The Social Position of the Surgeon in London, 1350-1450 Bryon Grigsby

Essays in Medieval Studies 13
[Page numbers of the printed text appear at the right in bold.]

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The Social Position of the Surgeon in London, 1350-1450

Bryon Grigsby

Many critics' familiarity with the medieval medical community comes from Chaucer's characterization of the Doctor of Physic: "In al this world ne was there noon hym lik, / To speke of phisik and of surgerye."1 But what few critics fail to realize is that there is an important difference between the Doctor's ability to speak of surgery and his ability to perform.2 In the 33 lines used to characterize the doctor, Chaucer never mentions a surgical procedure. This seems to indicate that doctors might not perform surgical operations. In fact, medieval medical and surgical manuals often demonstrate ideological differences between the two different roles doctor and surgeon.3 This conflict of ideologies informs the tensions behind Chaucer's portrait of the Physician. During the late Middle Ages, doctors were believed to be a repository of medical knowledge, thus their profession was seen as learned. The surgeon, on the other hand, was considered to be an artisan, thus his profession was seen as a craft.4 This craft ideology allowed access for untrained artisans to enter the field of surgery. In this paper, I will statistically demonstrate that the medieval English surgeon was threatened by the growing number of untrained practitioners between the years 1350 and 1450. In response to this threat, medieval surgeons attempted to institutionalize their profession. Ironically, the manner in which they defined their practice did not restrict untrained practitioners, but actually increased access for medically untrained artisans.

In Medical Practitioners in Medieval England, C. H. Talbot and E. A. Hammond collect biographical data on medical practitioners from the Anglo-Saxon period to William Munk's 1518 Roll of the Royal College of Physicians of London. As Talbot and Hammond state,
Among the problems encountered in the preparation of this register none has been greater than the sheer bulk and variety of materials which had to be examined. Every charter witness, lay subsidy role, chancery and

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exchequer record, household account, monastic chronicle, bishop's register, municipal ordinance, parliamentary roll had to be considered a potential source of biographical data.5
There is an immense amount of data in this work. Unfortunately it is organized alphabetically by the medical practitioner's first name. This type of organization lends itself to finding out about the biographical specifics of one doctor, but offers little information about the medical profession as a whole. As a way to narrow the 132 practitioners listed by Talbot and Hammond, I have focused only on those practitioners between 1350 and 1450. I chose the former year because it gives some idea of the number of medical practitioners during the first outbreak of the Bubonic plague, and the latter year because it gives some indication of the reasons why numerous legislative attempts were made to instutionalize surgery between 1421 and 1435. I further narrowed this search by focusing only on those medical practitioners in or near London. If Talbot and Hammond do not provide geographical information, I have removed that name from consideration. My results look like this:
Table 1:
Number of Medical Practitioners in London 1350-1450
Years ------ Surgeons Physicians
1350-1360 10 11
1360-1370 12 9
1370-1380 6 7
1380-1390 3 5
1390-1400 9 6
1400-1410 8 6
1410-1420 33 8
1420-1430 12 9
1430-1440 21 9
1440-1450 18 11

It must be emphasized that this information does not reflect all the medical practitioners available to the citizens of London during this period. This is only the number of practitioners visible to the historian in historical documents. Furthermore, while these numbers seem small, they are consistent with two similar studies on the number of medical practitioners in fourteenth-century Europe. Christian Guillere's 1985 study of the city of Garonne between 1320 and 1370 finds numbers of documented medical practitioners as low as 14 in 1370 and as high as 29 in 1340.6 And Michael R. McVaugh in Medicine Before the Plague finds in Barcelona 35 physicians and 33 surgeons between 1300 and 1340 and similiar numbers in Valencia.7

When we place this information on a line graph, we can make some

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rudimentary conclusions about the social position of documented surgeons in London between 1350 and 1450. (See Chart 1 in the Appendix.) The first thing we notice is that the number of surgeons fluctuates significantly, while the number of doctors remains relatively unchanged. Furthermore, there are consistently more surgeons on record than medical doctors. One reason that surgeons are more likely to be named in documents is because of the nature of their profession. Surgery, unlike medicine, has a direct causal effect on the health of the patient. Surgeons were often called to perform major operations in which they cut open the patient's body. Medical doctors, however, treated most of their patients' illnesses with medications derived from herbs. Most of these herbs did not actually cure the patient, but they also rarely did any harm.8 Therefore, when a doctor treats a patient, even if the person dies, it is difficult to ascribe blame directly to his treatment because most patients get worse over a period of time. However, the surgeon is not as fortunate the effects of his craft are immediate the person either lives or dies. Consequently, a large portion of the documentation on surgeons comes from court records concerning malpractice suits. For example, of the eleven surgeons mentioned between 1350 and 1360, nine are in litigation. Compare this to the eleven doctors mentioned in the same period: only one is mentioned in litigation and he was offering testimony for a surgeon.

