FEES IN MEDICAL HISTORY* By HOWARD DITTRICK, M.B., (TOR.)

CLEVELAND, OHIO

EDICAL fees constitute an index wifery and surgery grew up outside the of the training of the profession priesthood as arts to be practiced by slaves, at any given period, and of the menials and charlatans, as well as by standing of its members in the respectable practitioners working outside esteem and confidence of their ownthe comtemples.- Mmunity. Any consideration of the subject,3. An Unlicensed Lay Phase, the worst of because of rarity of data, consists of the all in regard to the dignity and morality of arrangement of isolated bits, strung like the profession. beads on the thread of the historical devel- 4. A Licensed or Organized Lay Phase, opment of medicine. A quest for such infor- wherein medicine and surgery were com- mation becomes a diversion for leisure bined outside the priesthood and its hours; an intriguing meandering journey limitations. among the colorful temples which were the The earliest Patriarchal Phase is almost shrines of ancient medicine; among the lost in the mists of antiquity, and only an courts of caliphs, emperors, popes and kings; occasional vestige of it finds place in this and lastly, among the consulting rooms of study. Passing on to the Sacerdotal Phase, the masters of medicine. the origin of medicine in the temples is The pursuit of this theme was suggested more clearly understood when it is remem- by Osler’s idea that volumes of his recorded bered that ancient peoples believed not fees should be preserved for their probable only healing to be the gift of the gods, but interest to posterity. also, pestilence, disease and death to be the The art of healing has passed through four punishment of their wrath. To regain their distinct phases, a review of which will serve favor was to regain health, hence in its to illuminate the study of the rewards of its origin, healing was intimately connected practitioners (ref. no. 26, p. 597). with religion and mythology. 1. A Patriarchal Phase, which corre- In both Greece and Egypt, medicine had sponds to the origin of society, to an epoch its rise in these sources and came down in when the chief of a family united in himself two main streams, the one flowing through all power and was the depository of all priestly channels to Hippocrates and his traditions. followers, the other through physicians who 2. A Sacerdotal Phase, which reigned long practiced outside the temples, though gen- in Egypt, flourished in Greece from the erally in friendly relation to them. Trojan War to Hippocrates, and which Following up the priestly channel, we find reappeared in Europe during the Middle that in the early days of Babylonian and Ages. During this phase the healing art was Egyptian medicine, the sick were exposed usurped by the priesthood. But because the in public that they might profit by the sacred precincts of the temples would have experience of others who had been thus been profaned by birth or death, and afflicted (ref. no. 14, p. 104). At a later date, because the letting of blood, and later, the those cured were required to inscribe in the necessary studies of anatomy by dissection temples their disease and the method of its were forbidden to priests, therefore mid- cure. The temples of Canopus and Vulcan * Read before the Academy of Medicine, Cleve- (ref. no. 26) at Memphis, became the chief land, Ohio, May 21, 1926. depots of these registers which the priests 90 kept with greatest care for purposes of which classification came the dreams of consultation. From the mass of data the temple sleep. priests formed a medical code called the Having reviewed the course of medicine Sacred Book, to the provisions of which they during the Sacerdotal Phase, we may now were obliged to adhere. If in so doing the enjoy the gossip of the ancients regarding patient’s life was lost, they were not held the fees of the period. responsible, but if they varied from the code, In part of the oldest known code of and the result was unsuccessful, they were laws, that of hammurabi of Babylon,13 circa punished with death (ref. no. 26, p. 30). In 2250 b .c ., is included specific regulation of the this manner medicine came to be the prerog- practice of medicine, the scale of fees, and ative of the priesthood, who alone had the penalties of malpraxis. Fairly recently access to the records and who also had the these laws have been deciphered from the necessary education to comprehend them. original block of black diorite, at the top of The temples became dispensaries, in which which is a relief showing the king receiving advice was given, remedies administered them from the Sun-god. Replicas of the and students trained. At first training was stone were set in public places, that anyone given only to those of the priesthood, later might determine the application of the laws it became accessible to any person who could to his own problem. The following arc pass the initiatory tests and pay expenses of excerpts from clauses of medical interest: instruction (ref. no. 26, p. 90). This move- If a physician operate upon a gentleman for a ment was given impetus in Greece by the severe wound with a bronze lancet, and save dispersion of the Pythagoreans early in the the man’s life, or if he open an abscess of the fifth century b .c . Promulgation of the eye and save the gentlemen’s eye, he shall medical doctrines of Knidos and Kos, receive ten shekels of silver as his fee. collected later as the Hippocratic works, If he be a freeman, he shall pay five shekels. assisted in opening the secrets of practice If he be a slave, the owner shall give two shek- to the profane (ref. no. 26, p. 298). els to the physician. Meanwhile physicians outside the temples If he operate upon a gentleman for a severe were maintaining offices, conducting hospi- wound and cause his death, or open an abscess of the eye and destroy the eye, they shall cut tals equipped with consulting rooms, oper- off his fingers. ating rooms and instruments, and holding If he operate on a slave for a severe wound and office as city physicians of large cities, paid cause his death, he shall restore a slave of equal by public funds. value. Both these streams were merged in the If he open an abscess of the eye and destroy temple schools of Kos, Knidos, Kroton and the eye of the slave, he shall pay silver equal to finally Alexandria. The healing art emerged half his price. from these schools, enriched by painstak- If he set a broken bone for a gentleman or ingly recorded observations, clarified, codi- cure his diseased bowels, the patient shall give fied, a fit foundation for later science. five shekels of silver to the physician. If he The methods of the temple healing were be a slave the owner shall give two shekels to two (ref. no. 14, p. 228): the physician. 