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

Pagel says that Lanfranc must be considered as one of the greatest of the surgeons of the Middle Ages and the real founder of the French School of Surgery which continued to be the most prominent in the world down to the nineteenth century. Lanfranc had equalled, if not surpassed, his great master William Salicet. His own disciple, Mondeville, accomplished almost as much for surgery as his master, however. Both of them were {177} destined to be thrown into the shade for succeeding generations by another great French surgeon of the next half-century, Guy de Chauliac. Pagel can scarcely say enough of the capacity as a teacher of Lanfranc. The seeds of surgical doctrine which he sowed bore fruit richly. His important successors in French surgery walked for the most part in his tracks and thus furnished the best proof of the enduring character of his capacity as a teacher.

The next great name in thirteenth century surgery, for we are not yet out of that fruitful period, is Henri de Mondeville. He was known by his contemporaries and immediate successors as the most cultured of the surgeons. Whatever he wrote bears the traces of his wide reading and of his respect for authority, yet shows also his power to make observations for himself, and his name is due much more to his independent work both in the technics and the diagnostics of surgery, than to his reputation for scholarship or the depth of his culture. Lanfranc (whose name was Lanfranchi) had been an Italian. Mondeville was born in Normandy sometime about the beginning of the last quarter of the thirteenth century. The place of his education is not absolutely sure, but there is good authority for saying that he was, for a time at least, in Bologna. On his return from Italy he passed some time, just at the beginning of the fourteenth century, in Montpelier. He seems to have looked for a professorship at Montpelier, but instead received the appointment as surgeon to the French king, Philip Le Bel. This brought him to Paris, where the first portion of his book on surgery was written about 1306. This was not completed until 1312. His work was interrupted by several campaigns on which he attended {178} the king along the Northern coast. When he again took up his work of writing, he revised what he had written at first by the light of the experience that he had acquired in the campaign. Pagel says that his style is lively and clear and often full of meat. Many of his own opinions and experiences are incorporated in his work, and in spite of his tendency to display his erudition by quotations, his originality is not seriously interfered with.

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

Pagel notes the fact that when he prescribed drinks for his patients this medieval surgeon suggested that certain verses of the psalms which were usually recited, according to the custom of the times, whenever anything was administered to a patient, should be said. Pagel considers it quite natural that as a believing physician he should have realized how much his believing patients would be influenced for the better by such a procedure. He did not place any supreme faith in its efficacy, but {179} knew that it could do no harm, and had probably seen, as has many a physician and surgeon of the modern time, that such a practice does good, if not by the direct interference of Providence, then at least by the calmness of mind which it superinduces in the patient. In the same way Mondeville was not averse to his patients going on pilgrimages. He did not expect that they would all be cured miraculously, but according to Pagel, his discussion of this subject is quite modern. Travel and change of scene would do good anyhow in many cases, expectancy would help the patient's condition, and the hope aroused was also good. The best merit, however, of this French surgeon is undoubtedly the immense influence which he exerted over his great successor, Guy de Chauliac.

We are really only beginning to accumulate knowledge with regard to the surgery of the thirteenth and fourteenth centuries. Pagel has devoted three very full pages, in his compressed account of surgery, to John Yperman, a surgeon of the early fourteenth century of whom practically nothing was known until about twenty-five years ago, when the Belgian historian Broeck brought to light his works and gathered some details of his life. He was a pupil of Lanfranc's, and at the end of the thirteenth century studied at Paris on a scholarship provided by his native town of Ypres, which deliberately sent him in order that he might become expert in surgery. This may seem a strange thing for a medieval town to do, at least it may seem so to those who have been accustomed to think little of the Middle Ages, but it will not to anyone who knows anything about the wonderful civic spirit of the Free Towns. In the chapter on Science at the Medieval Universities I have quoted {180} from Prince Kropotkin's work on Mutual Aid in the Medieval Towns, and further consultation of that as a ready reference, would make all cause for ignorant surprise with regard to the culture and the enterprise of medieval towns disappear. Ypres, while a town of only fifteen thousand inhabitants now, was one of the most important towns of Flanders in the Middle Ages, noted for its manufacture of linens and fine laces, and has a handsome cathedral dating from the thirteenth century and a town hall, the famous Cloth Hall, from the same period, which is one of the most beautiful architectural monuments in Europe and one of the finest municipal buildings in the world.

