Chapter XI: Introduction (9)

We do not know enough of the details of Mondeville's life to be sure whether he was married or not. It is probable that he was not, for all of these surgeons of the thirteenth century before Mondeville's time, Theodoric, William of Salicet, Lanfranc, and Guy de Chauliac, after him belonged to the clerical order; Theodoric was a bishop; the others, however, seem only to have been in minor orders. It is therefore from the standpoint of a man who views married life from without that Mondeville makes his remarks as to the difficulty often encountered when wives nurse their husbands. He says that the surgeon has difficulty oftener when husbands or wives care for their spouses than at other times. This is much more likely to take place when the wives are caring for the husbands. "In our days," he says, "in this Gallican part of the world, wives rule their husbands, and the men for the most part permit themselves to be ruled. Whatever a surgeon may order for the cure of a husband then will often seem to the wives to be a waste of good material, though the men seem to be quite willing to get anything that may be ordered for the cure of their wives. The whole cause of this seems to be that every woman seems to think that her husband is not as good as those of other women whom she sees around her." It would be interesting to know how Mondeville was brought to a conclusion so different from modern experience in the matter.

For those who are particularly interested in medical history one of the sections of Henry's book has a special appeal, because he gives in it a sketch of the history of surgery. We are little likely to think, as a rule, that at this time, full two centuries before the close of the Middle Ages, men were interested enough in the doings of those who had gone before them to try to trace the history of the development of their specialty. It is characteristic of the way that the scholarly Mondeville views his own life work that he should have wanted to know something about his predecessors and teach others with regard to them. He begins with Galen, and as Galen divides the famous physicians of the world into three sects, the Methodists, the Empirics, and the Rationalists, so Mondeville divides modern surgery into three sects: first, that of the Salernitans, with Roger, Roland, and the Four Masters; second, that of William of Salicet and Lanfranc; and third, that of Hugo de Lucca and his brother Theodoric and their modern disciples. He states briefly the characteristics of these three sects. The first limited patients' diet, used no stimulants, dilated all wounds, and got union only after pus formation. The second allowed a liberal diet to weak patients, though not to the strong, but generally interfered with wounds too much. The third believed in a liberal diet, never dilated wounds, never inserted tents, and its members were extremely careful not to complicate wounds of the head by unwise interference. His critical discussion of the three schools is extremely interesting.

Another phase of Mondeville's work that is sympathetic to the moderns is his discussion of the irregular practice of medicine and surgery as it existed in his time. Most of our modern medicine and surgery was anticipated in the olden time; but it may be said that all of the modes of the quack are as old as humanity. Galen's description of the travelling charlatan who settled down in his front yard, not knowing that it belonged to a physician, shows this very well. There were evidently as many of them and as many different kinds in Mondeville's time as in our own. In discussing the opposition that had arisen between physicians and surgeons in his time and their failure to realize that they were both members of a great profession, he enumerates the many different kinds of opponents that the medical profession had. There were "barbers, soothsayers, loan agents, falsifiers, alchemists, meretrices, midwives, old women, converted Jews, Saracens, and indeed most of those who, having wasted their substance foolishly, now proceed to make physicians or surgeons of themselves in order to make their living under the cloak of healing."

What surprises Mondeville however, as it has always surprised every physician who knows the situation, is that so many educated, or at least supposedly well-informed people of the better classes, indeed even of the so-called best classes, allow themselves to be influenced by these quacks. And it is even more surprising to him that so many well-to-do, intelligent people should, for no reason, though without knowledge, presume to give advice in medical matters and especially in even dangerous surgical diseases, and in such delicate affections as diseases of the eyes. "It thus often happens that diseases in themselves curable grow to be simply incurable or are made much worse than they were before." He says that some of the clergymen of his time seemed to think that a knowledge of medicine is infused into them with the sacrament of Holy Orders. He was himself probably a clergyman, and I have in the modern time more than once known of teachers in the clerical seminaries emphasizing this same idea for the clerical students. It is very evident that the world has not changed very much, and that to know any time reasonably well is to find in it comments on the morning paper. We are in the midst of just such a series of interferences with medicine on the part of the clergy as this wise, common-sense surgeon of the thirteenth century deprecated.