However, litigation does not explain the two sharp increases of documented surgeons during the decades 1410-1420 and 1430-1440. The documented number of surgeons between 1410 and 1420 demonstrates the growing importance of surgeons as a component of war. In 1415, King Henry V indentured Thomas Morstede and fifteen persons, twelve of whom were surgeons (the three others were to be archers) in his campaign against France.9 The Battle of Agincourt in 1415 is monumental in the development of the surgeon for military campaigns. One need only recall Roger of Hoveden's story of how in 1199, during a siege of the castle Chaluz, Richard I suffered an arrow wound to the arm. Unfortunately for Richard, his physician, Malger, had returned to England to become the bishop of Worcester. Being without a doctor, the captain of Richard's mercenaries, Marchadeus, badly treated his injury. By failing to extract the arrow head, Marchadeus nearly amputated the arm before removing the arrow. The king died a few days later.10

Before 1415, it was not uncommon for a mercenary or knight to practice medicine. Wolfram von Eschenbach's Parzival clearly demonstrates that medical knowledge was common knowledge for a knight. In this tale, Gawan comes across a knight and maiden in the woods. The knight is suffering from internal bleeding into the lungs. After Gawan diagnoses the injury, he places a small linden bark tube into the knight and tells the maiden to suck out the blood.11 Even Guy de Chauliac, a fourteenth-century surgeon, lists knights as medical practitioners.12 But by 1415, surgeons began to appear as a necessary component of military campaigns.

Besides the twelve surgeons commissioned by Henry for the Battle of Agincourt, he also commissioned William Bradwardine and nine other surgeons to care for the sick and wounded.13 It appears that Morstede's surgeons would

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be taking care of the hurt and injured on the front line (especially with the emphasis on archers), while Bradwardine's surgeons would be behind the lines caring for those transported back to the camp. But it would also appear that Bradwardine's surgeons were not only responsible for the sick and injured, but were also responsible for making surgical equipment most surgeons were also expert craftsmen in metals.14 This is evident in Henry's second expedition in 1416 in which he commissioned Morstede to indenture as many surgeons as he wanted (possibly pointing to the fact that 23 surgeons were too few to handle the wounded in the first campaign) and to bring along makers of surgical equipment.15 The implication of this order is that in the first campaign, surgeons must have been delayed in crafting surgical instruments to the detriment of the wounded. Thus, by bringing along metal workers, the surgeons of the second campaign were free to perform their medical duties. While doctors normally attended military excursion to treat the King, the Battle of Agincourt demonstrates a growing need for surgeons.

This new alliance between surgeons and the crown helped surgeons institutionalize their profession. For example, Morstede's service at Agincourt led him to the job of supervisor of surgery for the City of London in 1423.16 This close proximity to the King influenced regulations concerning those who could practice medicine. The final product of Morstede's involvement with the Crown was the Fellowship of Surgeons in 1435.17 While this demonstrates the second jump in the number of documented surgeons, I must point out that the Fellowship was only the first national attempt to institutionalize surgery; there were numerous local attempts which had failed. For example, as early as 1368, the mayor of the city of London appointed three Master Surgeons to regulate and supervise surgical practices in the city.18 Again in 1392, the mayor assigned Master Thomas Stodley, surgeon, and two assisting clerks to the "mistery of surgery" in which they were to supervise and report any transgressions to the mayor.19 It would appear that these supervisory positions were ineffectual at controlling transgressions in surgery because in 1421, both physicians and surgeons led by Morstede petitioned Henry V that he allow only those who were educated to practice medicine. The petition reads:
Worthy Sovereign, as it is known to your high discretion, many uncunning and unapproved in the forsaid science practise and specially in Physick, so that in this Realm is everyman be he never so lewd taking upon him practise, is suffered to use it, to great harm and slaughter of many men. Where if no man practised therein, but only cunning men and proved sufficiently learned in Art, Philosophy, and Physick as it is kept in other lands and realms, then should any man that dieth for default of help live, and no man perish by uncunning.20
This petition demonstrates the urgent concern surgeons had about their field primarily its lack of educated practitioners. Unlike medicine, surgery lacked an institutional framework. During the 1400s, England's medical establishments were at least 100 years behind those on the Continent, where already by the

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twelfth and thirteenth centuries medical universities had been established at Paris and Salerno.21 England's first medical university was established in 1423 (an important date which we will be returning to), only to be dissolved in eighteen months and reestablished in 1518.22 Before 1423, English students who desired to study medicine had two options: either enroll in a medical university on the Continent and return to England with a degree, or study medicine in a more limited fashion in England as a component of the Bachelor of Arts degree.23 At this time, medicine was subsumed under the larger rubric of practical philosophy, a philosophy which centered on ars and scientia or art and science.24 While medicine was considered a less virtuous pursuit, far below that of theology and law, universities still offered degrees that demonstrated the individual's knowledge as a doctor. Medicine, therefore, required learning.