1. Direct, that is, by intervention of the These regulations would indicate that deity or transmission of divine power by even at this early period there was recogni- means of a sacred object or agent. tion of surgical practice. 2. Indirect, by laying on of hands by the The influence of priestly medicine is god or his priests; by divine power trans- observed in the healing of Naaman, the mitted through animals (serpents or dogs Syrian, by Elisha, the Prophet of Jehovah. being commonly used in Acsculapian tem- Incidentally the fee offered by Naaman was ples), or by oracles, visions or drcams, under 10 talents of silver, 6000 pieces or shekels of gold, and io changes of raiment. This jar of gold filled with gold coins. He was was declined by Elisha, but his servant, granted also a sumptuous house, a seat at Gehazi, pursued Naaman surreptitiously the king’s table, and all that heart could and importuned him. Naaman generously desire except freedom to return to Greece. gave him 2 talents and 2 changes of raiment, Later he healed the king’s wife of an ulcer doubling the amount requested. Elisha of the breast, and in return, she persuaded detected the deception of his servant, and Darius to organize a military expedition to declared unto him, “The leprosy therefore Greece with Democedes as medical adviser of Naaman shall cleave unto thee and thy and pilot. Darius requested him to take all seed forever,” and he went out from his his valuables as gifts to his family, assuring presence, a leper white as snow.3 him of greater gifts on his return but the The first of the Greeks who immortalized wily physician profited by the opportunity himself by extraordinary cures was Mel- to remain in his native land. At this time, ampus, seventh century b .c ., one of whose the sixth century b .c ., city physicians were fees is worthy of note. Proetus, king of already employed in Greece, and in this Argos, had two daughters who had taken capacity Democedes was paid 1 talent vows of celibacy, and who became subject (about $2000) annually at Aegina, later a to fits of hysteria, during which they ran similar appointment at Athens paid him wild in the forests. Other women became 100 minae (about $2400) and at Samos a sympathetically deranged. Melampus gave like amount. them white hellebore infused in milk, and The regulations of ancient Persians with caused them to be chased by youths until respect to fees and qualifications have been fatigued. They were then enchanted and recorded with more detail than their medicine. made to bathe in a fountain of Arcadia, Persons of varying degrees of importance called Cletorian. For this cure the king as listed, paid with animals of commensiir offered Melampus the hand of one of his rate value, also listed. Thus, as Baas daughters and a third of his kingdom, which puts it, the famous doctors of the day were Melampus accepted on condition that his able to acquire, in place of our modern brother should have a reward equal to his stocks, a tolerably fine collection of live- own (ref. no. 26, p. 46). stock. As for examinations, any physician Emoluments and honors granted to the who had “cut” three unbelievers and had Greek Dcmocedes (ref. no. 4, p. 183) at the “done for” them all, failed to pass; if how- court of Darius of Persia, are enumerated ever the unbelievers survived, the faithful by Herodotus. Darius had suffered a luxa- might give him a trial (ref. no. 2, p. 27). tion of the ankle-joint, which was treated The course of temple medicine in Greece by Egyptian physicians at his court. They is marked by the celebrated temples of twisted and violently handled it, causing Asklepios, the first of which was built at acute pain which persisted eight days. Titanus, fifty years after the destruction of Someone recommended Democedes of Troy. Very soon the worship of this god, Crctona, who was a captive lodged with who was the son of Apollo, spread through- slaves, and he was brought before the king out Greece and passed into Asia, Africa in fetters and rags. Democedes applied and Italy. strong fomentations and soothing remedies. Concerning payment for benefits received Relief was immediate, and the grateful in the temples, Robinson says (ref. no. 27, Darius presented him with 2 pairs of fetters p. 17): of gold. On the protest of Democedes that A mortal like Socrates refused remuneration these would but double his calamity, the for his teaching, but Aesculapius demanded king sent him to the apartments of the silver and gold for his services, at least so the women for his reward, which proved to be a priests claimed. Indeed on one occasion the god so far forgot himself as to say aloud to the But votive offerings of greatest interest to patient “Thou art healed, now pay the fee.” medicine are the models of organs, normal Those who recovered left money or other testi- or diseased, made of ivory, gold, silver, monials of their gratitude. Those who received bronze or terra cotta, presented in gratitude no aid believed that their offerings were rejected for restoration to health. Interesting because insufficient