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

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

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

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

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

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

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

Like many another distinguished member of his profession, Chauliac did not settle down in the scene of his ultimate labors at once, but was something of a wanderer. His own words are, "Et per multa tempora operatus fui in multis partibus." Perhaps out of gratitude to the clerical patrons of his native town to whom he owed so much, or because of the obligations he considered that he owed them for his education, he practised first in his native diocese of Mende; thence he removed to Lyons, where we know that he lived for several years, for in 1344 he took part as a canon in a chapter that met in the Church of St. Just in that city. Just when he was called to Avignon we do not know, though when the black death ravaged that city in 1348 he was the body-physician of Pope Clement VI, for he is spoken of in a Papal document as "venerabilis et circumspectus vir, dominus Guido de Cauliaco, canonicus et praepositus ecclesiae Sancti Justi Lugduni, medicusque domini Nostri Papae." All the rest of his life was passed in the Papal capital, which Avignon was for some seventy years of the fourteenth century. He served as chamberlain-physician to three Popes, Clement VI, Innocent VI, and Urban V. We do not know the exact date of his death, but when Pope Urban V went to Rome in 1367, Chauliac was putting the finishing touches on his "Chirurgia Magna," which, as he tells us, was undertaken as a solatium senectutis—a solace in old age. When Urban returned to Avignon for a time in 1370 Chauliac was dead. His life work is summed up for us in this great treatise on surgery, full of anticipations in surgical procedures that we are prone to think much more modern.

Nicaise has emphasized the principles which guided Guy de Chauliac in the choice and interpretation of his authorities by a quotation from Guy himself, which is so different in its tone from what is usually supposed to have been the attitude of mind of the men of science of the time that it would be well for all those who want to understand the Middle Ages better to have it near them. Speaking of the surgeons of his own and immediately preceding generations, Guy says: "One thing particularly is a source of annoyance to me in what these surgeons have written, and it is that they follow one another like so many cranes. For one always says what the other says. I do not know whether it is from fear or from love that they do not deign to listen except to such things as they are accustomed to and as have been proved by authorities. They have to my mind understood very badly Aristotle's second book of metaphysics where he shows that these two things, fear and love, are the greatest obstacles on the road to the knowledge of the truth. Let them give up such friendships and fears. 'Because while Socrates or Plato may be a friend, truth is a greater friend.' Truth is a holy thing and worthy to be honored above everything else. Let them follow the doctrine of Galen, which is entirely made up of experience and reason, and in which one investigates things and despises words."

After all, this is what great authorities in medicine have always insisted on. Once every hundred years or so one finds a really great observer who makes new observations and wakes the world up. He is surprised that men should not have used their powers of observation for themselves, but should have been following old-time masters. His contemporaries often refuse to listen to him at first. His observations, however, eventually make their way. We blame the Middle Ages for following authority, but what have we been always doing but following authority, except for the geniuses who come and lift us out of the rut and illuminate a new portion of the realm of medicine. After they have come, however, and done their work, their disciples proceed to see with their eyes and to think that they are making observations for themselves when they are merely following authority. When the next master in medicine comes along his discovery is neglected because men have not found it in the old books, and usually he has to suffer for daring to have opinions of his own. The fact of the matter is that at any time there is only a very limited number of men who think for themselves. The rest think other people's thoughts and think they are thinking and doing things. As for observation, John Ruskin once said, "Nothing is harder than to see something and tell it simply as you saw it." This is as true in science as in art, and only genius succeeds in doing it well.

Chauliac's book is confessedly a compilation. He has taken the good wherever he found it, though he adds, modestly enough, that his work also contains whatever his own measure of intelligence enabled him to find useful (quae juxta modicitatem mei ingenii utilia reputavi). Indeed it is the critical judgment displayed by Chauliac in selecting from his predecessors that best illustrates at once the practical character of his intellect and his discerning spirit. What the men of his time are said to have lacked is the critical faculty. They were encyclopedic in intellect and gathered all kinds of information without discrimination, is a very common criticism of medieval writers. No one can say this of Chauliac, however, and, above all, he was no respecter of authority, merely for the sake of authority. His criticism of John of Gaddesden's book shows that the blind following of those who had gone before was his special bete noir. His bitterest reproach for many of his predecessors was that "they follow one another like cranes, whether for love or fear, I cannot say."

