a thousand years surgery was considered dishonorable." For the sake of
contrast with this opinion of President White's, read for a moment the
following remarks which constitute the opening sentences of Pagel's
paragraphs on Surgery from 1200 to 1500, in Puschmann's Handbuch of
the History of Medicine, already referred to. Before making the
quotation, let me recall attention to the fact that Professor Pagel is
the best informed living writer on the history of medicine. This book
was issued in 1902. It is universally conceded to contain the last
words on the history of medical development. There is no doubt at all
about its absolute authoritativeness. President White has been calling
on his imagination; Professor Pagel has consulted original documents
in the history of surgery. He says:
{172}
"A more favorable star shone during the whole Middle Ages over
surgery than over practical medicine. The representatives of this
specialty succeeded earlier than did the practical physicians in
freeing themselves from the ban of scholasticism. In its development
a more constant and more even progress cannot fail to be seen. The
stream of literary works on surgery flows richer during this period.
While the surgeons are far from being able to emancipate themselves
from the ruling pathological theories, there is no doubt that in one
department, that of manual technics, free observation came to occupy
the first place in the effort for scientific progress. Investigation
is less hampered and concerns itself with practical things and not
with artificial theories. Experimental observation was in this not
repressed by an unfortunate and iron-bound appeal to reasoning." I
am tempted to add as a reflection, deduction was not allowed to
replace attention to facts, though it has in some supposed surgical
history of this period.
Pagel continues: "Indeed, the lack of so-called scholarship, the
freshness of view free from all prejudice with which surgery,
uninfluenced by scholastic presumption, was forced to enter upon the
objective consideration of things, while most of the surgeons
brought with them to their calling an earnest vocation in union with
great technical facility, caused surgery to enter upon ways in which
it secured, as I have said, greater relative success than did
practical medicine."
President White has evidently never bothered to look into a history of
surgery at all, or he would not have fallen into the egregious error
of saying that the period from 1200 to 1400 was barren of surgery, for
it is really one of the most important periods in the development of
{173} modern surgery. Further evidence as to this is rather easy to
obtain.
I have cited two German authorities in the history of medicine and
surgery. Here is an English writer who is quite as authoritative. In
the address on The Historical Relations of Medicine and Surgery to the
end of the Sixteenth Century, which Professor Clifford Allbutt, the
Regius Professor of Physic at the University of Cambridge, delivered
by special invitation at the Congress of Arts and Sciences of St.
Louis in 1904, this distinguished authority in the history of medicine
had much to say with regard to the wonderful development of surgery in
the thirteenth and fourteenth centuries, that is, during the period
when, if we were to accept President White's declarations, surgery
either did not exist, or else had been relegated to such mere
handicraftsmen that no real scientific progress in it could possibly
be expected. As Professor Allbutt was trying only to give a twentieth
century audience some idea of the magnificent work that had been
accomplished by fellow members of his profession of medicine seven
centuries before, and had no idea of discussing the influence,
favorable or otherwise, of the Church upon the progress of medical
science, I have preferred to quote directly from this address for
evidence of the surgery of these centuries, than to gather the details
from many sources, when it might perhaps be thought that I was making
out a more favorable case than actually existed, for the sake of the
Church and the Popes.
"Both for his own great merits as an original and independent
observer and as the master of Lanfranc, William Salicet (Gugliemo
Salicetti of Piacenza, in Latin G. Placentinus or de Saliceto--now
Cadeo) was eminent {174} among the great Italian physicians of the
latter half of the thirteenth century. Now, these great Italians
were as distinguished in surgery as in medicine, and William was one
of the protestants of the period against the division of surgery
from inner medicine--a division which he regarded as a separation of
medicine from intimate touch with nature. Like Lanfranc and the
other great surgeons of the Italian tradition, and unlike Franco and
Pare, he had the advantage of the liberal university education of
Italy; but, like Pare and Wuertz, he had large practical experience
in hospital and in the battlefield. He practiced first at Bologna,
afterwards in Verona. William fully recognized that surgery cannot
be learned from books only. His surgery contains many case
histories, for he rightly opined that good notes of cases are the
soundest foundation of good practice; and in this opinion and method
Lanfranc followed him. William discovered that dropsy may be due to
a "durities renum"; he substituted the knife for the Arabist abuse
of the cautery; he investigated the causes of the failure of healing
by first intention; he described the danger of wounds of the neck;
he sutured divided nerves; he forwarded the diagnosis of suppurative
disease of the hip; and he referred chancre and phagedaena to "their
proper causes."