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

All this would seem to show that Yperman was a {181} thoroughly representative medical man. When I add that Pagel says he shows a well marked striving to free himself from the bondage of authority and that most of his therapeutic prescriptions rest upon his own experience, it will be seen that he deserves the greatest possible credit. His work in medicine, however, Pagel considers as nothing compared to his work in surgery. A special feature of this is the presence of seventy illustrations of instruments of the most various kinds, together with a plate showing the anatomical features of the stitching of a wound of the head. The work as we have it is only a fragment. The last part of it which treated of the extremities is defective. If anyone thinks for a moment that surgery was a neglected specialty at the end of the thirteenth and the beginning of the fourteenth century, he should consult the text of this, or even Pagel's brief account of its contents. Some of the features of it are noteworthy. There is a chapter devoted to intoxications, which includes the effects of cantharides as well as alcohol, and treats of the bites of snakes, scorpions, and of hydrophobia due to the bites of mad hounds. There is scarcely a feature of modern surgery of the head that is not touched upon very sensibly in this work.

The best proof, however, at once of the flourishing state of surgery during the fourteenth century and of the utter absurdity of saying that surgery did not develop because of the opposition of the Church or of ecclesiastics, and above all of the Popes, is to be found in the life of Guy de Chauliac, who has been deservedly called the Father of Modern Surgery and whose contributions to surgery occupy a prominent place in every history of medicine that one picks up. While the works of other {182} great writers in surgery of the thirteenth and fourteenth centuries have as a rule only come to be commonly known during the latter part of the nineteenth century, Guy de Chauliac's position and the significance of his work and his writings have been a commonplace in the history of medicine for as long as it has been written seriously. We have already stated in several places in this volume his relations to the Popes. He was a chamberlain of the Papal Court while it was at Avignon, and while he was teaching and developing surgery at the University of Montpelier he was also body physician to three of the Popes, and the intimate friend and influential adviser to whom they turned for consultation in matters relating to medical education and to science generally.

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

"Of his substantial advances in surgery no sufficient account is possible; but some chief points, with the aid of Haeser, Malgaigne, and Nicaise, I may briefly sum up thus: He pointed out the dangers of surgery of the neck, among them that of injuring the voice by section of the recurrent laryngeal nerve, a precaution he probably learned from Paul. He urges a low diet for the wounded, as did Mondeville and many others. He uses sutures well and discreetly (p. 9), but with far too many salves. {183} On fractures of the skull he is at his best; he noted the escape of cerebro-spinal fluid, and the effect of pressure on the respiration. It is somewhat strange that in days of war the study of chest wounds had been rather neglected by Galen, Haly, and Avicenna; their practice, however, was to leave them open, lest pus should gather about the heart. Theodoric and Henry ordered chest wounds to be closed 'lest the vital spirits escape.' Guy also closed these wounds, unless there were any effusion to be removed. In empyema he objects to caustics and prefers the knife. For haemorrhages he used sutures--a little too closely perhaps--styptics, cautery or ligature. Sinuses he dilated with tents of gentian root, or he incised them upon a director. On ulcers his large experience is fully manifest. He describes the carcinomatous kind as hopeless, unless the mass can be excised at a very early stage and the incision followed by caustics. If in fractures and dislocations he tells us nothing new, these sections testify to a remarkable fulness of knowledge at a period when the Hippocratic treatises were unknown. Haeser says that in respect of position in fractured femur he was the best physician in the Middle Ages."

Guy de Chauliac's Cauteries:--5, 6, 7, 8, cauteries called from their shapes: knife, sword, olive, date kernel; 9, cautery with protective nail to be inserted cold; 10, protective plate for cauteries.

Guy de Chauliac's Cauteries:--11, 12, long, smooth cautery and canula protector; 13, 14, ring cautery with five buttons and the protective plate with five openings.

This is the period, it must not be forgotten, when, according to President White, surgery was in such a state that the application of various ordures relieved fractures; the touch of the hangman cured sprains; the breath of a donkey expelled poison; friction with a dead man's tooth cured a toothache. [Footnote 23]

[Footnote 23: Quite as curious notions as these which President White mentions still exist in popular medicine in our own day. I have myself known a man to blow the dried excrement of the dog into the throat of his child suffering from diphtheria, and he assured me that it cured him. In the country districts they still use ordure poultices for sprains of various kinds, and I have known doctors prescribe them. I have seen an intelligent woman smoking dried angleworms in a pipe for toothache. I sincerely hope, however, that no serious(!) historian of the twenty-fifth century will gather up side remarks like the present with regard to such curious customs--real superstitions that have nothing to do with religion, as most supersititions have not--and state them as showing the ignorance of our generation, and above all as indicating the low state of medicine in our time.]