and redoubled their gifts. examples include models of the uterus or Thus both good and bad results added to the ovary, uterus septus, uterus with salpingo- glory of the temple and the profit of the priests (ref. no. 26, p. 63). Nor was^their income entirely oophoritis, abdomen showing fetus in situ, dependent upon curative skill, for the temple and also abdominal viscera. Existing col- endowments were extensive and untaxable lections include almost every human organ, (ref. no. 2, p. 17). some of heroic size,1 others of correct pro- portion, animal statuettes, which were At the temple of Diana at Nemi, there in all probability children’s toys, family were unearthed more than a thousand groups given in gratitude for offspring.29 medals and coins, as well as many statuettes Examples of pregnant women kneeling of terra cotta and bronze. Relics of many were probably representations of one of the kinds were deposited in the temples in Nixi, goddesses of childbirth.28 gratitude for cures, a notable example being Excavations on the site of the Acsculapian the spear and breastplate of Alexander the temple in Rome on an island of the Tiber, Great in the temple at Gortys (ref. no. 21). disclosed shops for the sale of these offerings Grateful suppliants brought temple furni- clustered about the approaches of the ture, bronze rings, ornaments, bas-reliefs, temple and stocked with large numbers of statues and paintings. Inscribed tablets votive offerings. Doubtless these shops were recording cures were placed on the walls, under the control of the priesthood and and frequently others beside them “warned therein were resold indefinitely, votive, of dreadful happenings if the suppliant donated offerings. should fail to keep his vows or should neglect Pausanius relates22 the interesting case of to reward the service of the deity. Instances Phalysios who built a temple to Asklepios. were related of cures revoked and of punish- He was nearly blind and the god sent a ments inflicted on such recreants.” There messenger to him with a sealed tablet which is even evidence of deferred payment being he was bidden to read. This seemed impos- agreed upon. A suppliant possessing literary sible, but hoping for benefit, he broke the gifts presented to the god, paeans or hymns seal, and as he gazed upon the tablet his of praise, prayers, dramas concerning the sight was restored, whereupon he gave the life of the god. It is said that Asklepios messenger what was written upon the appeared to Sophocles, commanding him to tablet, namely 2000 gold staters (about write a paean in his honor, and that such an $9500). one has been discovered. Several orations of Asklepios not only healed the sick, but Aristeides eulogizing Asklepios are supposed brought the dead to life. Among those so to have a similar origin (ref. no. 14, p. 233). revivified was Hippolytos, and Pindar refers An inscription at the Island Cos4 records to the charge that in this case Asklepios the granting of an honorary decree to a was prompted by an improper desire for physician who had distinguished himself by gold. Because of such avarice, and because devotion to the poor during an epidemic. he imparted his art to mortals contrary to Another decrees a crown of gold to Metro- the will of the gods, or because Hades com- dorus, “who during twenty years as a public plained that the success of Asklepios in physician, has saved many citizens, and averting death, threatened to depopulate now lives in poverty, having refused from his realm, Hesiod relates that he was them any fees.” slain by a thunderbolt from Zeus. This manner of death was held to constitute potamus, perhaps pregnant. These figures proof of divinity (ref. no. 26, p. 48). were probably disease demons, made terri- Plato, in the Phaedo, records the dying fying to drive away disease, and were words of Socrates, upon drinking the fatal placed in niches in the walls of houses, or hemlock: “Crito, we owe a cock to Aescu- worn as a help in parturition.14’20 lapius, pay it therefore, and do not neglect At the museum in Alexandria organized it.” The meaning of this farewell tribute, by Ptolemy at the instance of Alexander in as interpreted by Dyer, is that to Aescu- the fourth century b .c ., medicine was lapius, a god who was always prescribing taught on a par with the arts and divorced potions, was due that welcome remedy from the priesthood. This became in effect which cured all the pains and ended all the the first university in the world, and its woes of Socrates. The offering of a cock was professors and fellows were appointed and plainly intended for Aesculapius as the paid by one of the Pharaohs.31 It flourished awakener of the dead to life everlasting. in this form for about one hundred years. Meanwhile the Egyptian Aesculapius was But this Alexander of exalted vision Imhotep (he who cometh in peace), “the could also be petty and cruel. Plutarch tells god who sent sleep to those suffering and in of a soldier called Hephaestion, who fell pain,” whether deities or men. He was the sick of a fever. During the absence of his learned physician to King Zozer of the third physician Glaucus, Hephaestion partook of Dynasty (about 2900 b .c .) and was ele- a fowl and a copious draught of wine, and vated to the rank of healing divinity (about forthwith died. Alexander vented his wrath 700 b .c .). Originally worshipped at his upon the physician, whom he ordered cru- tomb near the pyramid of Sakkara, of which cified (ref. no. 24, p. 256). he had been architect, his cult spread until Yet kings could not always command his temples, called by the Greeks Asklepieia, physicians, for Artaxerxes, King of Persia, were found in many Egyptian cities (ref. is reported to have offered in vain to no. 14, p. 62). Hippocrates, large sums of money, and Of yet more widespread worship in Egypt even entire cities, to come into Persia to was Apis, the healing divinity to whom the the relief of plague-stricken