not settle down in the scene of his ultimate labors at once, but was
something of a wanderer. His own words are, "_Et per multa tempora
operatus fui in multis partibus_." Perhaps out of gratitude to the
clerical patrons of his native town to whom he owed so much, or because
of the obligations he considered that he owed them for his education, he
practised first in his native diocese of Mende; thence he removed to
Lyons, where we know that he lived for several years, for in 1344 he
took part as a canon in a chapter that met in the Church of St. Just in
that city. Just when he was called to Avignon we do not know, though
when the black death ravaged that city in 1348 he was the body-physician
of Pope Clement VI, for he is spoken of in a Papal document as
"_venerabilis et circumspectus vir, dominus Guido de Cauliaco, canonicus
et praepositus ecclesiae Sancti Justi Lugduni, medicusque domini Nostri
Papae_." All the rest of his life was passed in the Papal capital, which
Avignon was for some seventy years of the fourteenth century. He served
as chamberlain-physician to three Popes, Clement VI, Innocent VI, and
Urban V. We do not know the exact date of his death, but when Pope Urban
V went to Rome in 1367, Chauliac was putting the finishing touches on
his "Chirurgia Magna," which, as he tells us, was undertaken as a
_solatium senectutis_--a solace in old age. When Urban returned to
Avignon for a time in 1370 Chauliac was dead. His life work is summed up
for us in this great treatise on surgery, full of anticipations in
surgical procedures that we are prone to think much more modern.
Nicaise has emphasized the principles which guided Guy de Chauliac in
the choice and interpretation of his authorities by a quotation from Guy
himself, which is so different in its tone from what is usually supposed
to have been the attitude of mind of the men of science of the time that
it would be well for all those who want to understand the Middle Ages
better to have it near them. Speaking of the surgeons of his own and
immediately preceding generations, Guy says: "One thing particularly is
a source of annoyance to me in what these surgeons have written, and it
is that they follow one another like so many cranes. For one always says
what the other says. I do not know whether it is from fear or from love
that they do not deign to listen except to such things as they are
accustomed to and as have been proved by authorities. They have to my
mind understood very badly Aristotle's second book of metaphysics where
he shows that these two things, fear and love, are the greatest
obstacles on the road to the knowledge of the truth. Let them give up
such friendships and fears. 'Because while Socrates or Plato may be a
friend, truth is a greater friend.' Truth is a holy thing and worthy to
be honored above everything else. Let them follow the doctrine of Galen,
which is entirely made up of experience and reason, and in which one
investigates things and despises words."
After all, this is what great authorities in medicine have always
insisted on. Once every hundred years or so one finds a really great
observer who makes new observations and wakes the world up. He is
surprised that men should not have used their powers of observation for
themselves, but should have been following old-time masters. His
contemporaries often refuse to listen to him at first. His observations,
however, eventually make their way. We blame the Middle Ages for
following authority, but what have we been always doing but following
authority, except for the geniuses who come and lift us out of the rut
and illuminate a new portion of the realm of medicine. After they have
come, however, and done their work, their disciples proceed to see with
their eyes and to think that they are making observations for themselves
when they are merely following authority. When the next master in
medicine comes along his discovery is neglected because men have not
found it in the old books, and usually he has to suffer for daring to
have opinions of his own. The fact of the matter is that at any time
there is only a very limited number of men who think for themselves. The
rest think other people's thoughts and think they are thinking and doing
things. As for observation, John Ruskin once said, "Nothing is harder
than to see something and tell it simply as you saw it." This is as true
in science as in art, and only genius succeeds in doing it well.
Chauliac's book is confessedly a compilation. He has taken the good
wherever he found it, though he adds, modestly enough, that his work
also contains whatever his own measure of intelligence enabled him to
find useful (_quae juxta modicitatem mei ingenii utilia reputavi_).
