maguelone* Agde, Lodeve, and Avignon, promulgated a char-92 t e r 7 in the name of the Holy See. In this he writes: "For many years the profession of medical science has flourished gloriously at Montpellier, from whence i t has spread over the diverse parts of the earth the abundant health and multiplicity of i t s f r u i t s . " Now, under the auspices of the church, i t was to continue to prosper. Specific regu-lations were set for the teaching and the study of medicine at Montpellier. No one was to lecture at Montpellier who had not taught there before unless he was examined and ap-90. Hastings Rashdall, Universities, vol. 2, p. 1 2 2 ; Sonoma Cooper, "The Medical School of Montpellier in the Fourteenth Century. Annals of Medical History. 1930, 2: 166. The text of Guilhem's proclamation i s found in Cartulaire de l'universite de Montpellier (Montpellier: Richard Freres, 1 8 9 0 - 1 9 1 2 ) , vol. 1, nr. 1, pp. I 7 9 - I 8 O . 91. Rashdall, Universities, vol. 2, pp. 122 f. 92. Cartulaire. vol. 1, nr. 2, pp. I 8 O - I 8 3 . In 1239 thi charter was confirmed by a legate of Gregory IX: ibid., vol. 1 nr. 4, p. 186; and by Alexander IV in 1258: ibid., vol. 1, nr. 171 proved by the Bishop of Maguelone in conjunction with some masters of medicine chosen by the bishop. The Bishop of Maguelone was assisted various other responsibilities in-cluding the judging of criminal cases, appointing, in con-sultation with the masters of medicine, one master to dis-pense justice to colleagues and students alike. Included in Conrad's charter are provisions for licen-sure to practise medicine. He writes: Since i t often happens that, on account of ignorance of the causes [of disease]and lack of training, phy-sicians cause the death of the patient when there was hope for his l i f e , we order and command by the present edict that nobody dare practise unless previously exa-mined by two masters chosen by the venerable Bishop of Maguelone from the college of masters, and after he has been examined and has passed, he shall receive a certificate from the Bishop and the doctors who exa-mined him . . . .93 Note that here ecclesiastical authorites articulated the same concern expressed eleven years later by Frederick II for his kingdom: the dangers incurred by the general pub-l i c when exposed to treatment by i l l - q u a l i f i e d medical prac-titioners. This i s a theme that w i l l recur in requests for charters, in the granting of charters, and in pleas that privileges granted by charters be enforced. 93. It is here specified that surgeons were not re-quired to pass an examination. Luke Demaitre, "Theory and Practice in Medical Education at the University of Mont-pe l l i e r in the Thirteenth and Fourteenth Centuries," Journal of the History of Medicine and All i e d Sciences, 1975, 30: 104, comments that the surgeons "were usually members of guilds and thereby subject to certain standards." The stan-dards of surgeons' guilds in other areas w i l l be discussed below. 172 Sonoma Cooper points out that "the protection of the rights of the masters of the medical faculty had been the chief concern of Cardinal Conrad" in granting, these sta-tutes.^ 1 And Conrad's regulations do indeed achieve that end. For example they specify that no one was to study medicine at Montpellier unless under the supervision of one master exclusively and they prohibit such things as one master receiving under his instruction any student who was having d i f f i c u l t i e s with another master over fees or any other matter. Masters were prohibited from attracting students away from their colleagues' classes. What was created by Conrad's charter was essentially a closed shop, identical to the stereotype of the later medieval craft guild, both in respect to training and, after completion of training, in respect to practice. Various statutes were enacted over the next century and a half governing the study and practice of medicine. In 1240 i t was stipulated that, before being presented by his master for a license to practise, the candidate must 95 practise outside the city of Montpellier for six months.7J 94. Sonoma Cooper, "The Medical University at Mont-pel l i e r , " p. 172. 