However, surgery was not as fortunate. Since few Continental universities taught surgery as a specialized field of knowledge, and if they did teach surgery, they focused mainly on the science and not the art of surgery, the surgeon's guilds functioned to fill the growing need for trained surgeons.25 The surgeon's guild became a separate institution in the medical community in England as early as 1368.26 Unlike the barber's guild, the surgeon's guild required a university degree prior to entry.27 Furthermore, the surgeon's guild provided the practical experience needed for surgery through apprenticeships. The apprenticeship for a surgeon took six years. If the apprentice did not pass a surgical exam within twelve years, he was not allowed to become a master of surgery.28 However, if we look at the number of educated surgeons in London between 1350 and 1450, it becomes evident that Morstede's concern over the uneducated is firmly rooted in reality.

Table 2:
Trained Medical Practitioners in London 1350-1450
Years Surgeons Physicians 1350-1360 6 9 1360-1370 11 6 1370-1380 5 6 1380-1390 2 4 1390-1400 5 3 1400-1410 2 3 1410-1420 4 6 1420-1430 3 6 1430-1440 2 7 1440-1450 2 9

To compile this information, I gathered those medical practitioners who had a university degree or were designated as Master of the Guild. If the biographical

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data lacked information about the practitioner's education, I excluded the doctor or surgeon from consideration. When this information is placed on a line graph, we see an inversion of the previous chart. (See Chart 2 in the Appendix.) The number of educated physicians drops off steadily from 1350 to 1400 which we can probably attribute to the Bubonic Plague.29 But after 1400, the numbers climb steadily. However, the surgeon is at an all-time high in 1360 (the decade of the surgeon's guild) and then drops off steadily. This demonstrates that the practice of surgery was being usurped by the uneducated.

During the later Middle Ages, the medical hierarchy appears to be firmly established. On the top of the hierarchy is the learned doctor who deals with specific congenital malformations and complexion imbalances. The surgeon stands in the middle and deals with major trauma, while the barber is on the bottom and performs minor surgery such as bloodletting and simple cauterization.30 However, because people perceived surgery to be a learned craft more than a science and because other guilds taught rudimentary surgery without requiring a university degree, there was a general fear among educated surgeons that many barbers and other artisans would take up the profession of surgery. This fear is most evident in Guy de Chauliac's statement that "If the surgeon has not learned geometry, astronomy, dialectics, nor any other good discipline, soon; the leather workers, carpenters and furriers will quit their own occupations and become surgeons."31

The primary reason surgery was so open to untrained artisans was that surgeons defined their profession more as an art than a science. Before the thirteenth century, most medical and surgical learning occurred in the monasteries. But as of 1215, the Fourth Lateran Council forbade the clergy from surgical practices such as cautery and incisions.32 While this prohibition went mainly unheeded, it does suggest a type of ideological separation between the knowledge of medicine and the practice of surgery.33 The clergy allowed members to study but not perform surgery because they felt the performance of surgery was unclean. In Chirurgie, Henri Mondeville seems to be responding to this. As Mondeville states, God acted as a surgeon when creating Eve from out of Adam's rib, and Jesus used clay to heal the blind man's eyes; yet nowhere in the Scriptures do they test urine or feel for a pulse.34

It is not fair to ascribe all the blame for this dichotomy only on the Fourth Lateran Council. In trying to outdo their colleagues, surgeons also created their own problems. With respect to medicine, they claimed their profession required a practical art. But this definition allowed unknowledgeable artisans into the profession. So with respect to unknowledgeable artisans, they claimed their profession required learning. This wavering between practical art and learning is common in surgical manuals. For example, Lanfrank analyzes the word "surgery" as coming from the Greek cheir hand' and ergon work,' thus making surgery an art or craft in which practitioners use their hands to heal sickness. Lanfrank then defines surgery as "a medicinal science, which techi us to worche wi handis in mannes bodi."35 With this definition, Lanfrank attempts to define surgery, like medicine, as a learned profession. Also wavering between positions