provinces and origin of medicine was ascribed. Apis was armies. The Illyrians did likewise. These worshipped in the form of a bull, the beau- offers were indignantly refused. Thus he tiful image of the soul of Osiris. Pausanius answered Hystan, governor of the Helles- says that the manner of consulting the god pont, “Say to your master that I have was the same in Egypt as in Greece. The ample riches, that honor will not permit me lamps were filled with oil, money was placed to accept his proffered gifts to render suc- upon the altar, and with his mouth to the cour to the enemies of Greece.” But he did bull’s ear, the suppliant whispered his stay the plague in Athens, and the people request, drawing his answer from the first decreed a crown of gold, a right of citizen- words of the first person he met on leaving ship and a free education to the youth of the temple. Other Egyptian healing gods Cos. The senate of Abdera solicited Hippo- were Thoth, considered the embodiment of crates to visit Democritus, whom they be- divine wisdom, and Ptah, chief god of lieved insane. “If our city were all gold we Memphis, whose healing powers were chiefly would give it to restore Democritus to connected with blindness and deafness. health,” they wrote. Hippocrates convinced An interesting example of an Egyptian them that Democritus was sane, and refused amulet is that of Epet which appears in to receive a fee of 10 talents tendered him in Greek as Thoueris, the Great One, having payment (ref. no. 23, p. 3). elements belonging to the crocodile, the The divorce of medicine from the temples lion, and to man as well as to the hippo- originated in Greece, passed into Asia and Egypt, and penetrated Rome (ref. no. 20, our confidence, and poison us the more p. 248). Earlier medicine in Rome had been easily. In short remember that I have for- under the patriarchial form, wherein the bidden you to employ physicians.”9 This master of the home was the doctor for the aversion is further explained by Plutarch members of his family unless, as in many of in his life of Cato. Having heard of the larger households, he appointed in his Hippocrates’ refusal to aid barbarians who stead a slave or freedman who showed an were enemies to the Greeks, Cato asserted aptitude for medicine. This person was usu- that this was now become a common oath ally a Greek, and later practice was largely taken by all physicians, whence he inferred in the hands of Greeks, frequently Greek that such extreme patriotism might lead to slaves. During this era of charlatanism the poisoning. health of the citizens was in the hands of Though Pliny also registers adverse criti- any impostor who chose to call himself a cism, he leaves record as well of those highly doctor (ref. no. 26, p. 250). The abuse to honored in the profession. He says that4 which this liberty led during the unlicensed Cleombrotus received a hundred talents laity phase, became intolerable, laws were for the cure of King Antiochus, which by laid down to regulate medical practice, different standards of estimate, range from and thus emerged a legal or organized laity $121,000 to $156,000. Such eminent physi- phase. cians as Albertius, Arruntius, Colpitanus A Greek physician typical of his time who and Cassius and Rubrius, made 250,000 made his way into public favor in Rome sesterces ($9750) annually. Also Quintus during the fifth century b .c . was Archa- Stertinius was content to serve the Emperor gathos,4 a man who limited his practice Claudius for 500,000 sesterces per annum, to treatment of fractures and dislocations, which sum was double that usually paid a to amputations and the dressing of wounds, private physician by the emperor, but much ulcers and abscesses, internal maladies being less than that he could have earned in left to quacks. In spite of the fact that he private practice. He and his brother, who was dubbed “Carnifex” because of his was in receipt of a like income, after spend- methods, he was so highly esteemed that the ing large sums in beautifying Naples, left senate provided him with a house purchased an estate of 30 million sesterces($1,170,000). by public funds. Antonius Musa earned the gratitude of From the time of Constantine the Great, Augustus for the relief of an obstinate skin the term archiater is met with (ref. no. 26, affection. The emperor gave Musa his p. 251) in the edicts of emperors and refers freedom, Roman citizenship, much money, to physicians attached to sovereigns. Others, and the knight’s ring, the latter the proto- called popular archiaters, formed in each type of the ring subsequently placed upon town a college which supervised all things the finger of the graduating doctor (ref. no. relating to medical practice. They were 2, p. 147 footnote). Also Augustus caused the empowered to fine impostors 2000 drachmae. statue of Musa to be placed among the These archiaters were honorably pensioned Caesars. It may be of interest to note that by the state and enjoyed various privileges, this statue, at present in the Vatican, is in return for which, they cared for the poor widely known as that of Aesculapius. gratuitously, but charged all others. Indeed, another story has it that the head We find in Rome, second century b .c ., was struck off from an ancient statue of the widely divergent opinions of the benefits of god and that of Musa substituted. medicine. Cato writes diatribes upon the Charmis, a leading physician in Rome lack of common honesty and skill of the asked a fee of $10,000 to attend a patient in physicians of this time, culminating thus; the provinces. When we consider the dan- “They make us pay dearly for obtaining gers and inconveniences incident to travel in those days, the rewards of practice were that he dabbled much in alchemy, and merely commensurate with its perils.25 one story states that he abandoned this Among the distinguished patients of art because of a sound beating given by the Galen, second