Education: How Old The New

by James J. Walsh

Lanfranc had been invited to Paris to take the chair of surgery, because the authorities of the university wanted to add prestige to the medical school, which was not as well known as the school [{134}] of philosophy. The fame of William of Salicet had spread throughout academic Europe, and so Lanfranc was offered the chair at the University of Paris in order to carry his master's message there. The next in the succession of great teachers at Paris was Mondeville, who found less to do in an original way than his master Lanfranc and his protomaster William, but who accomplished much for surgery. All that he did was thrown into the shade by what was accomplished for succeeding generations by the next in the series, Guy de Chauliac, who studied for a time in Paris under Mondeville, though his early medical education was obtained at Montpellier, but had also had the advantage of spending a year in Italy at the various medical schools which were famous at that time. These two incidents, Lanfranc's invitation to Paris to be a teacher there from Italy more than a thousand miles away, and Guy de Chauliac's studies in all the important universities of Europe of the time before he took up his own work, illustrate better than any words of ours can the ardent enthusiasm for study, the thoroughgoing anticipation of our most modern methods in education. Mondeville, like Chauliac, had made very nearly the same round of the universities. It is a custom, not a chance incident, that we have to deal with here.

Guy de Chauliac has been given the name of the father of modern surgery. Any one who wants to see why should read the text-book on surgery that [{135}] Chauliac wrote and which for two centuries after his time (he died about the middle of the fourteenth century) continued to be the most used text-book of surgery in the medical schools of Europe. Chauliac, for instance, describes the treatment of conditions within all three of the important cavities of the body, the skull, the thorax and the abdomen. Pagel has three closely-printed pages in small type of titles alone of subjects in surgery which Chauliac treated with distinction. His description of instruments and methods of operation is especially full and suggestive. He describes the passage of a catheter, for instance, with the accuracy and complete technique of a man who knew the difficulties of it in complicated cases from practical experience. He even recognizes the dangers for the patient from the presence of anatomical anomalies of various kinds and describes certain of the more important of them. He has very exact indications for trephining. For empyema he advises opening of the chest and indicates where and how. He says very frankly that in wounds of the abdomen the patient will die if the intestines have been perforated and left untreated, and he describes a method of suturing wounds of the intestines in order to save the patient's life.

His treatment of bone surgery and of fractures and dislocations is especially interesting and shows how far these very practical men had reached conclusions resembling those of our time. [{136}] It was in hernia particularly that Chauliac's surgical genius manifested itself. He operated for hernia and its radical cure, placing the patient in an exaggerated Trendelenberg position, head down, feet fastened to a slanting board. For such work anatomy had to be known very well, and Chauliac had made special studies at Bologna under Bertruccio, the successor of Mondino. Chauliac once declared that the surgeon ignorant of anatomy carves the human body as a blind man would carve wood. Of ulcers of all kinds Chauliac writes from a knowledge evidently derived from experience. Of ulcers due to cancer he has much to say. He considers them hopeless unless they can be excised at a very early stage and the incision followed by caustics. For carcinomatous ulcers there is not much that we can do beyond this, even in our day. It is no wonder that the great historians of medicine have been unanimous in praise of this wonderful scientific genius. For my lecture on "Old-Time Medical Education," before the Johns Hopkins Historical Club, last year, I quoted some of those opinions. Portal, for instance, says of him, "It may be averred that Guy de Chauliac said nearly everything that modern surgeons say and that his work is of infinite price, but unfortunately too little pondered." Malgaigne declares Chauliac's "Chirurgia Magna," "A masterpiece of learned and luminous writing." Pagel says, "Chauliac represents the summit of attainment in mediaeval [{137}] surgery, and he laid the foundation of that primacy in surgery which the French maintained down to the nineteenth century." Professor Clifford Allbutt says of Chauliac's treatise, "This great work I have studied carefully and not without prejudice; yet I cannot wonder that Fallopius compared the author with Hippocrates or that John Freind calls him the prince of surgeons. The book is rich, aphoristic, orderly and precise." In a word it has all the qualities that are usually said to be lacking in the work of mediaeval scientists, and it is a standing reproach to those who ignorantly have made so little of the work of these wonderful men of the olden time, who anticipated so many of the features of our modern medicine and surgery that we are prone to think of as representing climaxes in human progress, indications of a wonderful human evolution.

Two other names of great professors of surgery deserve to be mentioned because they make it very clear that this wonderful development of surgery was not confined to France and Italy, but made itself felt all over Europe. One of these is John Ypermann, a surgeon of the early fourteenth century, of whom almost 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, and at the end of the thirteenth century studied at Paris on a scholarship voted by his native town of Ypres, [{138}] which provided maintenance and tuition fees for him at the great French university expressly in order that he might become expert in surgery. We are likely to think of Ypres as an unimportant town, but it was one of the great industrial centres of Europe and one of the most populous, busy towns of Flanders in the Middle Ages, noted for its manufacture of linens and fine laces. The famous Cloth Hall, erected in the thirteenth century, one of the most beautiful architectural monuments in Europe, and one of the finest buildings of its kind in the world, was the result of the same spirit that sent Ypermann to Paris.