Indeed it is the critical judgment displayed by Chauliac in selecting
from his predecessors that best illustrates at once the practical
character of his intellect and his discerning spirit. What the men of
his time are said to have lacked is the critical faculty. They were
encyclopedic in intellect and gathered all kinds of information without
discrimination, is a very common criticism of medieval writers. No one
can say this of Chauliac, however, and, above all, he was no respecter
of authority, merely for the sake of authority. His criticism of John of
Gaddesden's book shows that the blind following of those who had gone
before was his special _bete noir_. His bitterest reproach for many of
his predecessors was that "they follow one another like cranes, whether
for love or fear, I cannot say."
Chauliac's right to the title of father of surgery will perhaps be best
appreciated from the brief account of his recommendations as to the
value of surgical intervention for conditions in the three most
important cavities of the body, the skull, the thorax, and the abdomen.
These cavities have usually been the dread of surgeons. Chauliac not
only used the trephine, but laid down very exact indications for its
application. Expectant treatment was to be the rule in wounds of the
head, yet when necessary, interference was counselled as of great value.
His prognosis of brain injuries was much better than that of his
predecessors. He says that he had seen injuries of the brain followed by
some loss of brain substance, yet with complete recovery of the patient.
In one case that he notes a considerable amount of brain substance was
lost, yet the patient recovered with only a slight defect of memory,
and even this disappeared after a time. He lays down exact indications
for the opening of the thorax, that _noli me tangere_ of surgeons at all
times, even our own, and points out the relations of the ribs and the
diaphragm, so as to show just where the opening should be made in order
to remove fluid of any kind.
In abdominal conditions, however, Chauliac's anticipation of modern
views is most surprising. He recognized that wounds of the intestines
were surely fatal unless leakage could be prevented. Accordingly he
suggested the opening of the abdomen and the sewing up of such
intestinal wounds as could be located. He describes a method of suture
for these cases and seems, like many another abdominal surgeon, even to
have invented a special needleholder.
To most people it would seem absolutely out of the question that such
surgical procedures could be practised in the fourteenth century. We
have the definite record of them, however, in a text-book that was the
most read volume on the subject for several centuries. Most of the
surprise with regard to these operations will vanish when it is recalled
that in Italy during the thirteenth century, as we have already seen,
methods of anaesthesia by means of opium and mandragora were in common
use, having been invented in the twelfth century and perfected by Ugo da
Lucca, and Chauliac must not only have known but must have frequently
employed various methods of anaesthesia.
In discussing amputations he has described in general certain methods of
anaesthesia in use in his time, and especially the method by means of
inhalation. It would not seem to us in the modern time that this method
would be very successful, but there is an enthusiastic accord of
authorities attesting that operations were done at this time with the
help of this inhalant without the infliction of pain. Chauliac says:
"Some prescribe medicaments which send the patient to sleep,
so that the incision may not be felt, such as opium, the juice
of the morel, hyoscyamus, mandrake, ivy, hemlock, lettuce. A
new sponge is soaked by them in these juices and left to dry
in the sun; and when they have need of it they put this sponge
into warm water and then hold it under the nostrils of the
patient until he goes to sleep. Then they perform the
operation."
Many people might be prone to think that the hospitals of Chauliac's
time would not be suitable for such surgical work as he describes. It
is, however, only another amusing assumption of this self-complacent age
of ours to think that we were the first who ever made hospitals worthy
of the name and of the great humanitarian purpose they subserve. As a
matter of fact, the old-time hospitals were even better than ours or, as
a rule, better than any we had until the present generation. In "The
Popes and Science," in the chapter on "The Foundation of City
Hospitals," I call attention to the fact that architects of the present
day go back to the hospitals of the Middle Ages in order to find the
models for hospitals for the modern times. Mr. Arthur Dillon, a
well-known New York architect, writing of a hospital built at Tonnerre
in France, toward the end of the thirteenth century (1292), says:
"It was an admirable hospital in every way, and it is doubtful
if we to-day surpass it. It was isolated; the ward was
separated from the other buildings; it had the advantage we so
often lose of being but one story high, and more space was
given to each patient than we can now afford.
