Bologna, Paris, and Avignon, especially you of the Papal Court with
whom I have been associated in the service of the Roman Pontiffs. The
exact words as given by Pagel are "Vobis dominis meis medicis
Montispessulani, Bononiae, Parisiis atque Avinionis, praecipue
papalibus, quibus me in servitio Romanorum pontificum associavi."
Pagel has three closely printed pages in small type of titles alone of
subjects which Chauliac treated with {185} distinction. His
description of instruments and methods of operation is especially full
and suggestive. He knew how to prescribe manipulations and set forth
the principles on which they were founded. Scarcely anything was added
to his method of taxis for hernia for five centuries after his time.
He describes the passage of a catheter with the accuracy and complete
technic of a man who knew all the difficulties of it in complicated
conditions. He recognizes the dangers that arise for the surgeon from
the presence of anatomical anomalies of various kinds, and describes
certain of the more important of them. He did not hesitate to suggest
some very serious operations. For instance, for empyema he advises
opening of the chest. He has very exact indications for trephining. He
recognizes the absolute fatality of wounds of the abdomen, in which
the intestines were opened, if they were left untreated, and describes
a method of suturing wounds of the intestines in order to save the
patient's life. In a word, there is nothing that has been attempted in
these modern times, with our aseptic precautions and the advantage of
anaesthesia, which this father of surgery did not discuss very
practically and with excellent common sense as well as surgical
acumen.
Chauliac's career is interesting because it is that of a self-made man
of the Middle Ages, which brings out the fact that men do not differ
so much as might be thought at this distance of time, and shows that
there were chances for a man to rise by his own genius from a lowly to
a lofty position at this time of the Middle Ages, when it is usually
supposed that men were excluded from such opportunities. Allbutt says
of him:
"Still, Guy of Chauliac, who flourished in the second {186} half of
the fourteenth century, was enabled to feed his virile and
inquisitive spirit on rich sources of learning. While he succeeded
to the stores of Arnold (of Villanova) and Gordon with his just and
cautious reason and wealth of experience, he cast out of them much
of the sorcery, jugglery, astrology and mysticism which were their
reproach. Chauliac is a village in the Auvergne, and Guy was but a
farmer's lad. It was by the aid of powerful friends that he studied
at Toulouse and Montpelier, took orders and the degree of Master of
Medicine; in his time there was no degree of Doctor of Medicine in
France. Then he studied anatomy at Bologna under Bertruccio, the
successor of Mondino, a study which, with Henry (de Mondeville) he
regarded as the foundation of surgery. The surgeon ignorant of
anatomy, he says, "carves the human body as a blind man carves
wood." [Footnote 24]
[Footnote 24: This is a very striking reflection on the necessity for
the study of anatomy for the practice of surgery to have been made
within a half century after the supposed prohibition of dissection by
the Popes, and at a time when, according to President White, "even
such serious matters as fractures, calculi and difficult parturition,
in which modern science has achieved some of its greatest triumphs,
were dealt with by relics," and when "there were religious scruples
against dissection," and surgery "was denounced by the Church," and
when "pastoral medicine had checked all scientific effort in medical
science." And the reflection was made by a chamberlain of the Papal
household.]
"Thence he paid a brief visit to Paris, where for a moment, by the
renown of Lanfranc, Jean Pitard, and Henry of Mondeville, surgery
was in the ascendant. For the moment the Church and the faculty had
not succeeded in paralyzing the scientific arm of medicine.
[Footnote 25] {187} Guy began practice in Lyons, whence he was
called to Avignon by Clement VI. as 'venerabilis et circumspectus
vir, dominus Guido de Cauliaco, canonicus et propositus ecclesiae
Sancti Justi Lugduni, medicusque domini nostri Papae.' In Avignon he
stayed, while other physicians fled, to minister to the victims of
the plague (A.D., 1348), and he may have attended Laura in spite of
Petrarch's tirades against all physicians and even against Guy
himself. His description of this epidemic is terrible in its naked
simplicity. He did not, indeed, himself escape, for he had an attack
with bubo, and was ill for six weeks. He gave succor also in a later
epidemic in Avignon, in 1360. His 'Chirurgia Magna' or Inventarium
seu Collectorium Artis Chirurgicalis Medicinae--so called in
distinction to the meagre little handbooks or Chirurgiae Parvae
compiled from the larger treatises--was in preparation in 1363.
This great work I have studied carefully, and not without prejudice;
and yet I cannot wonder that Fallopius compared the author to
Hippocrates, or that John Freind calls him the Prince of Surgeons.
It is rich, aphoristic, orderly and precise. _As a clerk_ he wrote
in Latin, in the awkward hybrid tongue that medical Latin then was,
containing many Arabian, Provencal and French words, but very little
Greek."