Chauliac's right to the title of father of surgery will perhaps be best appreciated from the brief account of his recommendations as to the value of surgical intervention for conditions in the three most important cavities of the body, the skull, the thorax, and the abdomen. These cavities have usually been the dread of surgeons. Chauliac not only used the trephine, but laid down very exact indications for its application. Expectant treatment was to be the rule in wounds of the head, yet when necessary, interference was counselled as of great value. His prognosis of brain injuries was much better than that of his predecessors. He says that he had seen injuries of the brain followed by some loss of brain substance, yet with complete recovery of the patient. In one case that he notes a considerable amount of brain substance was lost, yet the patient recovered with only a slight defect of memory, and even this disappeared after a time. He lays down exact indications for the opening of the thorax, that noli me tangere of surgeons at all times, even our own, and points out the relations of the ribs and the diaphragm, so as to show just where the opening should be made in order to remove fluid of any kind.

In abdominal conditions, however, Chauliac's anticipation of modern views is most surprising. He recognized that wounds of the intestines were surely fatal unless leakage could be prevented. Accordingly he suggested the opening of the abdomen and the sewing up of such intestinal wounds as could be located. He describes a method of suture for these cases and seems, like many another abdominal surgeon, even to have invented a special needleholder.

To most people it would seem absolutely out of the question that such surgical procedures could be practised in the fourteenth century. We have the definite record of them, however, in a text-book that was the most read volume on the subject for several centuries. Most of the surprise with regard to these operations will vanish when it is recalled that in Italy during the thirteenth century, as we have already seen, methods of anaesthesia by means of opium and mandragora were in common use, having been invented in the twelfth century and perfected by Ugo da Lucca, and Chauliac must not only have known but must have frequently employed various methods of anaesthesia.

In discussing amputations he has described in general certain methods of anaesthesia in use in his time, and especially the method by means of inhalation. It would not seem to us in the modern time that this method would be very successful, but there is an enthusiastic accord of authorities attesting that operations were done at this time with the help of this inhalant without the infliction of pain. Chauliac says:

"Some prescribe medicaments which send the patient to sleep, so that the incision may not be felt, such as opium, the juice of the morel, hyoscyamus, mandrake, ivy, hemlock, lettuce. A new sponge is soaked by them in these juices and left to dry in the sun; and when they have need of it they put this sponge into warm water and then hold it under the nostrils of the patient until he goes to sleep. Then they perform the operation."

Many people might be prone to think that the hospitals of Chauliac's time would not be suitable for such surgical work as he describes. It is, however, only another amusing assumption of this self-complacent age of ours to think that we were the first who ever made hospitals worthy of the name and of the great humanitarian purpose they subserve. As a matter of fact, the old-time hospitals were even better than ours or, as a rule, better than any we had until the present generation. In "The Popes and Science," in the chapter on "The Foundation of City Hospitals," I call attention to the fact that architects of the present day go back to the hospitals of the Middle Ages in order to find the models for hospitals for the modern times. Mr. Arthur Dillon, a well-known New York architect, writing of a hospital built at Tonnerre in France, toward the end of the thirteenth century (1292), says:

"It was an admirable hospital in every way, and it is doubtful if we to-day surpass it. It was isolated; the ward was separated from the other buildings; it had the advantage we so often lose of being but one story high, and more space was given to each patient than we can now afford.

"The ventilation by the great windows and ventilators in the ceiling was excellent; it was cheerfully lighted; and the arrangement of the gallery shielded the patients from dazzling light and from draughts from the windows and afforded an easy means of supervision, while the division by the roofless low partitions isolated the sick and obviated the depression that comes from sight of others in pain.