Anyone who knows the history of surgery and of supposed modern
progress in medicine will recognize at once that many of these ideas
of Salicet are anticipations of discoveries supposed to have been made
in the nineteenth century. The connection between dropsy and hardening
of the kidneys is a typical example of this. The fact that William
should have insisted that surgery cannot be learned from books is an
open contradiction {175} of what is so frequently said about
scholasticism having invaded the realm of medicine, and the study of
books having replaced the study of patients. It is not surprising that
with his study of cases William should have recognized the danger of
wounds of the neck, nor that he should have taught the suture of
divided nerves. It cannot fail to be a matter of surprise, however,
that he should have any hint of the possibility of union by first
intention, for that is supposed to be quite recent, and the knowledge
he displays of venereal diseases is supposed to have come into
medicine and surgery at least two centuries later.
Allbutt next takes up Salicet's great pupil Lanfranc. "Lanfranc's
'Chirurgia Magna' was a great work, written by a reverent but
independent follower of Salicet. He distinguished between venous and
arterial hemorrhage, and used styptics (rabbit's fur, aloes, and
white of egg was a popular styptic in older surgery), digital
compression for an hour, or in severe cases ligature. His chapter on
injuries of the head is one of the classics of medieval surgery.
_Clerk as he was_, Lanfranc nevertheless saw but the more clearly
the danger of separating surgery from medicine. 'Good God!' he
exclaims, 'why this abandoning of operations by physicians to lay
persons, disdaining surgery, as I perceive, because they do not know
how to operate ... an abuse which has reached such a point that the
vulgar begin to think that the same man cannot know medicine and
surgery... I say, however, that no man can be a good physician who
has no knowledge of operative surgery; a knowledge of both branches
is essential.' (Chir. Magna.) Is it not strange that this ancient
was wiser than most of us are even yet."
{176}
Striking as all this is, much more that is of interest might be added
to it from Pagel's account of Lanfranc's work. Pagel says that he has
excellent chapters on the affections of the eyes, the ears and mouth,
the nose, even the teeth, and treats of hernia in a very practical,
common sense way. He warns against the radical operation, and says in
phrases that have often been repeated even in our own time, that many
surgeons decide on operations too easily, not for the sake of the
patient, but for the sake of the money there is in them. He believes
that most of the danger and inconvenience of the hernia can be removed
by means of a properly fitting truss. He treats of stone in the
kidney, but insists that the main thing for this affection is
prophylaxis. He suggests that stone in the bladder should first be
treated by internal remedies; but in severe cases advises extraction.
Lanfranc's discussion of cystotomy, Pagel characterizes "as prudent,
yet rational," for he considers that the operation should not be
feared too much nor delayed too long. In patients suffering from the
inconvenience which comes from large quantities of fluid in the
abdomen, he advises _paracentesis abdominis_. He warns, however,
against putting the patient in danger from such an operation without
due consideration and only when symptoms absolutely demand it.
Pagel says that Lanfranc must be considered as one of the greatest of
the surgeons of the Middle Ages and the real founder of the French
School of Surgery which continued to be the most prominent in the
world down to the nineteenth century. Lanfranc had equalled, if not
surpassed, his great master William Salicet. His own disciple,
Mondeville, accomplished almost as much for surgery as his master,
however. Both of them were {177} destined to be thrown into the shade
for succeeding generations by another great French surgeon of the next
half-century, Guy de Chauliac. Pagel can scarcely say enough of the
capacity as a teacher of Lanfranc. The seeds of surgical doctrine
which he sowed bore fruit richly. His important successors in French
surgery walked for the most part in his tracks and thus furnished the
best proof of the enduring character of his capacity as a teacher.