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

(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, Bononiae, Parisiis atque Avinionis, praecipue papalibus, quibus me in servitio Romanorum pontificum associavi."

Pagel has three closely printed pages in small type of titles alone of subjects which Chauliac treated with {185} distinction. His description of instruments and methods of operation is especially full and suggestive. He knew how to prescribe manipulations and set forth the principles on which they were founded. Scarcely anything was added to his method of taxis for hernia for five centuries after his time. He describes the passage of a catheter with the accuracy and complete technic of a man who knew all the difficulties of it in complicated conditions. He recognizes the dangers that arise for the surgeon from the presence of anatomical anomalies of various kinds, and describes certain of the more important of them. He did not hesitate to suggest some very serious operations. For instance, for empyema he advises opening of the chest. He has very exact indications for trephining. He recognizes the absolute fatality of wounds of the abdomen, in which the intestines were opened, if they were left untreated, and describes a method of suturing wounds of the intestines in order to save the patient's life. In a word, there is nothing that has been attempted in these modern times, with our aseptic precautions and the advantage of anaesthesia, which this father of surgery did not discuss very practically and with excellent common sense as well as surgical acumen.

Chauliac's career is interesting because it is that of a self-made man of the Middle Ages, which brings out the fact that men do not differ so much as might be thought at this distance of time, and shows that there were chances for a man to rise by his own genius from a lowly to a lofty position at this time of the Middle Ages, when it is usually supposed that men were excluded from such opportunities. Allbutt says of him:

"Still, Guy of Chauliac, who flourished in the second {186} half of the fourteenth century, was enabled to feed his virile and inquisitive spirit on rich sources of learning. While he succeeded to the stores of Arnold (of Villanova) and Gordon with his just and cautious reason and wealth of experience, he cast out of them much of the sorcery, jugglery, astrology and mysticism which were their reproach. Chauliac is a village in the Auvergne, and Guy was but a farmer's lad. It was by the aid of powerful friends that he studied at Toulouse and Montpelier, took orders and the degree of Master of Medicine; in his time there was no degree of Doctor of Medicine in France. Then he studied anatomy at Bologna under Bertruccio, the successor of Mondino, a study which, with Henry (de Mondeville) he regarded as the foundation of surgery. The surgeon ignorant of anatomy, he says, "carves the human body as a blind man carves wood." [Footnote 24]

[Footnote 24: This is a very striking reflection on the necessity for the study of anatomy for the practice of surgery to have been made within a half century after the supposed prohibition of dissection by the Popes, and at a time when, according to President White, "even such serious matters as fractures, calculi and difficult parturition, in which modern science has achieved some of its greatest triumphs, were dealt with by relics," and when "there were religious scruples against dissection," and surgery "was denounced by the Church," and when "pastoral medicine had checked all scientific effort in medical science." And the reflection was made by a chamberlain of the Papal household.]

"Thence he paid a brief visit to Paris, where for a moment, by the renown of Lanfranc, Jean Pitard, and Henry of Mondeville, surgery was in the ascendant. For the moment the Church and the faculty had not succeeded in paralyzing the scientific arm of medicine. [Footnote 25] {187} Guy began practice in Lyons, whence he was called to Avignon by Clement VI. as 'venerabilis et circumspectus vir, dominus Guido de Cauliaco, canonicus et propositus ecclesiae Sancti Justi Lugduni, medicusque domini nostri Papae.' In Avignon he stayed, while other physicians fled, to minister to the victims of the plague (A.D., 1348), and he may have attended Laura in spite of Petrarch's tirades against all physicians and even against Guy himself. His description of this epidemic is terrible in its naked simplicity. He did not, indeed, himself escape, for he had an attack with bubo, and was ill for six weeks. He gave succor also in a later epidemic in Avignon, in 1360. His 'Chirurgia Magna' or Inventarium seu Collectorium Artis Chirurgicalis Medicinae--so called in distinction to the meagre little handbooks or Chirurgiae Parvae compiled from the larger treatises--was in preparation in 1363. This great work I have studied carefully, and not without prejudice; and yet I cannot wonder that Fallopius compared the author to Hippocrates, or that John Freind calls him the Prince of Surgeons. It is rich, aphoristic, orderly and precise. As a clerk he wrote in Latin, in the awkward hybrid tongue that medical Latin then was, containing many Arabian, Provençal and French words, but very little Greek."