After his return Ypermann settled down in his native town and obtained great renown not only at home, so that in that part of the country an expert surgeon is still spoken of as an Ypermann, but he became famous throughout all the Teutonic countries. He is the author of two books in Flemish. One of these is on medicine. Pagel calls it an unimportant compilation. The terms that occur in it, however, are enough to show us how much more than we are likely to think, these old masters in medicine discussed problems that are still puzzling us. 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, [{139}] bloody urine, diabetes, incontinence of urine, dysuria, strangury, gonorrhea and involuntary seminal emissions--all these terms are quoted directly from Pagel.

His work in medicine, however, is as nothing compared to his writings on surgery. A special feature of his book 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 in the head. Even Pagel's brief account of its contents will be a source of never-ending surprise for those who think that surgery has developed entirely in our time. Even in this work on surgery, however, there are many things that we now treat under medicine. As this gives us an opportunity to show how much more of medicine was known at this time than is usually thought, I venture to quote some of Pagel's brief resume of the contents of a single chapter. This is a chapter devoted to intoxications, which includes the effect of cantharides as well as alcohol, and treats of the bites of snakes, scorpions and of the fatal effects of wounds due to the bite of mad dogs.

The other great surgeon and surgical writer of the time, for there must have been many distinguished surgeons and only a few writers, if we can trust to common experience in that matter, was John Ardern, an English surgeon. He was educated in Montpellier, practised for a time in France, then settled for some years in the [{140}] small town of Newark in Nottinghamshire, and then for nearly thirty years in London. His "Practice of Surgery," as yet existing only in manuscript, is another one of these wonderful contributions to the applied sciences of anatomy and medicine at a time when such applications are often supposed to have been absent. He was an expert operator and had a wide reputation for his success in the treatment of diseases of the rectum. 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 contained numerous illustrations of instruments and operations. We fortunately possess an excellent manuscript copy in the Surgeon General's Library at Washington, and sometime it is hoped this will be edited and published.

The most interesting feature of the work of all of these men is their dependence on personal observation and not on authority. Guy de Chauliac's position in this matter can be very well appreciated from his criticism of John of Gaddesden's book in which he bewails the blind following of those who had gone before. His bitterest reproach for many of his predecessors was that, "They followed one another like cranes, whether for fear or love he would not say." Pagel praises Ypermann for the well-marked striving which he has noted in him to free himself from the bondage of authority, and because most of his therapeutic [{141}] descriptions rest upon his own experience. William of Salicet, at the beginning of this great period of surgery, had insisted that notes of cases were the most valuable sources of wisdom in medicine and surgery. The last of them, Ardern, gave statistics of his cases and was quite as proud as any modern surgeon of the large number that he had operated on. He gives these carefully and accurately.

I have dwelt on the medical side of these universities mainly, of course, because this is more familiar to me as a historian of medicine than their work in other scientific departments, but also to a great extent because the medical schools gathered unto themselves nearly all the scientific knowledge of the time. Botany, mineralogy, climatology, meteorology were all studied for the sake of what could be learned from them for the benefit of medicine. Even astronomy which was then the old astrology, was cultivated seriously, because of the supposed effect of the stars on human constitutions. For this we surely cannot blame these mediaeval students of science since four centuries later Galileo and even Kepler were still making horoscopes for their patrons and laying down laws from astronomy that were supposed to be applicable to medicine. Even Copernicus studied astronomy and medicine side by side and this combination of studies was not at all infrequent.

The medical schools, then, are the real index of [{142}] the serious interest of the mediaeval universities in science. Our scientific departments in modern universities have developed other interests, because of various applications that these have to life and its concerns. Always in scientific universities applied science is sure to encroach upon the domain of pure science, and no one knows that better than we do, for we have been bewailing the presence of machine shops and boiler factories on the university grounds. The old universities did not teach applied mechanics or engineering, but that does not mean that these subjects were not taught. There were special technical schools conducted by the gilds by means of apprenticeship and the journeyman training, which enabled them to teach those who cared to have it all the knowledge necessary for construction work of various kinds. The wonderful architectural engineering exhibited in the cathedrals, university buildings, town halls and castles of this time, and the magnificent bridges, some of which are still in existence, show us that the technical subjects were by no means neglected. [Footnote 9] Our mediaeval forefathers in education had the wisdom not to let the technical subjects interfere with pure science too much, as they inevitably do whenever the two are brought too closely together. Culture is always overshadowed by the practical, but not to the ultimate benefit of the race.