In every way Mondeville had the instincts of a teacher. He took advantage of every aid. He was probably the first to use illustrations in teaching anatomy. Guy de Chauliac, whose teacher in anatomy for some time Mondeville was, says in the first chapter of his "Chirurgia Magna" that pictures do not suffice for the teaching of anatomy and that actual dissection is necessary. The passage runs as follows: "In the bodies of men, of apes, and of pigs, and of many other animals, tissues should be studied by dissections and not by pictures, as did Henricus, who was seen to demonstrate anatomy with thirteen pictures."[21] What Chauliac blames is the attempt to replace dissections by pictorial demonstrations. Hyrtl, however, suggests that this invention of Mondeville's was probably very helpful, and was brought about by the impossibility of preserving bodies for long periods as well as the difficulty of obtaining them.

YPERMAN

One of the maxims of the old Greek philosophers was that good is diffusive of itself. As the scholastics put it, _bonum est diffusivum sui_. This proved to be eminently true of the old universities also, and especially of their training in medicine and in surgery. We have the accounts of men from many nations who went to the universities and returned to benefit their own people. Early in the thirteenth century Richard the Englishman was in Italy, having previously been in Paris and probably at Montpellier. Bernard Gordon, probably also an Englishman, was one of the great lights in medicine down at Montpellier, and his book, "Lilium De Medicina," is well known. Two distinguished surgeons whose names have come down to us, having studied in Paris after Lanfranc had created the tradition of great surgical teaching there, came to their homes to be centres of beneficent influence among their people in this matter. One was Yperman, of the town of Ypres in Belgium; the other Ardern of England. Yperman was sent by his fellow-townsmen to Paris in order to study surgery, because they wanted to have a good surgeon in their town and Paris seemed the best school at that time. Ypres was at this period one of the greatest commercial cities of Europe, and probably had a couple of hundred thousand inhabitants. The great hall of the cloth gild, which has been such an attraction for visitors ever since, was built shortly before the town determined upon the very sensible procedure of securing good surgery beyond all doubt by having a townsman specially educated for that purpose.

Yperman's work was practically unknown to us until Broeck, the Belgian historian, discovered manuscript copies of his book on surgery and gathered some details of his life. After his return from Paris, Yperman obtained great renown, which maintained itself in the custom extant in that part of the country even yet of calling an expert surgeon an Yperman. He is the author of two works in Flemish. One of these is a smaller compendium of internal medicine, which is very interesting, however, because it shows the many subjects that were occupying physicians' minds at that time. He treats of dropsy, rheumatism, under which occur the terms coryza and catarrh (the flowing diseases), icterus, phthisis (he calls the tuberculosis, 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, gonorrhea, and involuntary seminal emissions--all these terms are quoted directly from Pagel's account of his work; the original is not available in this country.

JOHN ARDERN

In English-speaking countries of course we are interested in what was done by Englishmen at this time. Fortunately we have the record of one great English surgeon of the period worthy to be placed beside even the writers already mentioned. This is John Ardern, whose name is probably a modification of the more familiar Arden, whose career well deserves attention. I have given a sketch of his work in "The Popes and Science."[22] He was educated at Montpellier, and practised 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 about the end of the century, was in London. He is the chief representative of English surgery during the Middle Ages. His "Practica," 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 careful 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.

Fortunately we possess here in America, in the Surgeon General's Library at Washington, a very interesting manuscript containing Ardern's surgical writings, though it has not yet been published. Even a little study of this and of the notes on it prepared by an English bibliophile before its purchase by the Surgeon General's Library, serves to show how valuable the work is in the history of surgery. There are illustrations scarcely less interesting than the text. Some of these illustrations were inserted by the original writer or copyist, and some of them later. In general, however, they show a rather high development of the mechanics of surgery at that time. Some of the pages have spaces for illustrations left unfilled, so that evidently the copyist did not complete his work. The titles of certain of the chapters are interesting, as illustrating the fact that our medical and surgical problems were stated clearly in the olden time, and thinking physicians, even six centuries ago, met them quite rationally. There is, for instance, a chapter headed "Against Colic and the Iliac Passion," immediately followed by the subheading, "Method of Administering Clysters." The iliac passion, _passio iliaca_ of the old Latin, is usually taken to signify some obstruction of the intestines causing severe pain, vomiting, and eventually fecal vomiting. A good many different forms of severe painful conditions, especially all those complicated by peritonitis, were included under the term, and the modern student of surgery is likely to wonder whether these old observers had not noted that the right iliac region was particularly prone to be the source of fatal conditions. There is a chapter entitled "Against Pain in the Loins and the Kidneys," followed by the chapter subheading, "Against Stone in the Kidneys." There is a chapter with the title, "Against Ulceration of the Bladder or the Kidneys." Another one, with the title "Against Burning of the Urine and Excoriation of the Lower Part of the Yard." Gonorrhea is frankly treated under the name _Shawdepisse_, evidently an English alliteration of the corresponding French word. As to the instrumentation of such conditions and for probing in general, Ardern suggests the use of a lead probe, because it may readily be made to bend any way and not injure the tissues.