[Footnote 25: It is worthy of remark, how even Prof. Allbutt, in a passage like this, where he is providing abundant material for the contradiction of the English Protestant tradition of the supposed opposition of the Church to science, and especially to surgery, yet cannot break away from the influence of that tradition entirely. It has been bred in him, and even while showing its falsity he is not entirely convinced himself, because the old mode of view has so firm a hold on him that he is not open to conviction. A little later in this same passage he speaks of taking up the study of Chauliac, prejudiced against him, and being convinced of his greatness against his will. Verily history has been a conspiracy against the truth, in which many people have joined almost unconsciously, led astray by feeling, not intellect.]

Guy de Chauliac's Instruments:--15, 16, cautery apparatus with canula for cauterizing the uvula and tonsils; 17, bistoury; 18, amputation knife; 19, small sickle knife for opening abscesses and fistulas.

Guy de Chauliac's Instruments:--21, bow for extracting arrows the head of which had penetrated a limb; 22, mechanical trephine revolved by up-and-down movement of cross-bar.

We have seen that there was great surgery in Italy, in France, and in the Netherlands, but it had also crossed the channel into England.

There was a famous English surgeon during the {188} fourteenth century by the name of John Ardern. He was educated at Montpelier and practiced surgery for a time in France. About the middle of the century, however, according to Pagel, he went back to his native land and settled for some twenty years at Newark, in Nottinghamshire, and then for nearly thirty years longer, until nearly the end of the century, was in London. He is the chief representative of English surgery during the Middle Ages. His Practice, as yet unprinted, contains, according to Pagel, a short sketch of internal medicine, but is mainly devoted to surgery. Contrary to the usual impression with regard to works in medicine and surgery at this time, the book abounds in references to case histories which Ardern had gathered, partly from his own and partly from others' experience. The therapeutic measures that he suggests are usually very simple, in the majority of cases quite rational, though, of course, there are many superstitions among them; but Ardern always furnished a number of suggestions from which to choose. He must have been an expert operator, and had excellent success in the treatment of diseases of the rectum. He seems to have been the first operator who made statistics of his cases, and was quite as proud as any modern surgeon, of the large numbers that he had operated on, which he gives very exactly. He was the inventor of a new clyster apparatus.

Daremberg, the medical historian, who saw a copy of Ardern's manuscript in St. John's College, Oxford, says that it contains numerous illustrations of instruments and operations. His work seems really to be a series of monographs or collection of special articles on different subjects, which Ardern had made at various times, rather than a connected work. Pagel bewails the fact {189} that a more thorough consideration of Ardern's work is impossible, because the greater part of what he wrote remains as yet unprinted.

In general, when we consider how difficult was the task of making copies of works on surgery by hand, and especially such as contain numerous illustrations, the wonder grows that we should have so much about the surgery of these centuries rather than so little. Some of these works have been preserved for us by the merest chance. There have been many centuries since their time, when what these surgeons wrote would have been thought of very little value because physicians were not educated up to them. In spite of this liability to loss, which must have caused the destruction of many valuable works, we still have enough to show us what wonderful men were these surgeons of the thirteenth and fourteenth centuries, who anticipated our best thinking of the modern times in many of the most difficult problems. It is only during the last twenty-five years that anything like justice has been done them. The only way to know what these men did and taught is to read their own works, and these have been buried in manuscript or hidden away in large folio volumes, printed very early in the history of printing, and considered so valuable that consultation of them was almost resented by librarians. Anyone who talks about the lack of surgery in Europe during the thirteenth and fourteenth centuries is supremely ignorant of the real course of history at this time, and when in addition he attributes the failure of surgery to develop to a trumped-up opposition of the Church or ecclesiastics, he is simply making a ridiculous exhibition of intolerance and of foolish readiness to accept anything, however groundless, that may {190} enable him to make out a case against the ecclesiastical authorities.

It is curious to reflect that in spite of all this wonderful progress in surgery, somehow there has crept in the tradition which has been very generally accepted by historians not acquainted with the details of medical history, that surgery was neglected during the thirteenth and fourteenth centuries. The existence of this tradition, and its acceptance by men who had no idea that they were being influenced by that peculiar state of mind which considers that nothing good can come out of the Nazareth of the times before the reformation so-called, is of itself a warning with regard to the way history has been written, especially for the Teutonic and English-speaking peoples, that should carry weight in other departments of history beside medicine and surgery.

