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The Church And Surgery During The Middle Ages

Depiction Of Surgery During The Middle Ages

( Originally Published 1911 )

It is with regard to surgery that the opposition of the Church is sometimes supposed to have been most serious in its effects upon the progress of medical science and its applications for the relief of human suffering. President White has stated this, as usual, very emphatically in certain paragraphs of his chapter on From Miracles to Medicine, especially under the caption of Theological Discouragement of Medicine. He says, for instance :

" As to surgery, this same amalgamation of theology with survivals of pagan beliefs continued to check the evolution of medical science down to the modern epoch. The nominal hostility of the Church to the shedding of blood withdrew, as we have seen, from surgical practice the great body of her educated men

hence surgery remained down to the fifteenth century a despised profession, its practice continued largely in the hands of charlatans, and down to a very recent period the name ' barber-surgeon' was a survival of this. In such surgery, the application of various ordures relieved fractures the touch of the hangman cured sprains ; the breath of a donkey expelled poison ; friction with a dead man's tooth cured toothache."

In another and earlier portion of the same chapter, under the heading " Theological Opposition to Anatomical Studies," he states the reasons why this low state of surgical practice existed. Once more it is declared to be because of a prohibitory decree, or several of them, directed against the practice of surgery by ecclesiastical authorities, These decrees, we shall find, as was true of previous supposed prohibitions, are entirely perverted from their real meaning by President White, who has the happy faculty of lighting upon mares' nests of Papal decrees and decrees of councils and neglecting to pay any attention to the real history of the science of which he writes. President White says :

"To those arguments against dissection was now added another one which may well fill us with amazement. It is the remark of the foremost of recent English philosophical historians, that of all organizations in human history, the Church of Rome has caused the greatest spilling of innocent blood. No one conversant with history, even though he admit all possible extenuating circumstances and honor the older Church for the great circumstances which can undoubtedly be claimed for her, can deny this statement. Strange is it, then, to note that one of the main objections developed in the Middle Ages against anatomical studies was the maxim that `The Church abhors the shedding of blood.' "

"On this ground, in 1248, the Council of Le Mans forbade surgery to monks. Many other councils did the same, and at the end of the thirteenth century came the most serious blow of all : for it was then that Pope Boni-face VIII., without any of that foresight of consequences which might well have been expected in an infallible teacher, issued a decretai forbidding a practice which had come into use during the Crusades, namely, the separation of the flesh from the bones of the dead whose remains it was desired to carry back to their own country." Note always the return to Pope Boniface's bull and always the perversion of the meaning of the word infallibility.

I have already stated the real significance of Boniface's bull. It neither forbade, nor did its interpretation in any way hamper, the development of anatomy. Just exactly the same thing is true with regard to the Papal regulations or decrees of councils that are claimed to have hampered surgery. President White and others have insisted that the prohibition of surgery to monks and priests prevented the development of surgery or was responsible for the low state of surgical practice. Here once more we are in the presence of a deduction, and not of an induction that represents the actual facts in the case. Most students at the universities were clerks, that is, had the privileges of clergymen, and were, as a rule, in minor orders. All the great surgeons of this time, and they were many, were ecclesiastics.

The climax of President White's treatment of the relationship of the Church to surgery and of the intense opposition manifested by ecclesiastics to surgical progress, and, I may add, the climax of absurdity as far as the real history of surgery is concerned, comes in the last para-graph of this portion of his chapter on From Miracles to Medicine, which President White has placed under the title Theological Opposition to Anatomical Studies. He says :

"So deeply was the idea rooted in the mind of the Universal Church that for over a thousand years surgery was considered dishonorable ; the greatest monarchs were often unable to secure an ordinary surgical operation ; and it was only in 1406 that a better beginning was made, when the Emperor Wenzel of Germany ordered that dishonor should no longer attach to the surgical profession."