[Footnote 25: It is worthy of remark, how even Prof. Allbutt, in a
passage like this, where he is providing abundant material for the
contradiction of the English Protestant tradition of the supposed
opposition of the Church to science, and especially to surgery, yet
cannot break away from the influence of that tradition entirely. It
has been bred in him, and even while showing its falsity he is not
entirely convinced himself, because the old mode of view has so firm a
hold on him that he is not open to conviction. A little later in this
same passage he speaks of taking up the study of Chauliac, prejudiced
against him, and being convinced of his greatness against his
will. Verily history has been a conspiracy against the truth, in which
many people have joined almost unconsciously, led astray by feeling,
not intellect.]
[Illustration:
Guy de Chauliac's Instruments:--15, 16, cautery apparatus with canula
for cauterizing the uvula and tonsils; 17, bistoury; 18, amputation
knife; 19, small sickle knife for opening abscesses and fistulas.]
[Illustration: Guy de Chauliac's Instruments:--21, bow for extracting
arrows the head of which had penetrated a limb; 22, mechanical
trephine revolved by up-and-down movement of cross-bar.]
We have seen that there was great surgery in Italy, in France, and in
the Netherlands, but it had also crossed the channel into England.
There was a famous English surgeon during the {188} fourteenth century
by the name of John Ardern. He was educated at Montpelier and
practiced surgery for a time in France. About the middle of the
century, however, according to Pagel, he went back to his native land
and settled for some twenty years at Newark, in Nottinghamshire, and
then for nearly thirty years longer, until nearly the end of the
century, was in London. He is the chief representative of English
surgery during the Middle Ages. His Practice, as yet unprinted,
contains, according to Pagel, a short sketch of internal medicine, but
is mainly devoted to surgery. Contrary to the usual impression with
regard to works in medicine and surgery at this time, the book abounds
in references to case histories which Ardern had gathered, partly from
his own and partly from others' experience. The therapeutic measures
that he suggests are usually very simple, in the majority of cases
quite rational, though, of course, there are many superstitions among
them; but Ardern always furnished a number of suggestions from which
to choose. He must have been an expert operator, and had excellent
success in the treatment of diseases of the rectum. He seems to have
been the first operator who made statistics of his cases, and was
quite as proud as any modern surgeon, of the large numbers that he had
operated on, which he gives very exactly. He was the inventor of a new
clyster apparatus.
Daremberg, the medical historian, who saw a copy of Ardern's
manuscript in St. John's College, Oxford, says that it contains
numerous illustrations of instruments and operations. His work seems
really to be a series of monographs or collection of special articles
on different subjects, which Ardern had made at various times, rather
than a connected work. Pagel bewails the fact {189} that a more
thorough consideration of Ardern's work is impossible, because the
greater part of what he wrote remains as yet unprinted.
In general, when we consider how difficult was the task of making
copies of works on surgery by hand, and especially such as contain
numerous illustrations, the wonder grows that we should have so much
about the surgery of these centuries rather than so little. Some of
these works have been preserved for us by the merest chance. There
have been many centuries since their time, when what these surgeons
wrote would have been thought of very little value because physicians
were not educated up to them. In spite of this liability to loss,
which must have caused the destruction of many valuable works, we
still have enough to show us what wonderful men were these surgeons of
the thirteenth and fourteenth centuries, who anticipated our best
thinking of the modern times in many of the most difficult problems.
It is only during the last twenty-five years that anything like
justice has been done them. The only way to know what these men did
and taught is to read their own works, and these have been buried in
manuscript or hidden away in large folio volumes, printed very early
in the history of printing, and considered so valuable that
consultation of them was almost resented by librarians. Anyone who
talks about the lack of surgery in Europe during the thirteenth and
fourteenth centuries is supremely ignorant of the real course of
history at this time, and when in addition he attributes the failure
of surgery to develop to a trumped-up opposition of the Church or
ecclesiastics, he is simply making a ridiculous exhibition of
intolerance and of foolish readiness to accept anything, however
groundless, that may {190} enable him to make out a case against the
ecclesiastical authorities.
It is curious to reflect that in spite of all this wonderful progress
in surgery, somehow there has crept in the tradition which has been
very generally accepted by historians not acquainted with the details
of medical history, that surgery was neglected during the thirteenth
and fourteenth centuries. The existence of this tradition, and its
acceptance by men who had no idea that they were being influenced by
that peculiar state of mind which considers that nothing good can come
out of the Nazareth of the times before the reformation so-called, is
of itself a warning with regard to the way history has been written,
especially for the Teutonic and English-speaking peoples, that should
carry weight in other departments of history beside medicine and
surgery.