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is Mondeville. He argues, "We surgeons, being more practical, do not engage in such searching investigations [as those of doctors]; we are satisfied with fewer books."36 Then he states, "surgery does not consist only of manual operation; it is above all a theoretical science, and this aspect of it cannot be mastered by any mere layman."37

While the definition of surgery opened the door for untrained artisans to enter, the creation of the vernacular surgical manual offered the knowlege for them to remain. While guilds provided the necessary structure and organization for students to practice surgery, their access to more general surgical knowledge was poor. Unlike the twelfth-century clergy who studied and wrote on medicine and surgery, the thirteenth- and fourteenth-century surgeon did not always have access to surgical books or, if he did, he did not have the language background needed to read surgical textbooks, which tended to be written in Latin. As Mondeville states, "I do not see any surgeon among my contemporaries who is inclined to study; very few of them are lettered, and if some few are, either they are incapable, or else they care only for gain and would not agree to lose three ha'pence from their accustomed profits so as to compose a treatise which would be of use to all of us."38 But by 1380, the first surgical text in the English vernacular was produced: Lanfrank's Science of Cirurgie.39 After 1380, there is an explosion in the number of surgical manuals written in the vernacular.40 The birth of the vernacular textbook allowed guild members access to critical surgical knowledge, but the textbook also allowed uneducated non-guild members to justify their knowledge of surgery.

Henry did pass Morstede's 1421 petition into law; however, this law did not end the problems between barbers and surgeons. After its passage, Morstede again petitioned the king to create the joint College of Physicians and Surgeons. This college would be led by two physicians, two surgeons, and one rector. On 28 May 1423, Morstede and Harwe were sworn in as the masters of surgery, John Sumbreshede and Thomas Southwell as the Masters of Physik, and Gilbert Kymer, a physician, as the rector.41 The staffing of this college further demonstrates the desire surgeons had to be recognized along institutional lines with physicians. By August of 1424, Harwe was replaced by Bradwardine as the Master Surgeon, but the college closed in eighteen months.42 The failure of the college can be ascribed to political pressure by the lower ranks of the medical hierarchy the barbers. By November 1424, the Barber's Guild petitioned the city that its members would not abide by the legislation and would continue to practice surgery as they had in the past. The Mayor gave into the political pressure and declared:
That the Masters of the faculty of Surgery in the Mistery of Barbers of the City shall exercise the said faculty as fully as they did in the days of Thomas Fauconer, late Mayor, and other Mayors, notwithstanding the claim which the Rector and Surveyor of Physicians and the Master of Surgery now newly impose upon the said Barbers by virtue of a certain ordinance made during the mayorality of William Walderne.43

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The political pressure by the guild on the government was enough to dissolve any unification between physicians and surgeons, at least in London.

However, even with the failed attempt of unifying physicians and surgeons, Morstede still attempted to regulate the field of surgery. In 1435, Morstede founded the Fellowship of Surgeons.44 While most of this document has been destroyed, the signing members' names exist which influences the number of visible surgeons between 1430 and 1440; however, it also demonstrates how few surgeons were actually educated.45 More importantly, the creation of the Fellowship demonstrates that certain surgeons felt the necessity, after numerous external attempts at control, to regulate their profession from within. The Fellowship of Surgeons lasted until 1540 and continued to grow in membership. Interestingly, in 1540 the Fellowship of Surgeons united, not with the physicians, but ironically with the Barbers Company.46

The medieval surgeon in England was in a very difficult position. Society perceived the surgeon to be beneath the learned physician. Through Church and university legislation, the field of surgery was separated from medicine by its practice. Physicians studied surgery and medicine, but only surgeons performed the art. This forced surgeons to justify their profession through the educational structures offered by practical philosophy, relying heavily on the art of their practice. While they meant to defend surgery, they also allowed access by uneducated practitioners enticed by lucrative salaries. Once surgical textbooks were translated and produced in the vernacular, both guild members and non-guild members had access to surgical knowledge. Guild membership started to decline, and learned surgeons sought legislative help to protect their profession from unscrupulous practitioners. However, when legislative procedures failed, the surgeon tried to unite with the more educated physician in an institutionalized college. After the failure of the college, surgeons sought internal means to control their craft. More importantly, the concern of surgeons over usurpation by the uneducated are not simply fictions expressed in a medieval textbook; they are also real, as demonstrated through a statistical analysis of the surgeons in London. Undermined by his own rhetorical defense of surgery, the medieval surgeon was in a precarious social situation well into the fifteenth century.