MEDIEVAL SURGERY

Even this brief account of the surgeons who taught and studied at the medieval universities demonstrates what fine work they did. It is surely not too much to say that the chapter on university education mainly concerned with them is one of the most interesting in the whole history of the universities. Their story alone is quite enough to refute most of the prevalent impressions and patronizing expressions with regard to medieval education. Their careers serve to show how interested were the men of many nations in the development of an extremely important application of science for the benefit of suffering humanity. Their work utterly contradicts the idea so frequently emphasized that the great students of the Middle Ages were lacking in practicalness. Besides, they make very clear that we have been prone to judge the Middle Ages too much from its speculative philosophies. It has been the custom to say that speculation ruled men's minds and prevented them from making observations, developing science, or applying scientific principles. There was much speculation during the Middle Ages, but probably not any more in proportion than exists at the present day. We were either not acquainted with, or failed to appreciate properly, until comparatively recent years, the other side of medieval accomplishment. Our ignorance led us into misunderstanding of what these generations really did. It was our own fault, because during the Renaissance practically all of these books were edited and printed under the direction of the great scholars of the time in fine editions, but during the eighteenth century nearly all interest was lost in them, and we are only now beginning to get back a certain amount of the precious knowledge that they had in the Renaissance period of this other side of medieval life. We have learned so much about surgery because distinguished scholars devoted themselves to this phase of the history of science. Doubtless there are many other phases of the history of science which suffered the same fate of neglect and with regard to which the future will bring us equally startling revelations. For this reason this marvellous chapter in the history of surgery is a warning as well as a startling record of a marvellous epoch of human progress.

XI

GUY DE CHAULIAC

One of the most interesting characters in the history of medieval medicine, and undoubtedly the most important and significant of these Old-Time Makers of Medicine, is Guy de Chauliac. Most of the false notions so commonly accepted with regard to the Middle Ages at once disappear after a careful study of his career. The idea of the careful application of scientific principles in a great practical way is far removed from the ordinary notion of medieval procedure. Some observations we may concede that they did make, but we are inclined to think that these were not regularly ordered and the lessons of them not drawn so as to make them valuable as experiences. Great art men may have had, but science and, above all, applied science, is a later development of humanity. Particularly is this supposed to be true with regard to the science and practice of surgery, which is assumed to be of comparatively recent origin. Nothing could well be less true, and if the thoroughly practical development of surgery may be taken as a symbol of how capable men were of applying science and scientific principles, then it is comparatively easy to show that the men of the later Middle Ages were occupied very much as have been our recent generations with science and its practical applications.

The immediate evidence of the value of old-time surgery is to be found in the fact that Guy de Chauliac, who is commonly spoken of in the history of medicine as the Father of Modern Surgery, lived his seventy-odd years of life during the fourteenth century and accomplished the best of his work, therefore, some five centuries before surgery in our modern sense of the term is supposed to have developed. A glance at his career, however, will show how old are most of the important developments of surgery, as also in what a thoroughly scientific temper of mind this subject was approached more than a century before the close of the Middle Ages. The life of this French surgeon, indeed, who was a cleric and occupied the position of chamberlain and physician-in-ordinary to three of the Avignon Popes, is not only a contradiction of many of the traditions as to the backwardness of our medieval forbears in medicine, that are readily accepted by many presumably educated people, but it is the best possible antidote for that insistent misunderstanding of the Middle Ages which attributes profound ignorance of science, almost complete failure of observation, and an absolute lack of initiative in applications of science to the men of those times.