Even Pagel could not get entirely away from the old tradition which
has existed for so long, that the Church, if she did not oppose, at
least hampered the progress of surgery. While his first paragraph
shows that he recognized the important advances that were made in the
Middle Ages, he cannot rid himself of the prejudice that has existed
so long and has tinged so much of the historical writing of the last
four centuries. He furnishes an abundance of material himself to
disprove the old opinion, and evidently has been influenced by this
evidence, but cannot give up notions that have been part and parcel of
his education from his earliest days in Protestant Germany. He says:--
"A set-back must also be recognized to some extent in surgery,
especially attributable to the fact that as a consequence of the
pressure of the Church upon scientific medicine, the representatives
of medical {191} science felt themselves bound to neglect the
practical art of surgical operation. Church regulations forbade the
shedding of blood to churchmen, and not a few physicians were more
than inclined to accept this prohibition as in accordance with their
own feelings. For this reason the practice of surgery was left for
the most part to the lower orders of those engaged in healing. This
went to such an extent, that physicians even came to look upon
surgery as an unworthy occupation. Even venesection, which was so
commonly employed and which came to be indispensable to the practice
of internal medicine, made it necessary to call for the services of
a barber-surgeon."
As we shall see, there were many other and much more important factors
at work in the degradation of surgery than the supposed repression of
the Church. The time to which Pagel refers is in the earlier centuries
of the Middle Ages, and not the later ones; yet it is from these later
centuries that the supposed prohibitory decrees are all quoted. The
contempt for surgery was due rather to the general lack of culture
before the foundation of the universities than to any ecclesiastical
repression. Just as soon as the great medical schools were opened--and
that at Salerno came into existence in the early part of the tenth
century if not earlier--surgery began to be in honor. Pagel himself
confesses this in the very next paragraph of this brief conspectus of
surgery, and shows how generally was the uplift of surgery made
possible by university education, though there still remained many
drawbacks to progress because of the jealousy of physicians.
"Gradually, however, a beneficial transformation of customs in this
matter began to be manifest. Physicians {192} who were
scientifically trained began to take up surgery with enthusiasm, and
from that time (end of twelfth century) dates the visible uplift of
this specialty. Eventually the most noteworthy literary events and
remains of the representatives of the great schools of the Middle
Ages--Salerno, Bologna, Paris and Montpelier--concern quite as much
the department of surgery as of practical medicine. These medieval
literary contributions constitute the principal steps in the
historical development of scientific surgery. The Crusades represent
an extremely important influence upon the perfecting of the surgery
of wounds. Italian surgeons in large numbers took prominent parts
therein. They took the abundant opportunities afforded them to
gather experience, which they used to great advantage in their
practice and in their teaching after their return home. From Roger,
the first and most important of the representatives of the
Salernitan school (whose life occupies the end of the twelfth and
the beginning of the thirteenth century), and down to Guy de
Chauliac (who died toward the end of the fourteenth century), in a
space therefore of not quite two hundred years, a complete breach
with the blood-fearing traditions of the Arabs was made. In no
European land does one fail to find evidence of intense as well as
successful scientific occupation with surgery."
As a reflection that throws a brilliant light on the true conditions
that brought about the diminished estimation in which surgery came to
be held, Guy de Chauliac has an interesting passage in which he
suggests an explanation for it, which is surely much nearer the truth
than any modern explanation is likely to be. He says that, after the
time of the Arabs, who were all both physicians and surgeons, either
because of the lack of interest of {193} physicians or their laziness,
for the practice of surgery is a difficult matter, or because they
came to be too much occupied with the ills which they might hope to
cure by medicines alone, surgery became separated from medicine and
passed down into the hands of mere mechanics. This is a complaint not
infrequently heard even at the present day, that medicine and surgery
are drawing too much apart for the good of either specialty. Both the
Regius Professors of medicine in England have recently insisted that
physicians must oftener be present at operations if they would really
appreciate the value of diagnosis, while there has been for many years
a feeling that surgery would be benefitted if surgeons did not always
wish to have recourse to the knife, but appreciated how much good
might be accomplished by other remedial measures. The great French
Father of Surgery, then, was only expressing what was to be a
perennial complaint in the domain of medicine and surgery when he
explained the separation of the two departments of healing. He has
nothing whatever to say of the evil influence upon surgery of any
Church regulations, though he must have been in a position to realize
their significance very well in this respect if they actually had any.
He was himself, as we have said, a member of the Papal household; he
was even a cleric, and seems to have encountered no difficulty at all
not only in devoting himself to surgery, but even in lifting up that
department of medicine from the slough of neglect into which it had
fallen because of the lack of initiative of preceding generations in
his native land.