century a .d ., was Marcus caliph when he was unable to transmute Aurelius, who said “I have but one physi- metals to order. Another version maintains cian, and he is a gentleman.” For a fort- that he injured his eyes in preparing an night’s attendance upon the wife of elixir and was obliged to pay the physician Broethus, Galen received 400 aurei, about who cured him a fee of 500 dinars. There- $2000.17 < upon he remarked that at last he had dis- The physicians Damian and Cosmos,4 covered the true alchemy and the best art of the sixth century a .d ., were two of making gold, and he spent the rest of his brothers, who, because they would accept life in the study and practice of medicine. no recompense, were nick-named Anargyri. A similar type of physician is portrayed When they had cured Justinian, Emperor of by Chaucer in the Canterbury Tales. Constantinople, of a grave disorder, he For gold in Phisik is a cordial, insisted on rewarding them. They would Therefore he lovede gold in special! accept nothing for themselves, but sug- gested that he build churches. This he did At that time gold was highly estimated as a on a magnificent scale. remedial agent, hence, the double meaning The status of practitioners of the period is of the doctor’s enthusiasm for collecting reflected Jin the code of Theodoric (ref. no. gold. 26, p. 274) which was in force in the western The Arabian caliph Nasr, when saved the world from the sixth to the twelfth cen- necessity of being cut for stone, presented to turies. At this time the unlicensed lay his physician, Abu Nasr, a fee of about phase had admitted swarms of practitioners $60,000 besides many rich presents.25 It of the lowest order. This code says in part: is apparent that he who found the gift of When a physician is called to treat a disease life such a boon did not share the philosophy or dress a wound, it is necessary immediately of Seneca (ref. no. 6), who said that life after having seen the patient, to give security would not be accepted if it were offered to and agree upon the price of his attention. If he such as knew it. Gabriel Bachtislua was happens to harm a gentleman, he must pay a paid by his caliph at the rate of about $5000 forfeit of a hundred sous. If the patient dies per month, and received nearly $6250 from the effects of this operation the physician besides robes of honor each New Year’s day. should be handed over to the relatives of the On one occasion he is said to have received deceased, who may do with him whatever they about $125,000 as a single fee.25 please. If in any way he cripple a serf or cause The Emperor Frederick 11 recognized the his death, he is held accountable for the restora- excellence of the medical school at Salerno tion of another to the lord. to such an extent that he placed within its These severe restraints have been adjudged jurisdiction the governance of all medical to be applicable only to surgical cases, the practice in the kingdom of Naples. Upon treatment of which was in the hands of completion of the eight years study leading individuals of the lowest order. Indeed to a master’s degree, whereby he might later yet, Cervantes in Don Quixote derides practice medicine, the candidate’s oath the graduates of Siguenza, saying that in included a clause that he would give gra- Spain the small universities for the sum of tuitous attention to the poor, and would not 2 doubloons make a doctor out of an ass. share in the profits of the apothecaries (ref. It is related of Rhazes,30 the first and no. 26, p. 277). most original of great Moslem physicians, Peter of Abano, who practiced in Padua practicing early in the tenth century, in the thirteenth century, stated that his salary as a teacher was 500 pounds a month. sum of 600 livres for a life service. This was This picturesque Peter of Abano was one of the origin of the Stadts Physikus in Ger- the most famous philosophers of his age. many, and of the salaried physicians and It is said that he would not attend the sick surgeons of France, who could now practice, under 150 florins a day, and that he freed from the control of the church, after demanded from Pope Honorius iv, 400 having been rivals of the monks for two ducats for each day’s attendance. Further hundred years. They now formed civil account says the Pope promised him a fee corporations and were granted by the of 100 florins, but gave him a 1000 when he monarchs certain privileges and statutes.15 had recovered his health. He was suspected The salaries paid by the other medieval of being enabled by magic to make the popes25 to their physicians varied from money he had spent come back into his that of John xxn, 5 to 6 florins a month, purse. Equally naive is the recommendation to that of Urban vi, 400 florins per annum. of Gaicosa contained in a Salernitan treatise Pedro Pintor, physician to Alexander vi, of about 1200 a .d . that “patients who show received a 100 gold ducats. Matteo Curti themselves ungrateful to the physician had a salary of 100 gold scudi from Julius after being cured, may be made to suffer hi . Taddeo Alderotti, a contemporary of again.”30 . Dante, and teacher in the University of Peter of Aichspalt, Bishop of Basle, was a Bologna, was regarded as the first citizen clerical physician who solicited of Pope of Bologna and as a public benefactor Clement v, an archbishopric, for another exempt from the payment of taxes. He friend. He cured the Pope of an accidental acquired wealth and is reputed to have sickness, and received in return for himself charged Pope Honorius iv, 200 florins a the Electorate of Mayence (ref. no. 2, p. day, besides a gratification of 6000 florins. 