Guy de Chauliac's life is modern in nearly every phase. He was educated in a little town of the south of France, made his medical studies at Montpellier, and then went on a journey of hundreds of miles into Italy, in order to make his post-graduate studies. Italy occupied the place in science at that time that Germany has taken during the nineteenth century. A young man who wanted to get into touch with the great masters in medicine naturally went down into the Peninsula. Traditions as to the attitude of the Church to science notwithstanding, Italy where education was more completely under the influence of the Popes and ecclesiastics than in any other country in Europe, continued to be the home of post-graduate work in science for the next four centuries. Almost needless to say, the journey to Italy was more difficult of accomplishment and involved more expense and time than would even the voyage from America to Europe in our time. Chauliac realized, however, that both time and expense would be well rewarded, and his ardor for the rounding out of his education was amply recompensed by the event. Nor have we any reason for thinking that what he did was very rare, much less unique, in his time. Many a student from France, Germany, and England made the long journey to Italy for post-graduate opportunities during the later Middle Ages.

Even this post-graduate experience in Italy did not satisfy Chauliac, however, for, after having studied several years with the most distinguished Italian teachers of anatomy and surgery, he spent some time in Paris, apparently so as to be sure that he would be acquainted with the best that was being done in his specialty in every part of the world. He then settled down to his own life work, carrying his Italian and French masters' teachings well beyond the point where he received them, and after years of personal experience he gathered together his masters' ideas, tested by his own observations, into his "Chirurgia Magna," a great text-book of surgery which sums up the whole subject succinctly, yet completely, for succeeding generations. When we talk about what he accomplished for surgery, we are not dependent on traditions nor vague information gleaned from contemporaries and successors, who might perhaps have been so much impressed by his personality as to be made over-enthusiastic in their critical judgment of him. We know the man in his surgical works, and they have continued to be classics in surgery ever since. It is an honorable distinction for the medicine of the later fourteenth, the fifteenth, and sixteenth centuries that Guy de Chauliac's book was the most read volume of the time in medicine. Evidently the career of such a man is of import, not alone to physicians, but to all who are interested in the history of education.

Chauliac derives his name from the little town of Chauliac in the diocese of Mende, almost in the centre of what is now the department of Lozere. The records of births and deaths were not considered so important in the fourteenth century as they are now, and so we are not sure of either in the case of Chauliac. It is usually considered that he was born some time during the last decade of the thirteenth century, probably toward the end of it, and that he died about 1370. Of his early education we know nothing, but it must have been reasonably efficient, since it gave him a good working knowledge of Latin, which was the universal language of science and especially of medicine at that time; and though his own style, as must be expected, is no better than that of his contemporaries, he knew how to express his thoughts clearly in straightforward Latin, with only such a mixture of foreign terms as his studies suggested and the exigencies of a new development of science almost required. Later in life he seems to have known Arabic very well, for he is evidently familiar with Arabian books and does not depend merely on translations of them.

Pagel, in the first volume of Puschmann's "Handbook of the History of Medicine," says, on the authority of Nicaise and others, that Chauliac received his early education from the village clergyman. His parents were poor, and but for ecclesiastical interest in him it would have been difficult for him to obtain his education. The Church supplied at that time to a great extent for the foundations and scholarships, home and travelling, of our day, and Chauliac was amongst the favored ones. How well he deserved the favor his subsequent career shows, as it completely justifies the judgment of his patrons. He went first to Toulouse, as we know from his affectionate mention of one of his teachers there. Toulouse was more famous for law, however, than for medicine, and after a time Chauliac sought Montpellier to complete his medical studies.

For English-speaking people an added interest in Guy de Chauliac will be the fact that one of his teachers at Montpellier was Bernard Gordon, very probably a Scotchman, who taught for some thirty-five years at this famous university in the south of France, and died near the end of the first quarter of the fourteenth century. One of Chauliac's fellow-students at Montpellier was John of Gaddesden, the first English Royal Physician by official appointment of whom we have any account. John is mentioned by Chaucer in his "Doctor of Physic," and is usually looked upon as one of the fathers of English medicine. Chauliac did not think much of him, though his reason for his dislike of him will probably be somewhat startling to those who assume that the men of the Middle Ages always clung servilely to authority. Chauliac's objection to Gaddesden's book is that he merely repeats his masters and does not dare to think for himself. It is not hard to understand that such an independent thinker as Chauliac should have been utterly dissatisfied with a book that did not go beyond the forefathers in medicine that the author quotes. This is the explanation of his well-known expression, "Last of all arose the scentless rose of England ['Rosa Angliae' was the name of John of Gaddesden's book], in which, on its being sent to me, I hoped to find the odor of sweet originality, but instead of that I encountered only the fictions of Hispanus, of Gilbert, and of Theodoric."