"It was, moreover, in great contrast to the cheerless white wards of to-day. The vaulted ceiling was very beautiful; the woodwork was richly carved, and the great windows over the altars were filled with colored glass. Altogether it was one of the best examples of the best period of Gothic Architecture."[24]

The fine hospital thus described was but one of many. Virchow, in his article on hospitals quoted in the same chapter, called attention to the fact that in the thirteenth and fourteenth centuries every town of five thousand or more inhabitants had its hospital, founded on the model of the great Santo Spirito Hospital in Rome, and all of them did good work. The surgeons of Guy de Chauliac's time would indeed find hospitals wherever they might be called in consultation, even in small towns. They were more numerous in proportion to population than our own and, as a rule, at least as well organized as ours were until the last few years.

It is no wonder that with such a good hospital organization excellent surgery was accomplished. Hernia was Chauliac's specialty, and in it his surgical judgment is admirable. Mondeville before his time did not hesitate to say that many operations for hernia were done not for the benefit of the patient, but for the benefit of the surgeon,—a very striking anticipation of remarks that one sometimes hears even at the present time. Chauliac discussed operations for hernia very conservatively. His rule was that a truss should be worn, and no operation attempted unless the patient's life was endangered by the hernia. It is to him that we owe the invention of a well-developed method of taxis, or manipulation of a hernia, to bring about its reduction, which was in use until the end of the nineteenth century. He suggested that trusses could not be made according to rule, but must be adapted to each individual case. He invented several forms of truss himself, and in general it may be said that his manipulative skill and his power to apply his mechanical principles to his work are the most characteristic of his qualities. This is particularly noteworthy in his chapters on fractures and dislocations, in which he suggests various methods of reduction and realizes very practically the mechanical difficulties that were to be encountered in the correction of the deformities due to these pathological conditions. In a word, we have a picture of the skilled surgeon of the modern time in this treatise of a fourteenth-century teacher of surgery.

Chauliac discusses six different operations for the radical cure of hernia. As Gurlt points out, he criticises them from the same standpoint as that of recent surgeons. The object of radical operations for hernia is to produce a strong, firm tissue support over the ring through which the cord passes, so that the intestines cannot descend through it. It is rather interesting to find that the surgeons of this time tried to obliterate the canal by means of the cautery, or inflammation producing agents, arsenic and the like, a practice that recalls some methods still used more or less irregularly. They also used gold wire, which was to be left in the tissues and is supposed to protect and strengthen the closure of the ring. At this time all these operations for the radical cure of hernia involved the sacrifice of the testicle because the old surgeons wanted to obliterate the ring completely, and thought this the easiest way. Chauliac discusses the operation in this respect and says that he has seen many cases in which men possessed of but one testicle have procreated, and this is a case where the lesser of two evils is to be chosen.

Of course Guy de Chauliac would not have been able to operate so freely on hernia and suggest, following his own experience, methods of treatment of penetrating wounds of the abdomen only that he had learned the lessons of antiseptic surgery which had been gradually developed among the great surgeons of Italy during the preceding century. The use of the stronger wines as a dressing together with insistence on the most absolute cleanliness of the surgeon before the operation, and careful details of cleanliness during the operation, made possible the performance of many methods of surgical intervention that would otherwise surely have been fatal. Probably nothing is harder to understand than that after these practical discoveries men should have lost sight of their significance, and after having carefully studied the viscous exudation which produces healthy natural union, should have come to the thought of the necessity for the formation of laudable pus before union might be expected. The mystery is really no greater than that of many another similar incident in human history, but it strikes us more forcibly because the discovery and gradual development of antiseptic surgery in our own time has meant so much for us. Already even in Chauliac's practice, however, some of the finer elements of the technique that made surgery antiseptic to a marked degree, if not positively aseptic in many cases, were not being emphasized as they were by his predecessors, and there was a beginning of surgical meddlesomeness reasserting itself.