"The ventilation by the great windows and ventilators in the
ceiling was excellent; it was cheerfully lighted; and the
arrangement of the gallery shielded the patients from dazzling
light and from draughts from the windows and afforded an easy
means of supervision, while the division by the roofless low
partitions isolated the sick and obviated the depression that
comes from sight of others in pain.
"It was, moreover, in great contrast to the cheerless white
wards of to-day. The vaulted ceiling was very beautiful; the
woodwork was richly carved, and the great windows over the
altars were filled with colored glass. Altogether it was one
of the best examples of the best period of Gothic
Architecture."[24]
The fine hospital thus described was but one of many. Virchow, in his
article on hospitals quoted in the same chapter, called attention to the
fact that in the thirteenth and fourteenth centuries every town of five
thousand or more inhabitants had its hospital, founded on the model of
the great Santo Spirito Hospital in Rome, and all of them did good work.
The surgeons of Guy de Chauliac's time would indeed find hospitals
wherever they might be called in consultation, even in small towns. They
were more numerous in proportion to population than our own and, as a
rule, at least as well organized as ours were until the last few years.
It is no wonder that with such a good hospital organization excellent
surgery was accomplished. Hernia was Chauliac's specialty, and in it his
surgical judgment is admirable. Mondeville before his time did not
hesitate to say that many operations for hernia were done not for the
benefit of the patient, but for the benefit of the surgeon,--a very
striking anticipation of remarks that one sometimes hears even at the
present time. Chauliac discussed operations for hernia very
conservatively. His rule was that a truss should be worn, and no
operation attempted unless the patient's life was endangered by the
hernia. It is to him that we owe the invention of a well-developed
method of taxis, or manipulation of a hernia, to bring about its
reduction, which was in use until the end of the nineteenth century. He
suggested that trusses could not be made according to rule, but must be
adapted to each individual case. He invented several forms of truss
himself, and in general it may be said that his manipulative skill and
his power to apply his mechanical principles to his work are the most
characteristic of his qualities. This is particularly noteworthy in his
chapters on fractures and dislocations, in which he suggests various
methods of reduction and realizes very practically the mechanical
difficulties that were to be encountered in the correction of the
deformities due to these pathological conditions. In a word, we have a
picture of the skilled surgeon of the modern time in this treatise of a
fourteenth-century teacher of surgery.
Chauliac discusses six different operations for the radical cure of
hernia. As Gurlt points out, he criticises them from the same standpoint
as that of recent surgeons. The object of radical operations for hernia
is to produce a strong, firm tissue support over the ring through which
the cord passes, so that the intestines cannot descend through it. It is
rather interesting to find that the surgeons of this time tried to
obliterate the canal by means of the cautery, or inflammation producing
agents, arsenic and the like, a practice that recalls some methods still
used more or less irregularly. They also used gold wire, which was to be
left in the tissues and is supposed to protect and strengthen the
closure of the ring. At this time all these operations for the radical
cure of hernia involved the sacrifice of the testicle because the old
surgeons wanted to obliterate the ring completely, and thought this the
easiest way. Chauliac discusses the operation in this respect and says
that he has seen many cases in which men possessed of but one testicle
have procreated, and this is a case where the lesser of two evils is to
be chosen.