331). These fees may not sound extravagant, but Military surgery, properly so called, is in addition they had many privileges, not mentioned in history till the fourteenth received valuable presents, lived at the century, but in the ancient chronicles con- Pope’s expense and used his servants and tinually there is found allusion to some carriages. Those who chose to take orders monk or clerk who accompanied military were sure of valuable preferment (ref. no. forces probably in the capacity of physician 17, p. 105). or barber surgeon, to dress wounds and That even royal patients neglected to attend the sick. Certainly the first army pay their physicians, was the bitter plaint surgeons were ecclesiastics, who at that of Henri de Mondeville25 one of the surgeons time had a monopoly of the science of to Philip Ie Bel of France in the fourteenth medicine. Later when urban and municipal century. “I have not met with any man associations gained their freedom from the rich enough, or rather honest enough what- feudal lord, they desired to be free of church ever were his station in life, ecclesiastic or control, and promoted barbers to be sub- otherwise, to be willing to pay that which ordinate surgeons. Thus in every important he had promised, without compulsion or town a number of surgeons were given a pressure.” His bitter experience is revealed fixed salary, and agreed to attend the in his emphatic recommendation to surgeons poor and follow to the wars the men fur- never to undertake treatment without a nished by the communes to fight for the clear understanding as to the fee. In true lord. In Holland, Italy, Germany as well as continental fashion he insists that the in France, these surgeons, educated in surgeon should begin by asking twice as monastic schools, were engaged in public much as he is willing to receive, and also service. Among these was Hugh of Lucca, advises others, “never dine with a patient physician at Parma, who was paid a lump who is in your debt, but get your dinner a an inn, otherwise he will deduct his hos- we do not apply, nor owe we, preventive treat- pitality from your fee.” ment, as they are the avaricious and all those Arpad Gerster says12 that in those days who prefer money to their own body’s welfare, there was neither emolument nor honor preferring to suffer in body, rather than in purse. in surgery, and yet this exceptional man, Furthermore we are not bound to use preven- de Mondeville, devoted his life exclusively tion in the case of those who pay after the case is finished, and according to the trouble expended to the despised profession. In speaking of on them. If these are cured rapidly, they pay preventive treatment, de Mondeville says: inadequately. If the cure is prolonged they Therefore it appears that the treatment that pay much more. Let us administer them feeble preserves from future malady is of greater medicines of slow action in the hope that their utility to the patient than all other treatment, fee may be pro rata, proportionate to the time but it is useless and prejudicial to the surgeon employed. as it impedes the advent of the disease, the cure Yet this rare soul was far from mer- of which would bring him profit. We must not therefore apply preventive measures except to cenary for Sir William Osler17 quotes thus the following five kinds of men. his quaint philosophy, full flavored with i st, to the truly poor, for the love of God. humanity and truth. “If you have operated From the middling poor however it is permis- conscientiously upon the rich for a proper sible to accept chickens, geese and capons. fee and upon the poor for charity, you need 2nd, to personal friends from whom we would not play the monk nor make pilgrimages not take any fixed payment or counted money; for your soul.” we may however receive from some friends The loquacious Benvenuto Cellini9 in victuals or jewels, a piece of cloth or plate in speaking of a Maestro Giacomo da Carpi, sign of old friendship, rather than as a remunera- (one of the first to use mercury in the tion for treatment. But as it is not seemly for treatment of syphilis) says, us to say this, should mention be made of a salary, price or money, our servants ought to he undertook the most desperate cases of the see to it saying, without our knowledge, as it so-called French disease. When therefore were, and behind our back, “Hush! my master Maestro Giacomo had made his talents known, will have none of that, but you ought to deal he professed to work miracles in the treatment courteously with him as far as to offer him a cup of such cases by means of certain fumigations of silver or something similar, although I am but he only undertook a cure after stipulating pretty certain that he won’t accept it.” And by for his fees, which he reckoned not by tens but this cleverness, a good servant may succeed in by hundreds of crowns. The Pope would fain getting more than the master by his operation. have had him in his service, but he replied that Likewise if the surgeon employ a horse in visit- he would not take service with anybody in the ing, on account of the horse, pay ought to be world, and that whoso had need of him might double. come to seek him out. He was a man of great 3rd, to those whom you have found to be sagacity and did wisely to get out of Rome for grateful after the cure is finished. It would not not many months afterwards all the patients be decent to deceive these, the poor, and one’s he had treated grew so ill that they were a hun- friends. dred times worse off than before he came. He 4th, Prevention is to be applied to people would certainly have been murdered if he had who are bad payers, to whom however we do not remained. dare to refuse treatment, our liege lords, their Francesco da Norcia, physician to three families, chamberlains, justices and lawyers. The longer be the treament of these persons, popes, treated Benvenuto for a severe illness the greater our loss; therefore let us hasten their over a considerable period of time “during cases as much as possible by using the very best which,” Benvenuto relates, “there came remedies. from my stomach a hairy worm a quarter 5th, We owe preventive treatment to those of a cubit in Iength.The hairs were long