Even Pagel could not get entirely away from the old tradition which has existed for so long, that the Church, if she did not oppose, at least hampered the progress of surgery. While his first paragraph shows that he recognized the important advances that were made in the Middle Ages, he cannot rid himself of the prejudice that has existed so long and has tinged so much of the historical writing of the last four centuries. He furnishes an abundance of material himself to disprove the old opinion, and evidently has been influenced by this evidence, but cannot give up notions that have been part and parcel of his education from his earliest days in Protestant Germany. He says:--

"A set-back must also be recognized to some extent in surgery, especially attributable to the fact that as a consequence of the pressure of the Church upon scientific medicine, the representatives of medical {191} science felt themselves bound to neglect the practical art of surgical operation. Church regulations forbade the shedding of blood to churchmen, and not a few physicians were more than inclined to accept this prohibition as in accordance with their own feelings. For this reason the practice of surgery was left for the most part to the lower orders of those engaged in healing. This went to such an extent, that physicians even came to look upon surgery as an unworthy occupation. Even venesection, which was so commonly employed and which came to be indispensable to the practice of internal medicine, made it necessary to call for the services of a barber-surgeon."

As we shall see, there were many other and much more important factors at work in the degradation of surgery than the supposed repression of the Church. The time to which Pagel refers is in the earlier centuries of the Middle Ages, and not the later ones; yet it is from these later centuries that the supposed prohibitory decrees are all quoted. The contempt for surgery was due rather to the general lack of culture before the foundation of the universities than to any ecclesiastical repression. Just as soon as the great medical schools were opened--and that at Salerno came into existence in the early part of the tenth century if not earlier--surgery began to be in honor. Pagel himself confesses this in the very next paragraph of this brief conspectus of surgery, and shows how generally was the uplift of surgery made possible by university education, though there still remained many drawbacks to progress because of the jealousy of physicians.

"Gradually, however, a beneficial transformation of customs in this matter began to be manifest. Physicians {192} who were scientifically trained began to take up surgery with enthusiasm, and from that time (end of twelfth century) dates the visible uplift of this specialty. Eventually the most noteworthy literary events and remains of the representatives of the great schools of the Middle Ages--Salerno, Bologna, Paris and Montpelier--concern quite as much the department of surgery as of practical medicine. These medieval literary contributions constitute the principal steps in the historical development of scientific surgery. The Crusades represent an extremely important influence upon the perfecting of the surgery of wounds. Italian surgeons in large numbers took prominent parts therein. They took the abundant opportunities afforded them to gather experience, which they used to great advantage in their practice and in their teaching after their return home. From Roger, the first and most important of the representatives of the Salernitan school (whose life occupies the end of the twelfth and the beginning of the thirteenth century), and down to Guy de Chauliac (who died toward the end of the fourteenth century), in a space therefore of not quite two hundred years, a complete breach with the blood-fearing traditions of the Arabs was made. In no European land does one fail to find evidence of intense as well as successful scientific occupation with surgery."

As a reflection that throws a brilliant light on the true conditions that brought about the diminished estimation in which surgery came to be held, Guy de Chauliac has an interesting passage in which he suggests an explanation for it, which is surely much nearer the truth than any modern explanation is likely to be. He says that, after the time of the Arabs, who were all both physicians and surgeons, either because of the lack of interest of {193} physicians or their laziness, for the practice of surgery is a difficult matter, or because they came to be too much occupied with the ills which they might hope to cure by medicines alone, surgery became separated from medicine and passed down into the hands of mere mechanics. This is a complaint not infrequently heard even at the present day, that medicine and surgery are drawing too much apart for the good of either specialty. Both the Regius Professors of medicine in England have recently insisted that physicians must oftener be present at operations if they would really appreciate the value of diagnosis, while there has been for many years a feeling that surgery would be benefitted if surgeons did not always wish to have recourse to the knife, but appreciated how much good might be accomplished by other remedial measures. The great French Father of Surgery, then, was only expressing what was to be a perennial complaint in the domain of medicine and surgery when he explained the separation of the two departments of healing. He has nothing whatever to say of the evil influence upon surgery of any Church regulations, though he must have been in a position to realize their significance very well in this respect if they actually had any. He was himself, as we have said, a member of the Papal household; he was even a cleric, and seems to have encountered no difficulty at all not only in devoting himself to surgery, but even in lifting up that department of medicine from the slough of neglect into which it had fallen because of the lack of initiative of preceding generations in his native land.

It may be wondered, then, how the tradition of opposition to surgery, which is so common in history, had its origin. Nearly always for these exaggerated stories {194} there is some basis of truth. For instance, with regard to the opposition to Vesalius, the origin of the stories of persecution by the Church and ecclesiastical authorities is evidently the fact that he was very much opposed by the old-time physicians and surgeons, who believed in Galen and thought it worse than heresy to break with him. It is the opposition of scientists, or pseudo-scientists, to scientific progress that constitutes the real bar to advance, and has over and over again been attributed to religious motives, when it is really due to that very human overconservatism, which so constantly places men in the position of opponents to novelties of any kind, no matter how much of value they may eventually prove to have. There has always existed a certain prejudice against surgery on the part of physicians--meaning by that term, for the moment, those who devote themselves to internal medicine. This feeling has never quite died out. There were times in the Middle Ages when it was very marked. Not a little of the feeling is due to professional jealousy, and that, it is to be feared, like the poor, we shall have always with us.