95. Luke Demaitre, "Theory and Practice," p. I I 9 . In I309 the period of required practice outside Montpellier was increased to eight months or two summers. A bachelor of medicine, being awarded that degree after three years of study, was required to swear that he would not practise medicine in Montpellier nor in i t s suburbs until he was awarded a master's degree. He would also report others practising i l l e g a l l y and would uphold the honor and interests of the university and i t s masters at 96 a l l times. After completing three more years of study and the period of practice mentioned above, the student was examined for the master's degree and a license to practise. The candidate then had to swear, among other things, to obey the statutes of the university and not to disclose i t s secrets, not to treat any leper at Montpellier for more than eight days, to c a l l a priest, i f possible, when treating a c r i t i c a l l y - i l l patient, and to reveal or, i f 9 7 possible, prevent any known pe r i l to the university. These regulations of 1240 were reiterated exactly a century later when, for the f i r s t time at Montpellier, the medical faculty sought to gain the right to supervise apo-thecaries. The statutes of 1340 specified that apothecaries must henceforth be licensed by the Bishop of Maguelone and that the candidate for an apothecary's license must be ap-proved by two-thirds of the masters of the medical faculty. 96. Sonoma Cooper, "The Medical University at Mont-pe l l i e r , " p. 175; Vern Bullough, The Development of Medi-cine, pp. 54 f. 97. Cooper, "The Medical University at Montpellier," p. 179. 174 Two masters of medicine were appointed to exercise sur-veillance of the makers of electuaries and the latter were required to swear an oath to the effect that they would make their drugs f a i t h f u l l y according to written formulas and without adulteration. A document is extant that purports to he an "Oath of the Faculty of Medicine at Montpellier." W. H. S. Jones, in his study of the Hippocratic oath, includes this docu-ment. Although no date i s given for the oath, the tone and content are not at a l l inconsistent with what one would expect in an oath for faculty at a medical school of a late-medieval university. Jones' translation reads: In the presence of the masters of this school, of my dear fellow-students, and before the image of Hippocrates, I promise and I swear, in the name of the supreme Being, to be faithful to the laws of man and of honour in the exercise of medicine. I w i l l give my services without fee to the needy, and I w i l l never exact a higher fee than my work deserves. When I am admitted inside houses, my eyes shall not see what goes on there, and my tongue shall be silent about the secrets which shall be entrusted to me, and I w i l l not abuse my position to corrupt morals or to encourage crime. Respectful and grateful towards my masters, I w i l l give back to their children the ins-truction that I have received from their fathers. May men grant me their esteem i f I am fait h f u l to my pro-mises. May I be covered with shame and despised by my fellows i f I f a l l short.99 A comparison of this oath with the so-called Hippocratic oath reveals immediately a strong, indeed predominant, clas-s i c a l component. The exception is the provision that the 9 8 . Cooper, "The Medical University at Montpellier." p. 179 -9 9 . W. H. S. Jones, The Doctor's Oath, p. 6 0 . 175 swearer of the oath w i l l give his services to the needy gratis and w i l l never exact a fee higher than his work deserves. Although I have seen nothing in the university statutes of Montpellier specifying free medical care for the poor and conscientiousness regarding fees, such pro-visions are fu l l y consonant with guild (and university collegia) regulations of this period. The medical school of Montpellier differed from i t s contemporary at Salerno in many ways. As pertains to our subject, the former was essentially a guild of masters who had organized themselves to protect their interests and had both sought and obtained from ecclesiastical authori-ties the right and enablement to exercise a monopoly both in medical teaching and practice. The interest of eccle-si a s t i c a l o f f i c i a l s in guarding against the dangers resul-ting from incompetent practitioners was happily consonant with the interests of the masters in protecting their own prerogatives. The interests of the masters at Salerno were neither granted nor protected by any authority; rather imperial proclamation unilaterally imposed upon them those regulations which Frederick II simply deemed to be in the best interest of his state. The masters at Montpellier had considerably greater control over the creation of the regulations by which they were governed than did the masters at Salerno. When conflicts arose regarding the regulations, at Montpellier arbitration determined the issue, while at Salerno imperial f i a t supplied the answer. 