It must not be thought, however, that it was only with the coarse applications of surgery that Chauliac concerned himself. He was very much interested in the surgical treatment of eye diseases and wrote a monograph on cataract, in which he gathers what was known before his time and discusses it in the light of his own experience. The writing of such a book is not so surprising at this time if we recall that in the preceding century the famous Pope John XXI, who had been a physician before he became Pope, and under the name of Peter of Spain was looked up to as one of the distinguished scientists of his time, had written a book on eye diseases that has recently been the subject of much attention.

Pope John had much to say of cataract, dividing it into traumatic and spontaneous, and suggesting the needling of cataract, a gold needle being used for the purpose. Chauliac's method of treating cataract was by depression. His care in the selection of patients may be appreciated from his treatment of John of Luxembourg, King of Bavaria, blind from cataract, who consulted Chauliac in 1336 while on a visit to Avignon with the King of France. Chauliac refused to operate, however, and put off the King with dietary regulations.

In the chapter on John of Arcoli and Medieval Dentistry we call attention to the fact that Chauliac discussed dental surgery briefly, yet with such practical detail as to show very clearly how much more was known about this specialty in his time than we have had any idea of until recent years. He recognized the dentists as specialists, calls them dentatores, but thinks that they should operate under the direction of a physician—hence the physician should know much about teeth and especially about their preservation. He enumerates instruments that dentists should have and shows very clearly that the specialty had reached a high state of development. A typical example of Chauliac's common sense and dependence on observation and not tradition is to be found in what he has to say with regard to methods of removing the teeth without the use of extracting instruments. It is characteristic of his method of dealing with traditional remedies, even though of long standing, that he brushes them aside with some impatience if they have not proved themselves in his experience.

"The ancients mention many medicaments, which draw out the teeth without iron instruments or which make them more easy to draw out; such as the milky juice of the tithymal with pyrethrum, the roots of the mulberry and caper, citrine arsenic, aqua fortis, the fat of forest frogs. But these remedies promise much and accomplish but little—mais ils donnent beaucoup de promesses, et peu, d'operations."

It is no wonder that Chauliac has been enthusiastically praised. Nicaise has devoutly gathered many of these praises into a sheaf of eulogies at the end of his biography of the great French surgeon. He tells us that Fallopius compared him to Hippocrates. John Calvo of Valencia, who translated the "Great Surgery" into Spanish, looks upon him as the first law-giver of surgery. Freind, the great English physician, in 1725 called him the Prince of Surgeons. Ackermann said that Guy de Chauliac's text-book will take the place of all that has been written on the subject down to his time, so that even if all the other works had been lost his would replace them. Dezimeris, commenting on this, says that "if one should take this appreciation literally, this surgeon of the fourteenth century would be the first and, up to the present time, the only author who ever merited such an eulogy." "At least," he adds, "we cannot refuse him the distinction of having made a work infinitely superior to all those which appeared up to this time and even for a long time afterwards. Posterity rendered him this justice, for he was for three centuries the classic par excellence. He rendered the study easy and profitable, and all the foreign nations the tributaries of our country." Peyrihle considered Guy's "Surgery" as the most valuable and complete work of all those of the same kind that had been published since Hippocrates and added that the reading of it was still useful in his time in 1784. Begin, in his work on Ambroise Pare, says "that Guy has written an immortal book to which are attached the destinies of French surgeons." Malgaigne, in his "History of Surgery," does not hesitate to say, "I do not fear to say that, Hippocrates alone excepted, there is not a single treatise on surgery,—Greek, Latin, or Arabic,—which I place above, or even on the same level with, this magnificent work, 'The Surgery of Guy de Chauliac.'" Daremberg said, "Guy seems to us a surgeon above all erudite, yet expert and without ever being rash. He knows, above all, how to choose what is best in everything." Verneuil, in his "Conference sur Les Chirurgiens Erudits," says, "The services rendered by the 'Great Surgery' were immense; by it there commenced for France an era of splendor. It is with justice, then, that posterity has decreed to Guy de Chauliac the title of Father of French surgery."