Professor Allbutt has in the address at St. Louis, already quoted from, a very interesting passage with regard to the College of St. 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 {195} entirely without foundation, some basis for them that will account for their universality, but will only render clearer the intolerance of those who have constantly perverted the meaning of this opposition to persecution on the part of Church authorities. Ecclesiastics not only had nothing to do with this, but more often than not were the active factors in such amelioration of the conditions it brought about as very much to lessen its effects.

Allbutt's story of the College of Surgeons of St. Côme at Paris is, as we have said, interesting from this standpoint. "Some of my readers may wonder how it is that in discoursing of medieval surgery I have not dwelt upon the Surgical College of St. 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 {196} privileges of the Faculty of Medicine, on a liberal education in arts and medicine, on a place in the university, on the suppression of unqualified surgical practice, and less, honourably, on relief from handicraft and urgent calls, the Faculty had to coquette with the barbers. Medicine, proclaimed the Faculty when it suited its purpose, contains the theoretical and the practical side of surgery; a surgeon is therefore but the servant of a physician. If St. Côme sought to provide lectures in surgery, the Faculty, which kept possession of teaching licenses and desired in the surgeon a docile assistant, took the teaching from the college and invited the barbers to lectures of its own. In their duplicity and conceit of caste, physicians of the Faculty condescended even to publish books on surgery, books as arid and as insincere as their lectures. On the other hand, in the person of the King's Barber, the barbers had a secret and potent influence at Court. The Faculty persisted in denying to St. 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." [Footnote 26]

[Footnote 26: As showing how professional jealously may exist in such ways in the modern times as to hinder progress, the following paragraph, which is the opening portion of Professor Allbutt's address, has seemed to me to deserve quotation here. It will illustrate a phase of the subject that is probably utterly unexpected by those unfamiliar with the inner history of medicine in our time, but which is not so surprising to physicians who know the jealousy with which men guard their specialties from what they consider the interference of others, in hospital work and in teaching, though this exclusiveness often proves detrimental both to the breadth of development of the student and to the good health of the patient.

"It was, I think, in the year 1864, when I was a novice on the Honorary Staff of the Leeds General Infirmary, that the unsurgical division of us was summoned in great solemnity to discuss a method of administration of drugs by means of a needle. This method having obtained some vogue, it behooved those who practiced 'pure' medicine to decide whether the operation were consistent with the traditions of purity. For my part, I answered that the method had come up early, if not originally, in St. George's Hospital, and in the hands of a house physician--Dr. C. Hunter; that I had accustomed myself already to the practice and proposed to continue it; moreover, that I had recently come from the classes of Professor Trousseau, who, when his cases demanded such treatment, did not hesitate himself to perform paracentesis of the pleura, or even incision of this sac, or of the pericardium. As, for lack not of will but of skill and nerve, I did not intend myself to perform even minor operations, my heresy, as one in thought only, was indulgently ignored, and we were set free to manipulate the drug needle if we felt disposed to this humble service."]

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. Whatever 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 {198} 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.

PAPAL PHYSICIANS.

Most of what historical writers generally, who follow the old traditions of the medieval eclipse of medicine, have to say with regard to the supposed Papal opposition to the development of medical science, is founded on the assumption that men who believed in miracles and in the efficacy of prayer for the relief of disease could not possibly be interested to any serious degree in scientific medicine. As Dr. White says, "out of all these inquiries came inevitably that question whose logical answer was especially injurious to the development of medical science: why should men seek to build up scientific medicine and surgery, when relics, pilgrimages, and sacred observances, according to an overwhelming mass of concurrent testimony, have cured and are curing hosts of sick folk in all parts of Europe." He goes even farther than this, however, when he suggests that "it would be expecting too much from human nature to imagine that Pontiffs who derived large revenues from the sale of the Agnus Dei, or priests who derived both wealth and honors from cures wrought at shrines under their care, or lay dignitaries who had invested heavily in relics, should favor the development of any science which undermined their interests."