1 7 6 References to a medical school in Paris appear toward the end of the twelfth century 1 0 0 hut there is no reason to suppose that the medical teachers there were organized into 101 a collegium or guild then. During the f i r s t quarter of the fourteenth century, the medical faculty claimed that regulations had been issued two hundred years earlier pro-1 0 2 tecting various of their prerogatives, but the earliest o f f i c i a l record of a medical university there dates from 103 1 2 1 3 . Pearl Kibre writes that " i t was probably toward 1 2 2 0 that the faculty of medicine obtained from the dio-cesan o f f i c a l a sentence reserving the right to practice medicine at Paris and in the faubourgs to those who had obtained the master's degree in medicine with the approval 104 of the chancellor of the university," although there is no extant record of this. The year 1 2 3 1 provides the ear-l i e s t record of a formal organization having both masters 105 and students in medicine. Approximately twenty-seven 1 0 0 . Bullough, Development of Medicine, p. 6 9 . 1 0 1 . Pearl Kibre, "The Faculty of Medicine at Paris, Charlatanism, and Unlicensed Medical Practices in the Later Middle Ages," Bulletin of the History of Medicine, 1 9 5 3 , 2 7 s 2 , and n. 4. 1 0 2 . Ibid., p. 2 . 1 0 3 . Chartularium Universitatis Parisiensis, ed. by H. Denifle and A. Chatelain (Pariss Delalain, I 8 8 9 - I 8 9 7 ) , vol. 1 , nr. 16, pp. 7 5 - 7 6 . 104. Kibre, "The Faculty of Medicine," p. 7 . n. 2 2 . 1 0 5 . Chartularium, vol. 1, nr. 8 9 , pp. 144-145. 1 7 7 years later is the f i r s t record of the existence of an or-ganization of surgeons. In a municipal ordinance surgery is l i s t e d with other guilds that were under the control . 106 of the provost of Paris. Since the document in question does not grant a charter to the guil d but recognizes i t as a municipally sanctioned organization, we can assume the pre-vious existence of a guild of surgeons in Paris although no date of i n i t i a l o f f i c i a l recognition is known. Thus, by the mid-thirteenth century we have in Paris an association of medical masters constituting a medical faculty which was a recognized part of the university, and a guild of surgeons, distinct from the university and not a f f i l i a t e d with i t in any way. The peculiar course of events in Parisian medical, surgical, and para-medical circles centered on f r i c t i o n between physicians, surgeons, barber-surgeons, apothecaries, and various varieties of charlatans, empirics, and quacks. In 1271 the masters of the medical faculty made a statute against various groups practising medicine in or about Paris. The statute opens with the assertion that some people, who are "not yet advanced in the art of.medicine and quite ignorant of the causes of medical procedure," have "by shameful and brazen usurpation" assumed the role of physicians "without consulting skilled 1 0 6 . Vera L. Builough, "The Development of the Medical Guilds at Paris," Medievalia et Humanistica, I 9 5 8 , 1 2 : 3 6 . 1 0 7 . Chartularium. vol. 1 , nr. 434, pp. 488-490. A translation of this document is provided by Lynn Thorndike, University Records and Life in the Middle Ages (New York: Columbia University Press, 1944), 8 3 f f . 178 persons." These practitioners are ignorant of such things as "what should be used as a base, what as a bridge, what as a spur" in the medicines that they "wretchedly administer to simple men and so by their treatments, made not according to art but rather by chance and fortune, have criminally handed over many to the suffering of death, which is at the p e r i l of their souls." This not only puts such prac-titioners into danger of excommunication but "further tends to the disgrace and grave infamy of a l l skilled in medicine." In light of these affairs, the "doctors teaching in the me-dical faculty at Paris at the devout and pious supplications of many, namely, the religious, clergy, scholars, likewise many citizens of Paris, wishing to check so many errors, perils and scandals, confirm a statute of ours"purportedly made long ago, supported by municipal and royal letters, prohibiting, under every penalty of secular