and who pay us in full and in advance. To all others the worm was very ugly, speckled of divers colors, green, black and red.” In dismissing their money before I trust them with my Art. the patient, his physician said, “when you The Draper is not bound to find Cloth for all are quite recovered, I beg you to make me the naked because he has enough in his shop, a madonna with your own hand, and I will nor yet to afford it at the Buyers’ price. The pay my devotions to it for your sake.” A Lawyer is not obliged to spend his voice and spirits for all the Injured in Forma Pauperis madonna by Cellini was no inconsiderable because he pleads well and shall be heard. fee. Acts of Charitie are more due from Kindred Bernal,4 intrepid physician on the first than from Strangers. When a Husband of suffi- voyage of Christopher Columbus, was paid cient means shall not think his Wife nor Child’s at the rate of 17 cents a day, but the fee life worth 10 Ii, I am not bound to bestow that of Marco, the surgeon, is not disclosed. on them which is of more value. I could instance The salary of Vesalius at Pisa was $1000, many such kind Husbands, and of late one, who equal according to Garrison, to $8000 at valued his word at 500 Ii but the danger of his present day values (ref. no. 1, p. 223). Wife not above 5 li, and that in question of King Charles 11 of England was guilty of cavelling if need had required it. In summe, I base ingratitude to his physician Sir am wholly tired out with the injuries, vexations Edmund King. The monarch being seized and losses of the business. with an apoplectic fit in the physician’s Not all royal physicians were so poorly presence, the latter promptly bled him with- recompensed. Fernel, physician to Catha- out sending for another physician. So con- rine de Medici, was paid 10,000 ecus when trary was this to medical regulations of the her long desired pregnancy was determined, court that it was thought a regular pardon and when couched, as much again with would be required. But since the king a buffet of silver. This she did at each was thereby relieved, the Privy Council accouchment.7 granted the physician a thousand pounds, Ambroise Pare was surgeon to four kings which obligation however, was never paid and during his long life had experiences by either Privy Council or king.16 Dr. varied and vivid. Paget relates20 that dur- Peter Chamberlen stood in a similar case, ing the reign of Henry 11 Pare joined physician to Queen Anne, and a member of the army as a follower of Colonel Monte- the great family1 of physicians to whom jan, having neither rank, recognition nor we owe the Chamberlen forceps. “I have regular payment. His fees make up in served these many years the King and romance for their irregularity; a cask of Queen by special Commands, and in some wine, 50 double ducats, a horse, a diamond, especiall services receiving only one Reward a collection of crowns and half crowns from and a Diamant Ring from her Majestie, the ranks, and “other honorable presents but not any stipend at all from either,” of great value;” from the king himself 300 he notes with bitterness. “I have served crowns and a promise that the king would the commonwealth now 27 years, toy- never let him be in want, and a soldier once ling both early and late, not without offered him a bag of gold. The king’s favors the frequent hazard of my life. I have spent were granted after Pare had been smuggled my Youth and Industry for Food and Rai- into Metz in 1552 and had remained to ment, never receiving any Publick Encour- treat the soldiers until the end of the siege. agement or Gratuity, but to be valued Sworn royal physicians, charged to report beyond my Condition or Demerit in Taxes.” in all legal trials, were established in the And further he sums up the ingratitude communes and cities of France by several of the public which he serves. kings, including Henry iv and Louis xv. To prevent both discontent on the one side This establishment, says Fodere, did not do and dishonesty on the other, I resolve to afford all the good it promised because it was my Labours to none but such as trust me with stricken from its birth with a mortal disease, the venality of officers. He hoped however bearer is very desirous of having your to see a similar institution founded free opinion. I do not know his case. He has no from this reproach (ref. no. 26, p. 470). money, and you do not want any, so that Louis xiv showed himself deserving of the you are well met. Ever Yours, John Hun- title the “Grand Monarch” in his treatment ter” (ref. no. 11, p. 396). Yet this generous of his many doctors.26 Reducing the amounts doctor has voiced in a human way, the for convenience to our own standards momentary irritation that comes to all of on the basis of 5 livres to the dollar, he us when interrupted in the pursuit of a paid Clement $2000 for services at the hobby, “I must go and earn this damned birth of the Duke of Burgundy. An opera- guinea, or I shall be sure to want it tion for fistula to which he was subjected in tomorrow.”19 1686 cost him or his people an equivalent of In the year 1792 Dr. Willis,26 who had $200,000. Felix the operator received charge of George hi in his periods of $60,000 and a landed estate. Two years derangement, was called to Lisbon to earlier the same surgeon was paid by the attend the Queen of Portugal, also mentally king a fee of $20,000 and six years later, he deranged. Terms agreed upon included a was granted a patent of nobility. Returning salary of 1000 pounds a month, travelling to the fistula operation Bessieres, who expenses, a table for himself and suite, and assisted Felix, received $8000. The physi- 20,000 pounds if he succeeded in curing the cians D’Aquin and Fagon received $20,000 queen. He was received with honors usually and $16,000 respectively for looking on, accorded royalty. while the four apothecaries each received The regular fee of Professor Botkin, for $2400, and