Of course Guy de Chauliac would not have been able to operate so freely
on hernia and suggest, following his own experience, methods of
treatment of penetrating wounds of the abdomen only that he had learned
the lessons of antiseptic surgery which had been gradually developed
among the great surgeons of Italy during the preceding century. The use
of the stronger wines as a dressing together with insistence on the most
absolute cleanliness of the surgeon before the operation, and careful
details of cleanliness during the operation, made possible the
performance of many methods of surgical intervention that would
otherwise surely have been fatal. Probably nothing is harder to
understand than that after these practical discoveries men should have
lost sight of their significance, and after having carefully studied the
viscous exudation which produces healthy natural union, should have come
to the thought of the necessity for the formation of laudable pus before
union might be expected. The mystery is really no greater than that of
many another similar incident in human history, but it strikes us more
forcibly because the discovery and gradual development of antiseptic
surgery in our own time has meant so much for us. Already even in
Chauliac's practice, however, some of the finer elements of the
technique that made surgery antiseptic to a marked degree, if not
positively aseptic in many cases, were not being emphasized as they were
by his predecessors, and there was a beginning of surgical
meddlesomeness reasserting itself.
It must not be thought, however, that it was only with the coarse
applications of surgery that Chauliac concerned himself. He was very
much interested in the surgical treatment of eye diseases and wrote a
monograph on cataract, in which he gathers what was known before his
time and discusses it in the light of his own experience. The writing of
such a book is not so surprising at this time if we recall that in the
preceding century the famous Pope John XXI, who had been a physician
before he became Pope, and under the name of Peter of Spain was looked
up to as one of the distinguished scientists of his time, had written a
book on eye diseases that has recently been the subject of much
attention.
Pope John had much to say of cataract, dividing it into traumatic and
spontaneous, and suggesting the needling of cataract, a gold needle
being used for the purpose. Chauliac's method of treating cataract was
by depression. His care in the selection of patients may be appreciated
from his treatment of John of Luxembourg, King of Bavaria, blind from
cataract, who consulted Chauliac in 1336 while on a visit to Avignon
with the King of France. Chauliac refused to operate, however, and put
off the King with dietary regulations.
In the chapter on John of Arcoli and Medieval Dentistry we call
attention to the fact that Chauliac discussed dental surgery briefly,
yet with such practical detail as to show very clearly how much more was
known about this specialty in his time than we have had any idea of
until recent years. He recognized the dentists as specialists, calls
them dentatores, but thinks that they should operate under the direction
of a physician--hence the physician should know much about teeth and
especially about their preservation. He enumerates instruments that
dentists should have and shows very clearly that the specialty had
reached a high state of development. A typical example of Chauliac's
common sense and dependence on observation and not tradition is to be
found in what he has to say with regard to methods of removing the teeth
without the use of extracting instruments. It is characteristic of his
method of dealing with traditional remedies, even though of long
standing, that he brushes them aside with some impatience if they have
not proved themselves in his experience.
"The ancients mention many medicaments, which draw out the
teeth without iron instruments or which make them more easy to
draw out; such as the milky juice of the tithymal with
pyrethrum, the roots of the mulberry and caper, citrine
arsenic, aqua fortis, the fat of forest frogs. But these
remedies promise much and accomplish but little--_mais ils
donnent beaucoup de promesses, et peu, d'operations_."