and ecclesias-t i c a l laws, Jews or Jewesses operating surgically or medi-cinally on any person of catholic faith. "Also, since certain manual operators make or possess some confections but totally ignore their cause and reason" and do not even "know how to administer them and the rela-tion which medicines have to disease . . . since these matters are reserved exclusively to the industry of the skilled physician." Yet such practitioners persist in treating cases "rashly and to public scandal. . . . There-fore we s t r i c t l y prohibit that any male or female surgeon, 179 apothecary or herbalist, by their oaths presume to exceed the limits or bounds of their craft secretly or publicly or in any way whatsoever." Surgeons henceforth are only to engage in manual practice and things pertaining to i t . The apothecary and herbalist are only to mix drugs that are to be administered exclusively by masters in medicine or by those licensed by the latter. "None of the afore-said shall v i s i t any sick person to administer to him any alterative medicine or laxative or anything else that per-tains to physicians, nor advise i t to be administered or procure i t , except through a master in medicine. . . ." Although these practitioners could administer those drugs "which are wont to be sold commonly" they are excluded "from every way and method of treatment in which medical s k i l l i s called for." Medical students were also forbidden by this statute to administer to anyone.whether sick or well, "any drug comforting, alterative, or even laxative without the presence of some master in medicine, or even v i s i t , except once, unless there is with him some master to direct him and show the way to work." The statute ends with instructions that anyone knowing of violations of the regulations here set forth should secretly reveal i t to the dean of the medical faculty who then w i l l shield the informer. This is the earliest recorded instance of the Paris medical faculty seeking to prohibit the practice of medi-180 cine to a l l save themselves. Their action differs from earlier developments in Salerno and Montpellier. In Salerno the medical licensure regulations were imposed by imperial f i a t , in Montpellier they were promulgated by ecclesiastical authorities at the request of the medical faculty. In Paris the regulations were entirely of the medical faculty's own making and at the faculty's i n i t i a -tive. The attempts to enforce these regulations necessi-tated, as we shall see, frequent pleas to municipal, royal, and ecclesiastical authorities to lend their support. There Is one matter in which the Paris statute of 1271 is similar to the medical licensure regulations of Salerno and Mont-pel l i e r , however, and that i s i t s strong emphasis on the common good. It was, after a l l , in response to the sup-plications of the religious, clergy, scholars, and many citizens of Paris, and in the face of imminent danger to the general public, as well as with a view to the good name of the medical profession that the statute was enacted. While a guild of surgeons i s known to have existed in Paris before 1258, i t must have been a relatively weak or-ganization. The provost of Paris found i t desirable to in-tervene in their operations in 1'3Q1 by stipulating that henceforth no one could practise the art of surgery in Paris or i t s environs unless he had f i r s t been approved through 1 OR an examination conducted by the master surgeons. Having l 0 8 - les metiers et corporations de la v i l l e de Paris. ? 2 A o A y R e ? G d e L e sPinasse (Paris: Imprimerie Nationale, 1886-1897), vol. 3, p. 628. 181 their own licensing authority, backed by the municipal government, the surgeons' position vis-a-vis the medical faculty's attempts at control was strengthened. While the medical faculty was a threat to the surgeons' pre-rogatives from above, the barbers impinged upon their territory from below. Six years after the ordinance issued by the provost requiring the licensing of Paris surgeons, a municipal statute was enacted which provided that a l l barbers practising surgery must cease such activity un t i l they had been examined by six masters of surgery. These masters were to be appointed by the provost of Paris and obligated under oath to be responsible for the loyalty and qualifications of the barbers who practised surgery. 