It may be wondered, then, how the tradition of opposition to surgery,
which is so common in history, had its origin. Nearly always for these
exaggerated stories {194} there is some basis of truth. For instance,
with regard to the opposition to Vesalius, the origin of the stories
of persecution by the Church and ecclesiastical authorities is
evidently the fact that he was very much opposed by the old-time
physicians and surgeons, who believed in Galen and thought it worse
than heresy to break with him. It is the opposition of scientists, or
pseudo-scientists, to scientific progress that constitutes the real
bar to advance, and has over and over again been attributed to
religious motives, when it is really due to that very human
overconservatism, which so constantly places men in the position of
opponents to novelties of any kind, no matter how much of value they
may eventually prove to have. There has always existed a certain
prejudice against surgery on the part of physicians--meaning by that
term, for the moment, those who devote themselves to internal
medicine. This feeling has never quite died out. There were times in
the Middle Ages when it was very marked. Not a little of the feeling
is due to professional jealousy, and that, it is to be feared, like
the poor, we shall have always with us.
Professor Allbutt has in the address at St. Louis, already quoted
from, a very interesting passage with regard to the College of St.
Come at Paris, in which this jealousy between physicians and surgeons
is very well brought out. I quote it here in order to illustrate once
more that opposition of scientists to scientific advance, for personal
reasons, which has always existed, is still one of the features of the
history of science, and will probably always continue to be a
noteworthy phase of scientific progress. It will serve at the same
time to furnish to those who cannot think that these stories with
regard to the hampering of surgical development are {195} entirely
without foundation, some basis for them that will account for their
universality, but will only render clearer the intolerance of those
who have constantly perverted the meaning of this opposition to
persecution on the part of Church authorities. Ecclesiastics not only
had nothing to do with this, but more often than not were the active
factors in such amelioration of the conditions it brought about as
very much to lessen its effects.
Allbutt's story of the College of Surgeons of St. Come at Paris is,
as we have said, interesting from this standpoint. "Some of my
readers may wonder how it is that in discoursing of medieval surgery
I have not dwelt upon the Surgical College of St. Come of Paris.
Well, St. Come did no great things for surgery. The truth is that,
infected with the exclusiveness and dialectical conceits of all the
schools of Paris, St. Come was almost ready to sacrifice surgery
itself if thereby it might choke off its parasites, the barbers.
Lest they should be suspected of mixing their philosophy with facts,
its members went about with their hands ostentatiously tied behind
them. If perhaps Malgaigne speaks too contemptuously of St. Come, it
must be admitted that the college was in a false position
throughout. In aping the Faculty of Medicine, it lost the touch of
mother earth without gaining any harbourage in the deep waters of
the proud. Nay, such is the Nemesis of pride, the barbers came to
command the position. It did not suit the Faculty to see the barbers
weakened; for in their weakness lay the strength of the surgeons of
St. Come, who sought incessantly to appear as lettered clerks, to
attach their college to the university, and even to claim a place
beside the Faculty itself. To bring St. Come to its knees, and to
check the presumptuous claims of this corporation on the {196}
privileges of the Faculty of Medicine, on a liberal education in
arts and medicine, on a place in the university, on the suppression
of unqualified surgical practice, and less, honourably, on relief
from handicraft and urgent calls, the Faculty had to coquette with
the barbers. Medicine, proclaimed the Faculty when it suited its
purpose, contains the theoretical and the practical side of surgery;
a surgeon is therefore but the servant of a physician. If St. Come
sought to provide lectures in surgery, the Faculty, which kept
possession of teaching licenses and desired in the surgeon a docile
assistant, took the teaching from the college and invited the
barbers to lectures of its own. In their duplicity and conceit of
caste, physicians of the Faculty condescended even to publish books
on surgery, books as arid and as insincere as their lectures. On the
other hand, in the person of the King's Barber, the barbers had a
secret and potent influence at Court. The Faculty persisted in
denying to St. Come all 'esoteric' teaching, all diagnosis, and all
use of medical therapeutics. Aristotle was pronounced to be
unfavorable to the 'vulgarizing of science.' Joubert was attacked
for editing Guy, but replied with dignity (in the notes of his
edition). While the Faculty thus tried to prevent the access to
letters of a presumptuous body of artisans, St. Come in mimic
arrogance disdained the barbers, sought to deny them the name of
surgeon, and was jealous of the diffusion of technical knowledge
among them in the vernacular tongue." [Footnote 26]
[Footnote 26: As showing how professional jealously may exist in
such ways in the modern times as to hinder progress, the following
paragraph, which is the opening portion of Professor Allbutt's
address, has seemed to me to deserve quotation here. It will
illustrate a phase of the subject that is probably utterly
unexpected by those unfamiliar with the inner history of medicine
in our time, but which is not so surprising to physicians who know
the jealousy with which men guard their specialties from what they
consider the interference of others, in hospital work and in
teaching, though this exclusiveness often proves detrimental both
to the breadth of development of the student and to the good
health of the patient.