President White insists over and over again that what-ever surgery there was, and especially whatever progress was made in surgery, was due to the Arabs, or at least to Arabian initiative. Gurlt, in his History of Surgery,' which we have referred to elsewhere, is very far from sharing this view. I need scarcely say that Gurlt is one of our best authorities in the history of surgery. In his sketch of Roger, the first of the great Italian surgeons of the thirteenth century who came after the foundation of the universities, Gurlt says that, " though Arabian writings on surgery had been brought over to Italy by Constantine Africanus a hundred years before Roger's time, those exercised no influence over Italian surgery in the next century, and there is not a trace of the surgical knowledge of the Arabs to be found in Roger's work." His writing depends almost entirely upon the surgical traditions of his time, the experience of his teachers and colleagues, to whom in two places he has given due credit, and on the Greek writers. There are no traces of Arabisms to be found in Roger's writing, while they are full of Grecisms. Roger represents the first important writer on surgery in modern times, and his works have been printed several times because of their value as original documents.

It is wonderfully amusing to anyone who knows Gurlt's History of Surgery, that the distinguished old professor of the University of Berlin, looked up to as so well in-formed as to the history of the branch of medical science to which he had devoted a long life, should have wasted some three hundred pages of his first volume on the History of Surgery in Middle and West Europe during the Middle Ages, for they are mainly taken up with the consideration of the period when President White asserts that there was no surgery in Europe. Gurlt even protests that he has not as much space as he would like to devote to these old-time masters of surgery, who did so much to lay the foundation of modern surgical practices. Those who have paid any attention to President White's assertion with regard to surgery at this time, should at least look over Gurlt. They will thus realize what a dangerous thing it is to attempt large conclusions in the history of a department of knowledge of which one knows nothing. They will also realize how easy it is for a writer with some prestige, to lead others astray in a matter of history, by simply making assertions without taking the trouble to see whether they are supported by the facts in the case or not.

The modern American historian of Theology and Science says, "for over a thousand years surgery was considered dishonorable. " For the sake of contrast with this opinion of President White's, read for a moment the following remarks which constitute the opening sentences of Pagel's paragraphs on Surgery from 1200 to 1500, in Puschmann's Handbuch of the History of Medicine, already referred to. Before making the quotation, let me recall attention to the fact that Professor Pagel is the best informed living writer on the history of medicine. This book was issued in 1902. It is universally conceded to contain the last words on the history of medical development. There is no doubt at all about its absolute authoritativeness. President White has been calling on his imagination ; Professor Pagel has consulted original documents in the history of surgery. He says :

"A more favorable star shone during the whole Middle Ages over surgery than over practical medicine. The representatives of this specialty succeeded earlier than did the practical physicians in freeing themselves from the ban of scholasticism. In its development a more constant and more even progress cannot fail to be seen. The stream of literary works on surgery flows richer during this period. While the surgeons are far from being able to emancipate themselves from the ruling pathological theories, there is no doubt that in one department, that of manual technics, free observation came to occupy the first place in the effort for scientific progress. Investigation is less hampered and concerns it-self with practical things and not with artificial theories. Experimental observation was in this not repressed by an unfortunate and iron-bound appeal to reasoning." I am tempted to add as a reflection, deduction was not allowed to replace attention to facts, though it has in some supposed surgical history of this period.

Pagel continues : " Indeed, the lack of so-called scholar-ship, the freshness of view free from all prejudice with which surgery, uninfluenced by scholastic presumption, was forced to enter upon the objective consideration of things, while most of the surgeons brought with them to their calling an earnest vocation in union with great technical facility, caused surgery to enter upon ways in which it secured, as I have said, greater relative success than did practical medicine."

President White has evidently never bothered to look into a history of surgery at all, or he would not have fallen into the egregious error of saying that the period from 1200 to 1400 was barren of surgery, for it is really one of the most important periods in the development of modern surgery. Further evidence as to this is rather easy to obtain.

I have cited two German authorities in the history of medicine and surgery. Here is an English writer who is quite as authoritative. In the address on The Historical Relations of Medicine and Surgery to the end of the Sixteenth Century, which Professor Clifford Allbutt, the Regius Professor of Physic at the University of Cam-bridge, delivered by special invitation at the Congress of Arts and Sciences of St. Louis in 1904, this distinguished authority in the history of medicine had much to say with regard to the wonderful development of surgery in the thirteenth and fourteenth centuries, that is, during the period when, if we were to accept President White's declarations, surgery either did not exist, or else had been relegated to such mere handicraftsmen that no real scientific progress in it could possibly be expected. As Professor Allbutt was trying only to give a twentieth century audience some idea of the magnificent work that had been accomplished by fellow members of his profession of medicine seven centuries before, and had no idea of discussing the influence, favorable or otherwise, of the Church upon the progress of medical science, I have preferred to quote directly from this address for evidence of the surgery of these centuries, than to gather the details from many sources, when it might perhaps be thought that I was making out a more favorable case than actually existed, for the sake of the Church and the Popes.