1 0^ These regulations were reinforced by King Philip IV in 1311 when, in response to the surgeons' request, he issued the f i r s t extant royal ordinance dealing with surgery. Philip required that a l l surgeons or barbers practising surgery in Paris be examined by master surgeons and he placed his own surgeon, Jean Pitard, in charge of these . . 110 examining masters. Whether as a response to the medical faculty's statute of I 2 7 I or owing to the loss of documentation to the contrary, i t appears that four decades passed without any significant s t r i f e between the masters of the medical faculty and i l l i -109. Kibre, "The Faculty of Medicine,'* p. 17. n. 55. 110. Chartularium. vol. 2, nr. 692, p. 149. 182 c i t practitioners. In l ' 3 l l and 1312 two cases came to l i -tigation. In the former, the dean of the faculty of medi-cine charged a charlatan or empiric with i l l e g a l l y practising medicine in Paris and in the next year a woman was excommu- . I l l nicated for her i l l i c i t practice. In I322 an interesting case arose involving a certain Jacqueline Felice de Almania who was prosecuted for i l l i c i t medical practice. Her t r i a l continued for several months, numerous witnesses were called both by the prosecution and the defense, and the summary occupies several pages in the Chartularium Universitatis „ • ' • . 112 Parisiensis. A famous knight and former surgeon to King Philip IV, John of Padua, was called as a witness for the prosecution. He stressed, among other things, the serious consequences to the common good in permitting an untrained and ignorant woman to practise medicine. The counsel for the defense countered with the assertion that Jacqueline had treated and cured many sick people and had provided them with com-fort when the physicians had failed. This was then cor-roborated by several witnesses. One woman te s t i f i e d that when she had been i l l with a fever, several physicians had visited her only to pronounce her case hopeless. Then Jacqueline had come and had cured her. The defense went on to attack the legality of the university statute that 111. Kibre, nThe Faculty of Medicine," p. 7 . 112. Chartularium. vol. 2, nrs. 811-816, pp. 255-267. 183 had given a monopoly to the medical faculty in the practice of medicine and asserted that the statute in question could not he binding as i t was demonstrably contrary to the public good. Such argument was of no avail, Jacqueline was excom-municated, and the public good was determined to be better served by basing the privilege of practising medicine on educational and licensure prerequisites rather than on efficacy of treatment. In the same year that Jacqueline was prosecuted by the medical faculty, the masters drew up articles "in the public interest'* which strengthened the faculty's control over the apothecaries which i t had previously assumed in 1 2 7 1 . Now a l l apothecaries and herbalists were required to appear annually before the medical faculty and swear that, among other things, they were conscientiously per-forming their pharmaceutical functions, and that they were using accurate weights and drugs which were not corrupted. The dean of the medical faculty and one apothecary appointed by the faculty would henceforth make periodic inspections of apothecary shops. The statute also forbade apothecaries from selling any laxative medicines, aborticides,poisons, or other dangerous drugs without the advice of a licensed 111 physician. 1 1 3 . Chartularium, vol. 2 , nr. 8 I 7 , pp.. 2 6 8 - 2 6 9 . This statute was reinforced and stren,sthened by King Philip VI in 1 3 3 6 s Ordonances des rols de France, ed. by E. J. de Lauriere e t a l . , Paris, 1 7 2 3 - 1 8 4 9 , vol. 2 , p. 116. An oath required of apothecaries in Paris from 1422 is recorded in Chartularium, v o l . 4 , pp. 4 0 6 - 4 0 7 , and a translation i s provided by Thorn-dike, University Records, pp. 2 9 8 f. They were required to 184 In spite of the t r i a l s and conviction of i l l i c i t practitioners in 1311, 1312, and 1322, charlatans and em-pi r i c s must have continued their enterprises in Paris, for in 1325 the medical faculty "humbly beseeched" Pope John XXII to intervene to protect the people's health and the physicians' monopoly. The pope wrote to Stephen, bishop of Paris, expressing grave concern over the many deaths allegedly caused in the city by those i l l e g a l l y practising medicine, and instructed him to cooperate with the medical faculty in preventing those ignorant of the art of medicine, especially