The more one reads of Chauliac's work the less is one surprised at the estimation in which he has been held wherever known. It would not be hard to add a further sheaf of compliments to those collected by Nicaise. Modern writers on the history of medicine have all been enthusiastic in their admiration of him, just in proportion to the thoroughness of their acquaintance with him. Portal, in his "History of Anatomy and Surgery," says, "Finally, it may be averred that Guy de Chauliac said nearly everything which modern surgeons say, and that his work is of infinite price but unfortunately too little read, too little pondered." Malgaigne declares Chauliac's "Chirurgia Magna" to be "a masterpiece of learned and luminous writing." Professor Clifford Allbutt, the Regius Professor of Physic at the University of Cambridge, says of Chauliac's treatise: "This great work I have studied carefully and not without prejudice; yet I cannot wonder that Fallopius compared the author to Hippocrates or that John Freind calls him the Prince of Surgeons. It is rich, aphoristic, orderly, and precise."[25]

If to this account of his professional career it be added that Chauliac's personality is, if possible, more interesting than his surgical accomplishment, some idea of the significance of the life of the great father of modern surgery will be realized. We have already quoted the distinguished words of praise accorded him by Pope Clement VI. That they were well deserved, Chauliac's conduct during the black death which ravaged Avignon in 1348, shortly after his arrival in the Papal City, would have been sufficient of itself to attest. The occurrence of the plague in a city usually gave rise to an exhibition of the most arrant cowardice, and all who could, fled. In many of the European cities the physicians joined the fugitives, and the ailing were left to care for themselves. With a few notable exceptions, this was the case at Avignon, but Guy was among those who remained faithful to his duty and took on himself the self-sacrificing labor of caring for the sick, doubly harassing because so many of his brother physicians were absent. He denounces their conduct as shameful, yet does not boast of his own courage, but on the contrary says that he was in constant fear of the disease. Toward the end of the epidemic he was attacked by the plague and for a time his life was despaired of. Fortunately he recovered, to become the most influential among his colleagues, the most highly admired of the physicians of his generation, and the close personal friend of all the high ecclesiastics, who had witnessed his magnificent display of courage and of helpfulness for the plague-stricken during the epidemic. He wrote a very clear account of the epidemic, which leaves no doubt that it was true bubonic plague.

After this fine example, Chauliac's advice to brother physicians in the specialty of surgery carried added weight. In the Introductory chapter of his "Chirurgia Magna" he said:

"The surgeon should be learned, skilled, ingenious, and of good morals. Be bold in things that are sure, cautious in dangers; avoid evil cures and practices; be gracious to the sick, obliging to his colleagues, wise in his predictions. Be chaste, sober, pitiful, and merciful; not covetous nor extortionate of money; but let the recompense be moderate, according to the work, the means of the sick, the character of the issue or event, and its dignity."

No wonder that Malgaigne says of him, "Never since Hippocrates has medicine heard such language filled with so much nobility and so full of matter in so few words."

Chauliac was in every way worthy of his great contemporaries and the period in which his lot was cast. Ordinarily we are not apt to think of the early fourteenth century as an especially productive period in human history, but such it is. Dante's Divine Comedy was entirely written during Chauliac's life. Petrarch was born within a few years of Chauliac himself; Boccaccio in Italy, and Chaucer in England, wrote while Chauliac was still alive. Giotto did his great painting, and his pupils were laying the deep, firm foundations of modern art. Many of the great cathedrals were being finished. Most of the universities were in the first flush of their success as moulders of the human mind. There are few centuries in history that can show the existence of so many men whose work was to have an enduring influence for all the after time as this upon which Chauliac's career shed so bright a light. The preceding century had seen the origin of the universities and the rise of such supremely great men as Albertus Magnus, Roger Bacon, Thomas Aquinas, and the other famous scholars of the early days of the mendicant orders, and had made the intellectual mould of university training in which men's minds for seven centuries were to be formed, so that Chauliac, instead of being an unusual phenomenon is only a fitting expression of the interest of this time in everything, including the physical sciences and, above all, medicine and surgery.