On the strength of assumptions such as these, that "medieval belief in miracles of healing must have checked medical science," and that therefore it did actually prevent the development of scientific medicine, statements are made with regard to the history of {200} medicine that are utterly at variance with the plain facts of history. Once more, as in the case of the supposed failure of surgery to develop during the Middle Ages, it is a deduction that has been made from certain supposed principles, and not an induction from the actual facts as we know them. Such historians would be the first to emphasize the narrowness of the schoolmen for their supposed dependence on deduction, but what they have to say on medical history is entirely deductive, and unfortunately from premises that will not stand in the presence of the story of the wonderful rise and development of medical science and medical education, mainly under the patronage of ecclesiastics, in the Middle Ages.

The argument may be stated formally with perfect fairness as follows: When men believe in miracles they cannot build up scientific medicine and surgery; but men believed in miracles in the Middle Ages, therefore they did not build up scientific medicine and surgery. When stated thus baldly in formal scholastic form, the argument loses most of the glamor that has been thrown around it. This is one of the advantages of the old scholastic method--it strips argument to its naked significance. Logic asserts herself and rhetoric loses its force.

With regard to the major premise that when men believe in miracles they will not successfully pursue investigations in the medical science, there are two answers. One of these concerns the actual attitude of mind towards scientific medicine of men who believe in miracles, for we have such men still with us, and have always had them all during the past seven centuries. The other portion of the answer concerns what men who were distinguished scientific investigators thought of {201} miracles, and how much they accomplished for the medical sciences while all the time maintaining their belief in the possibility of miraculous intervention for the cure of disease.

Apparently the writers who insist on the incompatibility of the belief in miracles with devotion to scientific medicine do not realize that the greater number of thinking physicians during the last seven centuries, and quite down to our own day, have been ready to confess their belief in the possibility of miraculous healing, yet have tried to do everything in their power to relieve suffering and cure human ills by the natural means at their command. Their attitude has been very much that attributed to Ignatius of Loyola, who said to the members of his order: "Do everything that you can with the idea that everything depends on you, and then hope for results just as if everything depended on God." There is no lack of logic in this; and the physician of the present day who realizes his impotency in the presence of so many of the serious ailments of mankind is not a scoffer at the attitude of mind that looks for help from prayer; but if he is sensible, welcomes the placidity of mind this will give his patient, even if he does not, as many actually do, however, believe in the possible interposition of supernatural forces.

If Prof. White knew anything about the lives of the men whose names are most distinguished in the history of medicine during the thirteenth, fourteenth and fifteenth centuries, we would have heard nothing of his almost incomprehensible negation of the existence of scientific medicine, during centuries when so many men who have stamped their names indelibly on the history of the medical sciences were doing their work and {202} writing. If he had taken any pains to learn even a few details of the personal relations of these old-time makers of medicine to the Popes, we would have heard none of this utter absurdity of Papal opposition to medicine or ecclesiastical hampering of medical science. To answer Prof. White's argument, that "it would be expecting too much from human nature to imagine that Pontiffs should favor the development of any science which undermined their interests," the simple story of the men the Popes choose as their own medical advisers, and who because of the prestige of their appointment as Papal Physicians helped to raise up in the eyes of the people the dignity of the medical profession which they represented, will be quite enough. It will also serve to show how different is history founded on an assumption from history founded on actual facts.

The best, most easily obtainable, and most impressive data for the inductive method of reaching the truth as regards the relation of the Popes to medical science and (because of the fact that physicians were the scientists par excellence of the Middle Ages) to all science, will be found in a brief consideration of the lives of the men who occupied the position of Papal Physician during the last seven centuries. I do not think that this group of men has ever been treated together before; at least I have been unable to find any work on the subject. While I am able to present a considerable amount of interesting material in brief form with regard to them, I am sure that there are many of them whom I have omitted. Practically up to the day of going to press I have been finding new references that led to further precious information with regard to this most wonderful group of men in medical history. It will be well {203} understood, then, that impressive as the consideration of the work and character of the men whose names I have found must be, this does not represent all the truth in the matter, but can be supplemented without much difficulty from other sources.

If the Popes had been interested only in the miraculous healing of disease, and had wished to teach the lesson that men should depend solely for their recovery from serious symptoms and ailments of all kinds on prayers and relics and pilgrimages, then they would either have had no physicians at all in regular attendance on them, or at least their physicians would not have been selected from among the men who were doing most to advance the cause of practical and scientific medicine and of medical education. The very opposite of this is the case. The Papal physicians were as a rule the most scientific medical men of their time. This is not a pious exaggeration, but is literally true for seven centuries of history, as we shall see presently. The wonder of it is that there were not some charlatans among them. The physicians whom educated people select are not, as physicians we'll know, always worthy examples of progressive medical men. Literary folk particularly seem to have a distinct tendency to want to be different from other people, and their physicians are often the veriest theorizers. A medical friend who occasionally quotes, but perverts the old line, "the people people have for friends are often very queer," says, half in jest of course, but alas! more than half in earnest, that "the people literary folk and the clergy have for doctors are the queerest ducks (docs.) of all."