The next great name in thirteenth century surgery, for we are not yet
out of that fruitful period, is Henri de Mondeville. He was known by
his contemporaries and immediate successors as the most cultured of
the surgeons. Whatever he wrote bears the traces of his wide reading
and of his respect for authority, yet shows also his power to make
observations for himself, and his name is due much more to his
independent work both in the technics and the diagnostics of surgery,
than to his reputation for scholarship or the depth of his culture.
Lanfranc (whose name was Lanfranchi) had been an Italian. Mondeville
was born in Normandy sometime about the beginning of the last quarter
of the thirteenth century. The place of his education is not
absolutely sure, but there is good authority for saying that he was,
for a time at least, in Bologna. On his return from Italy he passed
some time, just at the beginning of the fourteenth century, in
Montpelier. He seems to have looked for a professorship at Montpelier,
but instead received the appointment as surgeon to the French king,
Philip Le Bel. This brought him to Paris, where the first portion of
his book on surgery was written about 1306. This was not completed
until 1312. His work was interrupted by several campaigns on which he
attended {178} the king along the Northern coast. When he again took
up his work of writing, he revised what he had written at first by the
light of the experience that he had acquired in the campaign. Pagel
says that his style is lively and clear and often full of meat. Many
of his own opinions and experiences are incorporated in his work, and
in spite of his tendency to display his erudition by quotations, his
originality is not seriously interfered with.
Some of his remarks are very curiously interesting to the modern. He
seems to have had the idea that portions of metal which had penetrated
the body as the result of explosions, for gun-powder was already being
used, might be removed by means of a magnet. He would not have been a
distinguished surgeon without inventing a needle-holder, and
accordingly we find that he was one of the first of a long line of
such inventors. He invented certain instruments also for the removal
of arrow-heads, which because of their form and hooks become firmly
imbedded in the tissues. Mondeville had no such fear of trephining as
Lanfranc had, though he did not hesitate to emphasize the value of
expectant treatment in most of these cases of injury to the head that
might seem at first to demand the trephine.
Pagel notes the fact that when he prescribed drinks for his patients
this medieval surgeon suggested that certain verses of the psalms
which were usually recited, according to the custom of the times,
whenever anything was administered to a patient, should be said. Pagel
considers it quite natural that as a believing physician he should
have realized how much his believing patients would be influenced for
the better by such a procedure. He did not place any supreme faith in
its efficacy, but {179} knew that it could do no harm, and had
probably seen, as has many a physician and surgeon of the modern time,
that such a practice does good, if not by the direct interference of
Providence, then at least by the calmness of mind which it
superinduces in the patient. In the same way Mondeville was not averse
to his patients going on pilgrimages. He did not expect that they
would all be cured miraculously, but according to Pagel, his
discussion of this subject is quite modern. Travel and change of scene
would do good anyhow in many cases, expectancy would help the
patient's condition, and the hope aroused was also good. The best
merit, however, of this French surgeon is undoubtedly the immense
influence which he exerted over his great successor, Guy de Chauliac.