Felix’s apprentice Laraye was many years trusted physician of Alexander given 400 pistoles, or a trifle of $800. hi and the Czarina, is said to have been The payment of a life annuity for a suc- 100 rubles (about $50) for a consultation at cessful operation was a medieval custom still his own home and five times that amount for in vogue during the seventeenth century. a residence call within easy distance. Dr. Weiman records an annuity of 30 pounds Freyer was paid 10,000 pounds for attending per annum from one patient (ref. no. 11, p. a native Indian prince in London. Morrell 286). Quarin was given an annuity of Mackenzie was given 13,000 pounds for $10,000 per annum and was made a baron attendance on the Emperor Frederick. for his consultation with Joseph 11 of Charcot’s honorarium for watching for a Germany (ref. no. 11, p. 397). week at the bedside of the late Emperor of Empress Catharine of Russia was royally Brazil amounted to several thousand munificent to Dimsdale25 whom she brought pounds.26 from England in 1762 to introduce inocula- Sir Andrew Clark once refused a fee of tion against smallpox. For his services he 5000 pounds rather than leave an impecun- received a fee of 10,000 pounds, travelling ious patient requiring his attention. He expenses 2000 pounds, a portrait of the returned a check for 6000 pounds for a empress, sundry titles and a life pension of consultation in Cannes, stipulating that 500 pounds a year. 750 pounds was enough for a week’s The eminent John Hunter19 frequently absence from London.26 He told Sir William replied to patients who asked his fee, “Why Osler18 that he had striven ten years for that you must determine yourself. You bread, ten years for bread and butter are the best judge of your own circum- and twenty years for cakes and ale. stances, and it is far from my wish to The beloved Osler had a kindly memory deprive you of any of the comforts of life.” of his own “bread” earning years and he A terse note to his brother reflects his liked to exhibit to his students his first fee personality. “Dear Brother,” it reads, “The record, “Speck in cornea, 50^.” He also enjoyed telling of serving for a month as 4. Bombau gh , C. C. Johns Hopkins Hosp. Bull., 11, locum tenens for Dr. Charles O’Reilly of 183. Hamilton, for which he received “$25 and 5. Brennan , W. A. On Wounds and Fractures (Guy de Chauliac). Chicago, 1923. a pair of old fashoned elastic sided boots 6. Browne , T. Religio Medic., edit, by Symonds. which had proved too small for Charlie N. Y., 1677, 257. O’Reilly” (ref. no. 101, p. 120). 7. Caban es , A. The sterility of Catherine de In conclusion, the attitude of the average Medici. Ann . Med . His ., N. Y. 1919, 11, 92. patient in matters mercenary is epitomized 8. Cato . De Re Rustica (ref. no. 26) 249. somewhat cynically in the lines accompany- 9. Cellini . Life of Benvenuto Cellini, tr. by Symonds, N. Y., 1906. ing an old Dutch woodcut. 10. Cushi ng , H. W. Life of Sir William Osler. When the sick man lies abed distraught with pain N. Y., 1925. And dismal Death is clutching at his throat, 11. Garris on , F. H. History of Medicine, ed. 3, He likens me to GOD and all his house Phila., 1921. Kneel down and do me reverence. 12. Gerster , A. G. Charaka Club. N. Y., 1910 hi , 87. When easier lies his head and icy death 13. Harper , R. F. Code of Khammurabi. Chicago, Removes his hand and warm the blood rebounds, 1904. He blesses me as Messenger of God, 14. Jayne , W. A. Healing Gods of Ancient Civiliza- And Holy ANGEL from ethereal high. tion. New Haven, 1925. 15. Lacroi x , J. A. Science and Literature in the But when the full and rosy touch of life Middle Ages. Paris, 1859. Bestirs his flesh and puts his soul to sleep, 16. Macmichael , W. The Gold Headed Cane. N. Y., He greets me as a MAN, though one of might 1915, 189. And versed in all the wisdom of the world. 17. Osler , W. Evolution of Modern Medicine. New Haven, 1913. And then at last when recompense is asked, 18. Osler , W. Aequanimitas, with other addresses He passeth me in dread, for Io, to him I stand to medical students, nurses and practitioners A DEVIL, horned from out the lowest depths. of medicine. London, 1906, 142. 19. Paget , S. John Hunter. Lond., 1897. The attitude of the physician toward fees 20. Paget , S. Ambroise Pare and His Times. Lond., is beautifully expressed in the description 1897. of the qualities of a surgeon by Guy de 21. Pausani us . VIII, XXVIII, I. Chauliac,5 known as the Father of Surgery, 22. Pausanius . x , xxxviii , 13. 23. Pett igrew . Medical Biography, Hippocrates, 3. who lived in the fourteenth century. 24. Plutarch’s Lives, revised by A. H. Clough, 1914. Let the surgeon be bold in all sure things and Hearst’s int. lib. fearful in dangerous things; let him avoid all 25. Practitioner, London, 1895, lv , 157. faulty treatments and practices. He ought to 26. Renouard , P. V. History of Medicine, tr. by be gracious to the sick, considerate to his asso- Comegys. Cincinnati, 1856. 27. Robin so n , V. Pathfinders in Medicine. Med. ciates, cautious in his prognostications. Let him Rev. oj Rev., 1912, xviii, 40. be modest, dignified, gentle, pitiful and merciful, 28. Sambon , L. Donaria of medical interest in the not covetous nor an extortionist of money; but Oppenheimer collection of Etruscan and rather let his reward be according to his work, Roman antiquities. Brit. M. J., 1895, n> to the means of the patient, to the quality 146, 216. of the issue, and to his own dignity. 29. Schuman , E. A. Dieties concerned with child- birth among ancient peoples. Am. J. Obst. Bibliography Gynec., 1925, x, 570-577. 1. Aveling , J. H. The Chamberlens. Lond., 30. Thorndy ke , L. History of Magic and Experi- 1882. mental Science during the First Thirteen Cen- 2. Baas , J. H. Outlines of History of Medicine, turies of Our Era, N. Y., 1923. tr. by Handerson. N. Y., 1889. 31. Well s , H. G. Outline of History. N. Y., 3. Bible. 11 Kings, Chap. 5. 1921.