old women and soothsayers, from practising within the city or i t s suburbs. Stephen was further instructed to c a l l a council of men learned in medicine, i f necessary, in order to find out the truth of the matter, and to f o l -114 low their advice. Charlatans must have continued to thrive in Paris, for five years later the medical faculty again petitioned the pope. He wrote to Hugh, the new bishop of Paris, urging him to make every effort to ensure that only those who were masters or licentiates in the medical art be permitted to practise in Paris or i t s suburbs and swear to eight matters: 1) that they have the appropriate pharmaceutical books to follow, 2) they are using just weights, 3) w i l l not use corrupted medicines or 4) substitute one drug for another without the permission of the master giving the prescription, 5) w i l l not dispense drugs without a prescrip-tion, and 6) w i l l f i l l the prescriptions of only licensed physicians. The seventh and eighth points pertain to the supervision of their employees. 114. Chartularium. vol. 2, nr. 844, pp. 285-286. 185 that ecclesiastical censure be brought against those who 115 practise in violation of this dictum. J Ten years later, in 1 3 ^ 0 , Pope Clement VI ordered that not only those who practise medicine in Paris i l l e g a l l y be excommunicated, but also those who allow themselves to be treated by such 116 practitioners. In 1 3 4 7 and I 3 5 I , the medical faculty again petitioned the pope to lend his authority to the 117 faculty's campaign to stamp out charlatanism in Paris. ' In addition to battling against i l l i c i t medical prac-titioners, the medical faculty was engaged in drawn-out l i t i g a t i o n from 1 3 3 0 through 1 3 3 2 with the chancellor of the university. The latter had licensed a bachelor of me-dicine who had not been presented by the medical faculty. The faculty sought and obtained confirmation of their ex-clusive rights in the examination and approval of licen-tiates in medicine from the king, the pope, and the pro-vost of Paris. Troubles continued with the i l l i c i t practice of me-dicine and, in response to a petition of the dean and mas-ters of the medical faculty, King John in 1 3 5 2 issued a l l q royal ordinance. 7 He had been apprised that "many per-1 1 5 . Ibid., vol. 2, nr. 900, pp. 336-337. 116. Kibre, "The Faculty of Medicine," p. 1 3 . 1 1 7 . Chartularium. vol. 2, nr. U 3 8 , pp. 602-603, and vol. 3 , nr. 1 1 9 7 , pp. 7-8. 118. Ibid., vol. 2, nr. 918-943.. See Hastings Rash-d a l l , Universities, vol. 1, p. 458, n. 1, and p. 480. 1 1 9 - Chartularium, vol. 3, nr. 1211, pp. 16-17; trans-lation in Thorndike, University Records, pp. 2 3 5 f. 186 sons of both sexes, women and old wives, monks, rustics, some apothecaries and numerous herbalists, besides students not yet trained in the faculty of medicine or coming from foreign parts to the town of Paris to practice," were in-deed acting as physicians. These people were "ignorant of the science of medicine and unacquainted with human consti-tutions, the time and method of administering the virtues of medicines, particularly laxatives in which lurks p e r i l of death i f they happen to be administered unduly" and that these practitioners alter medicines "quite contrary to reason and the medical art." They administer strong laxative clysters "and other things unlawful for them in . . . Paris, calling into consultation no physicians whatever, which results in scandal of our people, grave danger to souls and bodies, and derision, prejudice and injury of the said petitioners, and science of medicine, and those expert in i t . " Homicides and abortion "on every hand and sometimes publicly" result. "Wherefore the said petitioners, unable further to tolerate the said practices with clear conscience or to wink at them, humbly beseech us that we deign to provide a suitable and lasting remedy to this." Terming the i l l i c i t medical practice "damnable interference, presumption and fatuous rashness," the king, for the public u t i l i t y of his subjects, decreed That no one, of whatever sex or condition in . . . Paris shall henceforth make, or advise the making, or dare to administer any medicine alterative, laxa-tive, sirup, electuary, laxative p i l l s , clysters of 187 any sort — for fear of death from flux or aggrava-tion of had symptoms in which i t is not l i k e l y that they know how to apply a remedy — opiate or anything else, or