We are really only beginning to accumulate knowledge with regard to
the surgery of the thirteenth and fourteenth centuries. Pagel has
devoted three very full pages, in his compressed account of surgery,
to John Yperman, a surgeon of the early fourteenth century of whom
practically nothing was known until about twenty-five years ago, when
the Belgian historian Broeck brought to light his works and gathered
some details of his life. He was a pupil of Lanfranc's, and at the end
of the thirteenth century studied at Paris on a scholarship provided
by his native town of Ypres, which deliberately sent him in order that
he might become expert in surgery. This may seem a strange thing for a
medieval town to do, at least it may seem so to those who have been
accustomed to think little of the Middle Ages, but it will not to
anyone who knows anything about the wonderful civic spirit of the Free
Towns. In the chapter on Science at the Medieval Universities I have
quoted {180} from Prince Kropotkin's work on Mutual Aid in the
Medieval Towns, and further consultation of that as a ready reference,
would make all cause for ignorant surprise with regard to the culture
and the enterprise of medieval towns disappear. Ypres, while a town of
only fifteen thousand inhabitants now, was one of the most important
towns of Flanders in the Middle Ages, noted for its manufacture of
linens and fine laces, and has a handsome cathedral dating from the
thirteenth century and a town hall, the famous Cloth Hall, from the
same period, which is one of the most beautiful architectural
monuments in Europe and one of the finest municipal buildings in the
world.
After his return Yperman settled down in his native town and practiced
surgery until his death, which probably took place about 1330. He
obtained a great renown, and this has been maintained so that in that
part of the country even yet, an expert surgeon is spoken of as an
Yperman. He is the author of two works in Flemish. One of these is
what Pagel calls an unimportant compilation on internal medicine, but
the headings of the chapters as he gives them can scarcely fail to
attract the attention of the modern physician. He treats of dropsy,
rheumatism, under which occur the terms coryza and catarrh, icterus,
phthisis (he calls the tuberculous, tysiken), apoplexy, epilepsy,
frenzy, lethargy, fallen palate, cough, shortness of breath, lung
abscess, hemorrhage, blood-spitting, liver abscess, hardening of the
spleen, affections of the kidney, bloody urine, diabetes, incontinence
of urine, dysuria, strangury, gonorrhoea and involuntary seminal
emissions--all these terms are quoted directly from Pagel.
All this would seem to show that Yperman was a {181} thoroughly
representative medical man. When I add that Pagel says he shows a well
marked striving to free himself from the bondage of authority and that
most of his therapeutic prescriptions rest upon his own experience, it
will be seen that he deserves the greatest possible credit. His work
in medicine, however, Pagel considers as nothing compared to his work
in surgery. A special feature of this is the presence of seventy
illustrations of instruments of the most various kinds, together with
a plate showing the anatomical features of the stitching of a wound of
the head. The work as we have it is only a fragment. The last part of
it which treated of the extremities is defective. If anyone thinks for
a moment that surgery was a neglected specialty at the end of the
thirteenth and the beginning of the fourteenth century, he should
consult the text of this, or even Pagel's brief account of its
contents. Some of the features of it are noteworthy. There is a
chapter devoted to intoxications, which includes the effects of
cantharides as well as alcohol, and treats of the bites of snakes,
scorpions, and of hydrophobia due to the bites of mad hounds. There is
scarcely a feature of modern surgery of the head that is not touched
upon very sensibly in this work.
The best proof, however, at once of the flourishing state of surgery
during the fourteenth century and of the utter absurdity of saying
that surgery did not develop because of the opposition of the Church
or of ecclesiastics, and above all of the Popes, is to be found in the
life of Guy de Chauliac, who has been deservedly called the Father of
Modern Surgery and whose contributions to surgery occupy a prominent
place in every history of medicine that one picks up. While the works
of other {182} great writers in surgery of the thirteenth and
fourteenth centuries have as a rule only come to be commonly known
during the latter part of the nineteenth century, Guy de Chauliac's
position and the significance of his work and his writings have been a
commonplace in the history of medicine for as long as it has been
written seriously. We have already stated in several places in this
volume his relations to the Popes. He was a chamberlain of the Papal
Court while it was at Avignon, and while he was teaching and
developing surgery at the University of Montpelier he was also body
physician to three of the Popes, and the intimate friend and
influential adviser to whom they turned for consultation in matters
relating to medical education and to science generally.