It is only too true that clergymen are especially prone to be erratic in the choice of their medical advisers and {204} lacking in a critical judgment as to the remedies and methods of treatment of which they become the willing recipients, and occasionally even the sponsors as regards other people, who look up to their judgment for other reasons with confidence. Prof. Osler once said that the nearer to the Council of Trent the clergyman, the nearer he was likely to be to truth and common sense in medical matters; but then perhaps all would not agree with him. It is all the more surprising under the circumstances, and very greatly to their credit, that the Popes should have had as their physicians a list of men whose names are the brightest on the roll of great contributors to medical literature and some of the most distinguished among the great discoverers in medical science.

This fact alone constitutes the most absolute contradiction of the declarations as to supposed Church opposition to medicine that could possibly be given. No better means of encouraging, fostering, and patronizing medical science could be thought of than to give the prestige and the emoluments of physician to the head of the Church to important makers of medicine in every generation. The physicians to the rulers of Europe have not always been selected with as good judgment, and, as I have already said, there is no list of physicians to any European Court, nor indeed any list of names of medical men connected together by any bond in history--no list, for instance, of any medical faculty of a university--which can be compared for prestige in scientific medicine with the Papal Physicians.

Before the beginning of the thirteenth century very little is known of the medical attendants of the Popes. We point out in the following chapter that the Papacy was closely in touch with the medical school at Salernum. {205} It seems not unlikely, and indeed there are some traditions to that effect, that in cases of severe illnesses of the Popes, important members of the medical faculty were sometimes summoned from the South of Italy to Rome. The relations of the Popes to the neighboring abbey of Monte Cassino might, as we have said, suggest this. We have, however, very few details in this matter. With the beginning of the great thirteenth century, however, the records of human achievement in every line are better kept, and at once we begin to know something definite about Papal Physicians. The first one of decided prominence was Guy or Guido of Montpelier, who was summoned to Rome by Pope Innocent III. in order that he might re-establish the hospital of the Santo Spirito at Rome, in accordance with what were considered to be the latest ideas in the matter of hospital building and the enlightened care of the sick. How well he accomplished this work, and how well he deserves to head the glorious roll of Papal Physicians, will be seen in the chapter on The Popes and City Hospitals.

The next of the Papal Physicians of whom much is known in the history of medicine was Richard the Englishman, usually spoken of as Ricardus Anglicus. He was the physician to the famous Pope Gregory IX. (1237-1241). Richard, who was born in England not long before the beginning of the thirteenth century, died shortly after the middle of that century. For a time he was at Paris, and accordingly is sometimes spoken of as Ricardus Parisiensis. According to Gabriel Naudé he was at Paris after the death of his patient, Gregory IX., and towards the end of his life retired to the Abbey of St. Victor, to spend his last days in recollection and prayer. In this he anticipated another great English physician {206} with a European reputation--Linacre--who, three centuries later, after having been the royal physician for many years to King Henry VIII., became a clergyman. It is interesting to realize that, early in history as Richard's life occurs, some works attributed to him contain definite information with regard to anatomy. Most of this, it is true, is taken from Hippocrates, Galen, and the Arabs, but some of it seems to be the result of his own personal experience, on the living, if not on the dead.

After Richard, the next of the physicians to the Popes who has an important place in the history of medicine is the famous Thaddeus Alderotti, who lived for more than eighty years during the thirteenth century. He has the added interest for this generation of having been a self-made man, for he was the son of very poor parents of the lowest rank. Up to his thirtieth year he remained without any special education. He made his living, it is said, by selling candles. Having acquired a little competency, at the age of thirty he began with great zeal the study of philosophy and of medicine, two sciences which in the old days were supposed to go very well together, though, unfortunately, they are often rigidly separated from each other in later times. Fifteen years after he began the study of medicine we hear of him as a medical teacher, and then ten years later he began to be famous as a writer on all sorts of medical topics. He became the physician of Pope Honorius IV., himself one of the most liberal and broadly educated of men, and as the result of the confidence awakened by his occupancy of this honorable position, he secured an immense success in practice and made an enormous fortune. Alderotti's work represents what is best in medicine for the whole of the thirteenth century.