"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 itself 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 scholarship, 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 [{173}] 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 Cambridge, 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 [{174}] 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 division 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 Würtz, 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 histories, 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 forwarded 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 [{175}] 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 Salicet. 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 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.