In the present chapter, then, we shall only discuss the contributions
to surgery of this surgeon of the Popes, at a time when, according to
President White, because of Church opposition, surgery was considered
dishonorable; "_when the greatest monarchs were often unable to secure
an ordinary surgical operation, and when it required an edict of the
German Emperor in order that dishonor should no longer attach to the
surgical profession._" This is what Chauliac accomplished, according
to Professor Allbutt:
"Of his substantial advances in surgery no sufficient account is
possible; but some chief points, with the aid of Haeser, Malgaigne,
and Nicaise, I may briefly sum up thus: He pointed out the dangers
of surgery of the neck, among them that of injuring the voice by
section of the recurrent laryngeal nerve, a precaution he probably
learned from Paul. He urges a low diet for the wounded, as did
Mondeville and many others. He uses sutures well and discreetly (p.
9), but with far too many salves. {183} On fractures of the skull he
is at his best; he noted the escape of cerebro-spinal fluid, and the
effect of pressure on the respiration. It is somewhat strange that
in days of war the study of chest wounds had been rather neglected
by Galen, Haly, and Avicenna; their practice, however, was to leave
them open, lest pus should gather about the heart. Theodoric and
Henry ordered chest wounds to be closed 'lest the vital spirits
escape.' Guy also closed these wounds, unless there were any
effusion to be removed. In empyema he objects to caustics and
prefers the knife. For haemorrhages he used sutures--a little too
closely perhaps--styptics, cautery or ligature. Sinuses he dilated
with tents of gentian root, or he incised them upon a director. On
ulcers his large experience is fully manifest. He describes the
carcinomatous kind as hopeless, unless the mass can be excised at a
very early stage and the incision followed by caustics. If in
fractures and dislocations he tells us nothing new, these sections
testify to a remarkable fulness of knowledge at a period when the
Hippocratic treatises were unknown. Haeser says that in respect of
position in fractured femur he was the best physician in the Middle
Ages."
[Illustration: Guy de Chauliac's Cauteries:--5, 6, 7, 8, cauteries
called from their shapes: knife, sword, olive, date kernel; 9, cautery
with protective nail to be inserted cold; 10, protective plate for
cauteries.]
[Illustration: Guy de Chauliac's Cauteries:--11, 12, long, smooth
cautery and canula protector; 13, 14, ring cautery with five buttons
and the protective plate with five openings.]
This is the period, it must not be forgotten, when, according to
President White, surgery was in such a state that _the application of
various ordures relieved fractures; the touch of the hangman cured
sprains; the breath of a donkey expelled poison; friction with a dead
man's tooth cured a toothache._ [Footnote 23]
[Footnote 23: Quite as curious notions as these which President White
mentions still exist in popular medicine in our own day. I have myself
known a man to blow the dried excrement of the dog into the throat of
his child suffering from diphtheria, and _he assured me that it cured
him_. In the country districts they still use ordure poultices for
sprains of various kinds, and I have known doctors prescribe them. I
have seen an intelligent woman smoking dried angleworms in a pipe for
toothache. I sincerely hope, however, that no serious(!) historian of
the twenty-fifth century will gather up side remarks like the present
with regard to such curious customs--real superstitions that have
nothing to do with religion, as most supersititions have not--and
state them as showing the ignorance of our generation, and above all
as indicating the low state of medicine in our time.]
{184}
Lest it should be thought that possibly Professor Allbutt had been
rather partial to the great Father of Modern Surgery in his enthusiasm
for these medieval surgeons, it seems worth while to compress here
something of what Pagel has to say with regard to this great man, who
represents in himself a full hundred years of progress in surgery. He
wrote an immense text-book of surgery, from which his teaching may be
learned with absolute authenticity. The great significance attached to
Guy's writings by his contemporaries and successors will be readily
appreciated from the immense number of manuscript copies, original
editions in print, and the many translations which are extant. This
monument of scientific surgery has for dedication a sentence that
would alone and of itself obliterate all the nonsense that has been
talked about Papal opposition to the development of surgery. It runs
as follows:--