"Both for his own great merits as an original and independent observer and as the master of Lanfranc, William Salicet (Gugliemo Salicetti of Piacenza, in Latin G. Placentinus or de Saliceto—now Cadeo) was eminent among the great Italian physicians of the latter half of the thirteenth century. Now, these great Italians were as distinguished in surgery as in medicine, and William was one of the protestants of the period against the di-vision of surgery from inner medicine—a division which he regarded as a separation of medicine from intimate touch with nature. Like Lanfranc and the other great surgeons of the Italian tradition, and unlike Franco and Paré, he had the advantage of the liberal university education of Italy ; but, like Paré and Wurtz, he had large practical experience in hospital and in the battlefield. He practiced first at Bologna, afterwards in Verona. William fully recognized that surgery cannot be learned from books only. His surgery contains many case his-tories, for he rightly opined that good notes of cases are the soundest foundation of good practice ; and in this opinion and method Lanfranc followed him. William discovered that dropsy may be due to a "durities renum "; he substituted the knife for the Arabist abuse of the cautery ; he investigated the causes of the failure of healing by first intention ; he described the danger of wounds of the neck ; he sutured divided nerves ; he for-warded the diagnosis of suppurative disease of the hip ; and he referred chancre and phagedaena to "their proper causes."

Anyone who knows the history of surgery and of supposed modern progress in medicine will recognize at once that many of these ideas of Salicet are anticipations of discoveries supposed to have been made in the nineteenth century. The connection between dropsy and hardening of the kidneys is a typical example of this. The fact that William should have insisted that surgery cannot be learned from books is an open contradiction of what is so frequently said about scholasticism having invaded the realm of medicine, and the study of books having replaced the study of patients. It is not surprising that with his study of cases William should have recognized the danger of wounds of the neck, nor that he should have taught the suture of divided nerves. It cannot fail to be a matter of surprise, however, that he should have any hint of the possibility of union by first intention, for that is supposed to be quite recent, and the knowledge he displays of venereal diseases is supposed to have come into medicine and surgery at least two centuries later.

Allbutt next takes up Salicet's great pupil Lanfranc. " Lanfranc's 'Chirurgia Magna' was a great work, written by a reverent but independent follower of Sali-cet. He distinguished between venous and arterial hemorrhage, and used styptics (rabbit's fur, aloes, and white of egg was a popular styptic in older surgery), digital compression for an hour, or in severe cases ligature. His chapter on injuries of the head is one of the classics of medieval surgery. Clerk as he was, Lanfranc nevertheless saw but the more clearly the danger of separating surgery from medicine. ` Good God ! ' he exclaims, ` why this abandoning of operations by physicians to lay persons, disdaining surgery, as I perceive, because they do not know how to operate . . . an abuse which has reached such a point that the vulgar begin to think that the same man cannot know medicine and surgery . . . I say, however, that no man can be a good physician who has no knowledge of operative surgery ; a knowledge of both branches is essential.' (Chir. Magna.) Is it not strange that this ancient was wiser than most of us are even yet."

Striking as all this is, much more that is of interest might be added to it from Pagel's account of Lanfranc's work. Pagel says that he has excellent chapters on the affections of the eyes, the ears and mouth, the nose, even the teeth, and treats of hernia in a very practical, common sense way. He warns against the radical opertion, and says in phrases that have often been repeated even in our own time, that many surgeons decide on operations too easily, not for the sake of the patient, but for the sake of the money there is in them. He believes that most of the danger and inconvenience of the hernia can be removed by means of a properly fitting truss. He treats of stone in the kidney, but insists that the main thing for this affection is prophylaxis. He suggests that stone in the bladder should first be treated by internal remedies but in severe cases advises extraction. Lan-franc's discussion of cystotomy, Pagel characterizes "as prudent, yet rational," for he considers that the operation should not be feared too much nor delayed too long. In patients suffering from the inconvenience which comes from large quantities of fluid in the abdomen, he advises paracentesis abdominis. He warns, however, against putting the patient in danger from such an operation without due consideration and only when symptoms absolutely demand it.