offer medical advice or otherwise exercise the office of a physician in any way, since the ad-ministration of the aforesaid belongs to experts and those learned in operating certainly on the human body and not to others, unless he is a master or licentiate in the said science of medicine at Paris or some other university, or unless that medicine was ordered by the advice and direction of some master or other person approved by the said faculty to practice. The appropriate o f f i c i a l s are ordered to correct and punish those acting contrary to this statute. Once again, in the name of the public good, but this time by royal mandate, medical practice is reserved exclu-sively for those duly licensed by the medical faculty of the university. A sharp distinction is clearly delineated between the ignorant and unskilled operators and the expert and learned physicians. The next year, the king issued an ordinance governing apothecaries in Paris. He required that a commission made up of representatives of the master apothecaries and two masters of medicine inspect the phar-maceutical shops in the city twice annually. He also for-bade apothecaries to deliver any medicinal remedies without a physician's express instructions. Severe penalties were to be visited upon any apothecaries who should presume to 120 violate these regulations. Between 1356 and 1364, various royal charters were issued repeating and supplementing the provisions of the 120. Chartularium. vol. 3, nr. 1215, p. 20. 188 royal ordinance of I 3 H protecting the rights of surgeons 121 m Paris. Vern Bullough comments on the surgeons that "as their status rose they turned an increasing number of operations and procedures over to the barbers on the grounds that to perform such tasks would be degrading to the sur-geons. This lai d the groundwork for the organization of i 1 2 2 the barbers to a position to challenge to the surgeons." Mention has already been made above to a municipal statute of 1 3 0 7 strengthened by a royal ordinance in 1 3 3 1 which required that barbers practising surgery be examined and approved by a commission of master surgeons. In I 3 7 I the barbers petitioned the king to renew their ancient but lost charter, "a common procedure of a guild applying for an 123 i n i t i a l charter." J Their request was granted and regu-lations were issued by the king distinguishing between the rights of barbers and of surgeons. It appears that the surgeons had petitioned the king to limit the barbers' 1 2 1 . See Rashdall, Universities, vol. 1, p. 4 2 5 , n. 2, and Bullough, Development of Medicine', p. 1 0 3 , and "Medical Guilds," p. 37"! 1 2 2 . Bullough, "Medical Guilds," p. 3 8 . 1 2 3 . Ibid. 189 surgical a c t i v i t i e s further than they already had been. The king maintained that i t would be contrary to the public good to limit the barbers' surgical purview since they treated the poor for many illnesses, handling cases that the surgeons would not deign to touch. Thus i t was in the public interest that the barbers be allowed to prepare and administer ointments, plasters, and other medicines which were appropriate for treating boils, tumors, bruises, and a l l woundswhich were not mortal, without the interference 124 of the surgeons. The medical faculty continued to have i t s d i f f i c u l t i e s in attempting to regulate medical practice within Paris. In 1375 the masters of medicine issued a statute requiring a l l bachelors in medicine and others who were s t i l l pending licensure to swear that they would not practise medicine nor v i s i t the sick unless they were 125 accompanied by a master. -'In 1390 the masters found i t necessary again to appeal to the king to protect their 124. Ordonances, vol. 5, pp. 530 f. In 1376 the king issued similar regulations for the town of Sens and later for Tours and Rouen. See Bullough,"Medical Guilds," P. 39. 125. Chartularium. vol. 3, nr. 1396, pp. 217-218. 