For some people it may be a source of surprise that Chauliac should have had the intellectual training to enable him to accomplish such judicious work in his specialty. Many people will be apt to assume that he accomplished what he did in spite of his training, genius succeeding even in an unfavorable environment, and notwithstanding educational disadvantages. Those who would be satisfied with any such explanation, however, know nothing of the educational opportunities provided in the period of which Chauliac was the fruit. He is a typical university man of the beginning of the fourteenth century, and the universities must be given due credit for him. It is ordinarily assumed that the universities paid very little attention to science and that scientists would find practically nothing to satisfy in their curricula. Professor Huxley in his address on "Universities, Actual and Ideal," delivered as the Rectorial Address at Aberdeen University in 1874, declared that they were probably educating in the real sense of the word better than we do now. (See quotation in "The Medical School at Salerno.")

In the light of Chauliac's life it is indeed amusing to read the excursions of certain historians into the relationship of the Popes and the Church to science during the Middle Ages. Chauliac is typically representative of medieval science, a man who gave due weight to authority, yet tried everything by his own experience, and who sums up in himself such wonderful advance in surgery that during the last twenty years the students of the history of medicine have been more interested in him than in anyone who comes during the intervening six centuries. Chauliac, however, instead of meeting with any opposition, encountered encouragement, liberal patronage, generous interest, and even enjoyed the intimate friendship of the highest ecclesiastics and the Popes of his time. In every way his life may be taken as a type of what we have come to know about the Middle Ages, when we know them as we should, in the lives of the men who counted for most in them, and do not accept merely the broad generalizations which are always likely to be deceptive and which in the past have led men into the most absurd and ridiculous notions with regard to a wonderful period in human history.

That Guy de Chauliac was no narrow specialist is abundantly evident from his book, for while the "Great Surgery" treats of the science and art of surgery as its principal subject, there are remarks about nearly everything else relating to medicine, and most of them show a deep interest, a thorough familiarity, and an excellent judgment. Besides we have certain expressions with regard to intellectual matters generally which serve to show Guy as a profound thinker, who thoroughly appreciated just how accumulations of knowledge came to men and how far each generation or member of a generation should go and yet how limited must, after all, be the knowledge obtained by any one person. With regard to books, for instance, he said, "for everyone cannot have all the books, and even if he did have them it would be too tiresome to read them all and completely, and it would require a godlike memory to retain them all." He realized, however, that each generation, provided it took the opportunities offered it, was able to see a little bit farther than its predecessor, and the figure that he employs to express this is rather striking. "Sciences," he said, "are made by additions. It is quite impossible that the man who begins a science should finish it. We are like infants, clinging to the neck of a giant; for we can see all the giant sees and a little more."

One of the most interesting features of the history of Guy de Chauliac is the bibliography of his works which has been written by Nicaise. This is admirably complete, labored over with the devotion that characterized Nicaise's attitude of unstinted admiration for the subject. Altogether he has some sixty pages of a quarto volume with regard to the various editions of Guy's works.