Pagel says that Lanfranc must be considered as one of the greatest of the surgeons of the Middle Ages and the real founder of the French School of Surgery which continued to be the most prominent in the world down to the nineteenth century. Lanfranc had equalled, if not surpassed, his great master William Salicet. His own disciple, Mondeville, accomplished almost as much for surgery as his master, however. Both of them were destined to be thrown into the shade for succeeding generations by another great French surgeon of the next half-century, Guy de Chauliac. Pagel can scarcely say enough of the capacity as a teacher of Lanfranc. The seeds of surgical doctrine which he sowed bore fruit richly. His important successors in French surgery walked for the most part in his tracks and thus furnished the best proof of the enduring character of his capacity as a teacher.

The next great name in thirteenth century surgery, for we are not yet out of that fruitful period, is Henri de Mondeville. He was known by his contemporaries and immediate successors as the most cultured of the surgeons. Whatever he wrote bears the traces of his wide reading and of his respect for authority, yet shows also his power to make observations for himself, and his name is due much more to his independent work both in the technics and the diagnostics of surgery, than to his reputation for scholarship or the depth of his culture. Lanfranc (whose name was Lanfranchi) had been an Italian. Mondeville was born in Normandy sometime about the beginning of the last quarter of the thirteenth century. The place of his education is not absolutely sure, but there is good authority for saying that he was, for a time at least, in Bologna. On his return from Italy he passed some time, just at the beginning of the fourteenth century, in Montpelier. He seems to have looked for a professorship at Montpelier, but instead received the appointment as surgeon to the French king, Philip Le Bel. This brought him to Paris, where the first portion of his book on surgery was written about 1306. This was not completed until 1312. His work was interrupted by several campaigns on which he attended the king along the Northern coast. When he again took up his work of writing, he revised what he had written at first by the light of the experience that he had acquired in the campaign. Pagel says that his style is lively and clear and often full of meat. Many of his own opinions and experiences are incorporated in his work, and in spite of his tendency to display his erudition by quotations, his originality is not seriously interfered with.

Some of his remarks are very curiously interesting to the modern. He seems to have had the idea that portions of metal which had penetrated the body as the result of explosions, for gun-powder was already being used, might be removed by means of a magnet. He would not have been a distinguished surgeon without in-venting a needle-holder, and accordingly we find that he was one of the first of a long line of such inventors. He invented certain instruments also for the removal of arrow-heads, which because of their form and hooks be-come firmly imbedded in the tissues. Mondeville had no such fear of trephining as Lanfranc had, though he did not hesitate to emphasize the value of expectant treatment in most of these cases of injury to the head that might seem at first to demand the trephine.

Pagel notes the fact that when he prescribed drinks for his patients this medieval surgeon suggested that certain verses of the psalms which were usually recited, according to the custom of the times, whenever anything was administered to a patient, should be said. Pagel considers it quite natural that as a believing physician he should have realized how much his believing patients would be influenced for the better by such a procedure. He did not place any supreme faith in its efficacy, but knew that it could do no harm, and had probably seen, as has many a physician and surgeon of the modern time, that such a practice does good, if not by the direct interference of Providence, then at least by the calmness of mind which it superinduces in the patient. In the same way Mondeville was not averse to his patients going on pilgrimages. He did not expect that they would all be cured miraculously, but according to Pagel, his discussion of this subject is quite modern. Travel and change of scene would do good anyhow in many cases, expectancy would help the patient's condition, and the hope aroused was also good. The best merit, however, of this French surgeon is undoubtedly the immense influence which he exerted over his great successor, Guy de Chauliac.