It is no wonder that Chauliac has been enthusiastically praised. Nicaise
has devoutly gathered many of these praises into a sheaf of eulogies at
the end of his biography of the great French surgeon. He tells us that
Fallopius compared him to Hippocrates. John Calvo of Valencia, who
translated the "Great Surgery" into Spanish, looks upon him as the first
law-giver of surgery. Freind, the great English physician, in 1725
called him the Prince of Surgeons. Ackermann said that Guy de Chauliac's
text-book will take the place of all that has been written on the
subject down to his time, so that even if all the other works had been
lost his would replace them. Dezimeris, commenting on this, says that
"if one should take this appreciation literally, this surgeon of the
fourteenth century would be the first and, up to the present time, the
only author who ever merited such an eulogy." "At least," he adds, "we
cannot refuse him the distinction of having made a work infinitely
superior to all those which appeared up to this time and even for a long
time afterwards. Posterity rendered him this justice, for he was for
three centuries the classic _par excellence_. He rendered the study easy
and profitable, and all the foreign nations the tributaries of our
country." Peyrihle considered Guy's "Surgery" as the most valuable and
complete work of all those of the same kind that had been published
since Hippocrates and added that the reading of it was still useful in
his time in 1784. Begin, in his work on Ambroise Pare, says "that Guy
has written an immortal book to which are attached the destinies of
French surgeons." Malgaigne, in his "History of Surgery," does not
hesitate to say, "I do not fear to say that, Hippocrates alone excepted,
there is not a single treatise on surgery,--Greek, Latin, or
Arabic,--which I place above, or even on the same level with, this
magnificent work, 'The Surgery of Guy de Chauliac.'" Daremberg said,
"Guy seems to us a surgeon above all erudite, yet expert and without
ever being rash. He knows, above all, how to choose what is best in
everything." Verneuil, in his "Conference sur Les Chirurgiens Erudits,"
says, "The services rendered by the 'Great Surgery' were immense; by it
there commenced for France an era of splendor. It is with justice, then,
that posterity has decreed to Guy de Chauliac the title of Father of
French surgery."
The more one reads of Chauliac's work the less is one surprised at the
estimation in which he has been held wherever known. It would not be
hard to add a further sheaf of compliments to those collected by
Nicaise. Modern writers on the history of medicine have all been
enthusiastic in their admiration of him, just in proportion to the
thoroughness of their acquaintance with him. Portal, in his "History of
Anatomy and Surgery," says, "Finally, it may be averred that Guy de
Chauliac said nearly everything which modern surgeons say, and that his
work is of infinite price but unfortunately too little read, too little
pondered." Malgaigne declares Chauliac's "Chirurgia Magna" to be "a
masterpiece of learned and luminous writing." Professor Clifford
Allbutt, the Regius Professor of Physic at the University of Cambridge,
says of Chauliac's treatise: "This great work I have studied carefully
and not without prejudice; 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."[25]
If to this account of his professional career it be added that
Chauliac's personality is, if possible, more interesting than his
surgical accomplishment, some idea of the significance of the life of
the great father of modern surgery will be realized. We have already
quoted the distinguished words of praise accorded him by Pope Clement
VI. That they were well deserved, Chauliac's conduct during the black
death which ravaged Avignon in 1348, shortly after his arrival in the
Papal City, would have been sufficient of itself to attest. The
occurrence of the plague in a city usually gave rise to an exhibition of
the most arrant cowardice, and all who could, fled. In many of the
European cities the physicians joined the fugitives, and the ailing were
left to care for themselves. With a few notable exceptions, this was
the case at Avignon, but Guy was among those who remained faithful to
his duty and took on himself the self-sacrificing labor of caring for
the sick, doubly harassing because so many of his brother physicians
were absent. He denounces their conduct as shameful, yet does not boast
of his own courage, but on the contrary says that he was in constant
fear of the disease. Toward the end of the epidemic he was attacked by
the plague and for a time his life was despaired of. Fortunately he
recovered, to become the most influential among his colleagues, the most
highly admired of the physicians of his generation, and the close
personal friend of all the high ecclesiastics, who had witnessed his
magnificent display of courage and of helpfulness for the
plague-stricken during the epidemic. He wrote a very clear account of
the epidemic, which leaves no doubt that it was true bubonic plague.
After this fine example, Chauliac's advice to brother physicians in the
specialty of surgery carried added weight. In the Introductory chapter
of his "Chirurgia Magna" he said:
"The surgeon should be learned, skilled, ingenious, and of
good morals. Be bold in things that are sure, cautious in
dangers; avoid evil cures and practices; be gracious to the
sick, obliging to his colleagues, wise in his predictions. Be
chaste, sober, pitiful, and merciful; not covetous nor
extortionate of money; but let the recompense be moderate,
according to the work, the means of the sick, the character of
the issue or event, and its dignity."