190 monopoly. Charles VI responded by issuing another royal 126 decree against i l l i c i t practice. Around 1420, as one of his f i r s t acts as regent of France, Henry V of England reaffirmed the statutes of the French kings against i l l i -c i t medical practice and threatened with imprisonment anyone 127 caught practising without a license. Meanwhile, the Paris surgeons were having their prob-128 lems with i l l i c i t surgical practice. In 1411 the master surgeons prosecuted a woman named Perretta Petonne for practising surgery "although she had been neither examined nor approved in the aforesaid art, as the privileges and statutes of that art, issued and confirmed by our predeces-sors, require and state." She had had the audacity to hang "before her said house or lodging a box or banner or sign after the manner of a public surgeon." She had been ordered to cease surgical practice u n t i l she could be examined and approved through normal examining and licensing procedures. She had f i n a l l y been placed under arrest and imprisoned* without b a i l . Her surgical books were to be examined by four physicians in the presence of representatives of the 126. Ibid., vol. 3, nr. 1 5 8 6 , pp. 53^-535. 1 2 7 . Ibid., vol. 4 , nr. 2 2 2 7 , p. 4 2 3 . 128. Ibid., vol. 4 , nr. I 9 I 2 , pp. 1 9 8 - 1 9 9 - A trans-lation is avilable in Thorndike. University Records, pp. 2 8 9 f. 1 191 surgeons' guild and Perretta herself was to be examined by the said physicians in the presence of the said examiner and clerk and of two surgeons in whom both parties could trust. When this had been done and the said examiner had been informed as to the cures of the sick of which Perretta boas-ted and as to which the said masters arid .jurati wished to give him information to the contrary, the same physicians, examiner and clerk should re-port their findings. . . . The court elected to permit Perretta to be released on ba i l ; the prosecution objected. Perretta, "because she had many sick persons or patients under her care, who required essential remedies and visitation, demanded that permission be granted her to v i s i t these sick persons and patients, the said prohibition notwithstanding." This request was denied. The court was adjourned until the next month and the parties remitted. The court "forbids the said Perretta, while this process i s pending, to exercise the profession or act of surgery in any way, or to place, or cause or presume to place, on her house a box, banner or other sign of a surgeon or surgeoness." Further re-cord of this case has not survived. The surgeons, while fighting to protect their mono-poly from infringement by unlicensed practitioners and to keep the barber-surgeons subservient, were also striving for equality with the physicians. In 1^36 the surgeons were admitted as actual "scholars" in the medical faculty. 192 In the document issued hy the university, the reason given for the surgeons' inclusion within the ranks of the univer-129 sity scholars was that "many quacks have arisen, not approved, and false or feigned surgeons, greatly distur-bing and cheapening the venerable science of surgery with grave and horrid popular scandal and injury to the same." That such quackery persists is "to the prejudice and no small detriment of the said petitioners, in view of the great and notable privileges conceded and bestowed by many kings of France upon the same petitioners and their predecessors in the said science of surgery." The surgeons are now to "be reputed scholars and enjoy their privileges, franchises, l i b e r t i e s , and immunities conceded to us or to be conceded, and that we aid them in this." It was pro-vided that the surgeons must attend the lectures of the i 3 0 masters in the medical faculty "as is customary." J It appears that this marriage of the physicians and surgeons was harmonious for a few years and in 1443 we find them "united to make common cause against a group of 129. The quacks referred to here are probably both the i l l i c i t surgeons such as Perretta, mentioned above, and the surgeons' ri v a l s , the barber-surgeons. For l i t i -gation between the surgeons and the barbers, see Chartu-larium, vol. 4, nr. 2253, PP- 442-443, and nr. 2621, pp. 675-676. 130. Kibre, "The Faculty of Medicine," p. 18. 193 i l l i c i t medical practitioners called 'cabasatores et 131 cabusatrices.'" But in 1446 relations soured when the medical faculty demanded that the surgeons take an oath in the presence of the medical faculty that they would not exceed their prescribed limits of practice. The surgeons 132 refused. There ensued a variety of unpleasantries cul-minating in the early 1490s with the faculty of medicine attempting to undermine the surgeons by opening i t s lec-tures to the corporation of barbers. The surgeons f i n a l l y humbled themselves and requested that the medical faculty close i t s lectures to the barbers. In 1496 an accord was reached, but two years later the medical faculty