We are really only beginning to accumulate knowledge with regard to the surgery of the thirteenth and fourteenth centuries. Pagel has devoted three very full pages, in his compressed account of surgery, to John Yperman, a surgeon of the early fourteenth century of whom practically nothing was known until about twenty-five years ago, when the Belgian historian Broeck brought to light his works and gathered some details of his life. He was a pupil of Lanfranc's, and at the end of the thirteenth century studied at Paris on a scholar-ship provided by his native town of Ypres, which deliberately sent him in order that he might become expert in surgery. This may seem a strange thing for a medieval town to do, at least it may seem so to those who have been accustomed to think little of the Middle Ages, but it will not to anyone who knows anything about the wonderful civic spirit of the Free Towns. In the chapter on Science at the Medieval Universities I have quoted from Prince Kropotkin's work on Mutual Aid in the Medieval Towns, and further consultation of that as a ready reference, would make all cause for ignorant surprise with regard to the culture and the enterprise of medieval towns disappear. Ypres, while a town of only fifteen thousand inhabitants now, was one of the most impor-tant towns of Flanders in the Middle Ages, noted for its manufacture of linens and fine laces, and has a hand-some cathedral dating from the thirteenth century and a town hall, the famous Cloth Hall, from the same period, which is one of the most beautiful architectural monuments in Europe and one of the finest municipal buildings in the world.

After his return Yperman settled down in his native town and practiced surgery until his death, which probably took place about 1330. He obtained a great renown, and this has been maintained so that in that part of the country even yet, an expert surgeon is spoken of as an Yperman. He is the author of two works in Flemish. One of these is what Pagel calls an unimportant compilation on internal medicine, but the headings of the chapters as he gives them can scarcely fail to attract the attention of the modern physician. He treats of dropsy, rheumatism, under which occur the terms coryza and catarrh, icterus, phthisis (he calls the tuberculous, tysiken), apoplexy, epilepsy, frenzy, lethargy, fallen palate, cough, shortness of breath, lung abscess, hemorrhage, blood-spitting, liver abscess, hardening of the spleen, affections of the kidney, bloody urine, diabetes, incontinence of urine, dysuria, strangury, gonorrhoea and involuntary seminal emissions all these terms are quoted directly from Pagel.

All this would seem to show that Yperman was a oughly representative medical man. When I add that Pagel says he shows a well marked striving to free himself from the bondage of authority and that most of his therapeutic prescriptions rest upon his own experience, it will be seen that he deserves the greatest possible credit. His work in medicine, however, Pagel considers as nothing compared to his work in surgery. A special feature of this is the presence of seventy illustrations of instruments of the most various kinds, together with a plate showing the anatomical features of the stitching of a wound of the head. The work as we have it is only a fragment. The last part of it which treated of the extremities is defective. If anyone thinks for a moment that surgery was a neglected specialty at the end of the thirteenth and the beginning of the fourteenth century, he should consult the text of this, or even Pagel's brief account of its contents. Some of the features of it are noteworthy. There is a chapter de-voted to intoxications, which includes the effects of cantharides as well as alcohol, and treats of the bites of snakes, scorpions, and of hydrophobia due to the bites of mad hounds. There is scarcely a feature of modern surgery of the head that is not touched upon very sensibly in this work.

The best proof, however, at once of the flourishing state of surgery during the fourteenth century and of the utter absurdity of saying that surgery did not develop because of the opposition of the Church or of ecclesiastics, and above all of the Popes, is to be found in the life of Guy de Chauliac, who has been deservedly called the Father of Modern Surgery and whose contributions to surgery occupy a prominent place in every history of medicine that one picks up. While the works of other great writers in surgery of the thirteenth and fourteenth centuries have as a rule only come to be commonly known during the latter part of the nineteenth century, Guy de Chauliac's position and the significance of his work and his writings have been a commonplace in the history of medicine for as long as it has been written seriously. We have already stated in several places in this volume his relations to the Popes. He was a chamberlain of the Papal Court while it was at Avignon, and while he was teaching and developing surgery at the University of Montpelier he was also body physician to three of the Popes, and the intimate friend and influential adviser to whom they turned for consultation in matters relating to medical education and to science generally.

In the present chapter, then, we shall only discuss the contributions to surgery of this surgeon of the Popes, at a time when, according to President White, because of Church opposition, surgery was considered dishonor-able ; "when the greatest monarchs were often unable to secure an ordinary surgical operation, and when it required an edict of the German Emperor in order that dishonor should no longer attach to the surgical profession." This is what Chauliac accomplished, according to Professor Allbutt :