The presence of a Scotch professor and an English fellow-student, afterwards a royal physician, at Montpellier, at the beginning of the fourteenth century, shows how much more cosmopolitan was university life in those times than we are prone to think, and what attraction a great university medical school possessed even for men from long distances.

After receiving his degree of Doctor of Medicine at Montpellier Chauliac went, as we have said, to Bologna. Here he attracted the attention and received the special instruction of Bertruccio, who was attracting students from all over Europe at this time and was making some excellent demonstrations in anatomy, employing human dissections very freely. Chauliac tells of the methods that Bertruccio used in order that bodies might be in as good condition as possible for demonstration purposes, and mentions the fact that he saw him do many dissections in different ways.

In Roth's life of Vesalius, which is usually considered one of our most authoritative medical historical works not only with regard to the details of Vesalius' life, but also in all that concerns anatomy about that time and for some centuries before, there is a passage quoted from Chauliac himself which shows how freely dissection was practised at the Italian universities in the fourteenth century. This passage deserves to be quoted at some length because there are even serious historians who still cite a Bull of Pope Boniface VIII, issued in 1300, forbidding the boiling and dismembering of bodies in order to transport them to long distances for burial in their own country, as being, either rightly or wrongly, interpreted as a prohibition of dissection and, therefore, preventing the development of anatomy. In the notes to his history of dissection during this period in Bologna Roth says: "Without doubt the passage in Guy de Chauliac which tells of having frequently seen dissections, must be considered as referring to Bologna. This passage runs as follows: 'My master Bertruccius conducted the dissection very often after the following manner: the dead body having been placed upon a bench, he used to make four lessons on it. In the first the nutritional portions were treated, because they are so likely to become putrefied. In the second, he demonstrated the spiritual members; in the third, the animate members; in the fourth, the extremities.'" (Roth, "Andreas Vesalius." Basel, 1896.)

Bertruccio's master, Mondino, is hailed in the history of medicine as the father of dissection. His book on dissection was for the next three centuries in the hands of nearly every medical scholar in Europe who was trying to do good work in anatomy. It was not displaced until Vesalius came, the father of modern anatomy, who revolutionized the science in the Renaissance time. Mondino had devoted himself to the subject with unfailing ardor and enthusiasm, and from everywhere in Europe the students came to receive inspiration in his dissecting-room. Within a few years such was the enthusiasm for dissection aroused by him in Bologna that there were many legal prosecutions for body-snatching, the consequence doubtless of a regulation of the Medical Department of the University of Bologna, that if the students brought a body to any of their teachers he was bound to dissect it for them. Bertruccio, Mondino's disciple and successor, continued this great work, and now Chauliac, the third in the tradition, was to carry the Bolognese methods back to France, and his position as chamberlain to the Pope was to give them a wide vogue throughout the world. The great French surgeon's attitude toward anatomy and dissection can be judged from his famous expression that "the surgeon ignorant of anatomy carves the human body as a blind man carves wood." The whole subject of dissection at this time has been fully discussed in the first three chapters of my "Popes and Science," where those who are interested in the matter may follow it to their satisfaction.[23]

After his Bologna experience Chauliac went to Paris. Evidently his indefatigable desire to know all that there was to be known would not be satisfied until he had spent some time at the great French university where Lanfranc, after having studied under William of Salicet in Italy, had gone to establish that tradition of French surgery which, carried on so well by Mondeville his great successor, was to maintain Frenchmen as the leading surgeons of the world until the nineteenth century (Pagel). Lanfranc, himself an Italian, had been exiled from his native country, apparently because of political troubles, but was welcomed at Paris because the faculty realized that they needed the inspiration of the Italian medical movement in surgery for the establishment of a good school of surgery in connection with the university. The teaching so well begun by Lanfranc was magnificently continued by Mondeville and Arnold of Villanova and their disciples. Chauliac was fortunate enough to come under the influence of Petrus de Argentaria, who was worthily maintaining the tradition of practical teaching in anatomy and surgery so well founded by his great predecessors of the thirteenth century. After this grand tour Chauliac was himself prepared to do work of the highest order, for he had been in touch with all that was best in the medicine and surgery of his time.

Like many another distinguished member of his profession, Chauliac did 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]