" Of his substantial advances in surgery no sufficient account is possible ; but some chief points, with the aid of Haeser, Malgaigne, and Nicaise, I may briefly sum up thus : He pointed out the dangers of surgery of the neck, among them that of injuring the voice by section of the recurrent laryngeal nerve, a precaution he probably learned from Paul. He urges a low diet for the wounded. as did Mondeville and many others. He uses sutures well and discreetly (p. 9), but with far too many salves. On fractures of the skull he is at his best ; he noted the escape of cerebro-spinal fluid, and the effect of pressure on the respiration. It is somewhat strange that in days of war the study of chest wounds had been rather neglected by Galen, Haly, and Avicenna ; their practice, however, was to leave them open, lest pus should gather about the heart. Theodoric and Henry ordered chest wounds to be closed `lest the vital spirits escape.' Guy also closed these wounds, unless there were any effusion to be removed. In empyema he objects to caustics and prefers the knife. For haemorrhages he used sutures a little too closely perhaps—styptics, cautery or ligature. Sinuses he dilated with tents of gentian root, or he incised them upon a director. On ulcers his large experience is fully manifest. He describes the carcinomatous kind as hopeless, unless the mass can be excised at a very early stage and the incision followed by caustics. If in fractures and dislocations he tells us nothing new, these sections testify to a remarkable fulness of knowledge at a period when the Hippocratic treatises were unknown. Haeser says that in respect of position in fractured femur he was the best physician in the Middle Ages."

This is the period, it must not be forgotten, when, ac-cording to President White, surgery was in such a state that the application of various ordures relieved fractures ; the touch of the hangman cured sprains ; the breath of a donkey expelled poison ; friction with a dead man's tooth cured a toothache.

Lest it should be thought that possibly Professor All butt had been rather partial to the great Father of Mod-ern Surgery in his enthusiasm for these medieval surgeons, it seems worth while to compress here some-thing of what Pagel has to say with regard to this great man, who represents in himself a full hundred years of progress in surgery. He wrote an immense text-book of surgery, from which his teaching may be learned with absolute authenticity. The great significance attached to Guy's writings by his contemporaries and successors will be readily appreciated from the immense number of manuscript copies, original editions in print, and the many translations which are extant. This monument of scientific surgery has for dedication a sentence that would alone and of itself obliterate all the nonsense that has been talked about Papal opposition to the develop-ment of surgery. It runs as follows :

(I dedicate this work) " To you my masters, physicians of Montpelier, 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, Bononiæ, 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 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 indi-cations 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 ansthesia, 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 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."'

" 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.

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 prepositus ecclesiae Sancti Justi Lugduni, medicusque domini nostri Pape.' 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 Medicine—so called in distinction to the meagre little handbooks or Chirurgie Parve 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, Provençal and French words, but very little Greek."

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 four teenth 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 his-tories 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 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 valu-able 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 manu-script or hidden away in large folio volumes, printed very early in the history of printing, and considered so valu-able 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 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 his-tory, 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 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 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 re-mains 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 develop-ment 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 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 en-countered 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 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. Côme 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 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. Côme at Paris is, as we have said, interesting from this stand-point. " 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. Côme of Paris. Well, St. Côme did no great things for surgery. The truth is that, infected with the exclusiveness and dialectical conceits of all the schools of Paris, St. Côme 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. Côme, 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. Côme, 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. Côme to its knees, and to check the presumptuous claims of this corporation on the 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. Côme sought to provide lectures in surgery, the Faculty, which kept possession of teaching licenses and de-sired 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. Côme 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. Côme 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. "

In conclusion, we may say that, in the Middle Ages, once men had lifted themselves up from the condition into which they had been plunged by the incursions of the barbarians, there was nothing like the neglect of surgery which is sometimes said to have existed. Surgery had its normal development, and reached as high a stage as medicine in that beginning Renaissance, which is the characteristic feature of the twelfth, thirteenth, and fourteenth centuries. The traditions of a low state of surgery at this time are all false and founded on insufficient knowledge of the real conditions, which have been so clearly revealed to us by the investigation of original documents in the last twenty-five years. This was, in fact, one of the greatest periods in the history of surgery that the world has ever known. What-ever of difficulty in development surgery encountered was due not to any Church opposition, but to unfortunate conditions that arose in the practice of medicine. Professional jealousy and shortsightedness was the main element in it. Even this, however, did not prevent the very wonderful development of surgery that came during the Middle Ages, and that made this department of human knowledge quite as progressive and successful as any other, in that marvelous period when the universities came into existence in the form which they have maintained ever since.

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