The first manuscript edition of Guy de Chauliac was issued in 1363, the first printed edition in 1478. Even in the fourteenth century Guy's great work was translated into all the languages generally used in Europe. Nicaise succeeded in placing 34 complete manuscripts of the "Great Surgery": 22 of these are in Latin, 4 are in French, 3 are in English, 2 only in Provencal, though that was the language spoken in the region where much of Chauliac's life was passed, and one each in Italian, in Low Dutch, and in Hebrew. Of the English manuscripts, one is number twenty-five English of the Bibliotheque Nationale, Paris; a second is number 3666 English of the Sloane collection in the British Museum, and a third is in the Library of the University of Cambridge.[26]

Paulin Paris, probably one of the best of recent authorities on the age and significance of old manuscripts, says in the third volume of his "Manuscrits Francais," page 346, "This manuscript [of Guy de Chauliac's "Great Surgery"] was made, if not during the life, then certainly very shortly after the death of the author. It is one of the oldest that can be cited, and the fact that an English translation was made so near to the time of the original composition of the book attests the great reputation enjoyed by Guy de Chauliac at this time, and which posterity has fully confirmed."

The Sloane copy in the British Museum contains some medical recipes at the end by Francis Verney. It was probably written in the fifteenth century. Its title is:

"The inventorie or the collectorie in cirurgicale parte of medicine compiled and complete in the yere of our Lord 1363, with some additions of other doctours, necessary to the foresaid arte or crapte (crafte?)."[27]

What we find in the period of manuscripts, however, is as nothing compared to the prestige of Guy de Chauliac's work, once the age of printing began. Nicaise was able to find sixty different printed editions of the "Great Surgery." Nine others that are mentioned by authors have disappeared and apparently no copies of them are in existence. Besides there are sixty editions of portions of the work, of compendiums of it and commentaries on it. Altogether 129 editions are extant. Of these there are sixteen Latin editions, forty-three French, five Italian, four Low Dutch, five Catalan, and one English. Fourteen appeared in the fifteenth century, thirty-eight in the sixteenth century, and seventeen in the seventeenth century. The fourteen editions belonging to the incunabula of printing, issued, that is, before the end of the fifteenth century, show what lively interest there was in the French surgeon of the preceding century, since printing presses at this precious time were occupied only with the books that were considered indispensable for scholars. The first edition of the "Great Surgery" was printed in 1478 at Lyons. Printing had only been introduced there five years before. This first edition, primus primarius or editio princeps, was a French translation by Nicholas Panis. In 1480 an Italian edition was printed at Venice. The first Latin edition was printed also in Venice in 1490.

It would be only natural to expect that the successors of Guy de Chauliac, and especially those who had come personally in contact with him, would take advantage of his thorough work to make still further advances in surgery. As matter of fact, decadence in surgery is noted immediately after his death. Three men taught at the University of Montpellier at the end of the fourteenth and the beginning of the fifteenth century, John de Tornamira, Valesco de Taranta, and John Faucon. They cannot be compared, Gurlt says, with Guy de Chauliac, though they were physicians of reputation in their time. Faucon made a compendium of Guy's work for students. Somehow there seemed to be the impression that surgery had now reached a point of development beyond which it could not advance. Unfortunate political conditions, wars, the withdrawal of the Popes from Avignon to Rome, and other disturbances, distracted men's minds, and surgery deteriorated to a considerable extent, until the new spirit at the time of the Renaissance came to inject fresh life into it.



XII

MEDIEVAL DENTISTRY—GIOVANNI OF ARCOLI

If there is one phase of our present-day medicine and surgery that most of us are likely to be quite sure is of very recent development it is dentistry. Probably most people would declare at once that they had every reason to think that the science and art of dentistry, as we have it now, developed for the first time in the world's history during the last generation or two. It is extremely interesting to realize then, in the light of this almost universal persuasion, founded to a great extent on the conviction that man is in process of evolution and that as a consequence we must surely be doing things now that men never did before, to find that dentistry, both as an art and science, is old; that it has developed at a number of times in the world's history, and that as fortunately for history its work was done mainly in indestructible materials, the teeth themselves and metal prosthetic apparatus, we have actual specimens of what was accomplished at a number of periods in the olden times. Surprising as it will seem to those who hear of it for the first time, dentistry reached high perfection even in what we know as ancient history. It is rather easy to trace scientific and craftsmanlike interest in it during the medieval period and in the magnificent development of surgery that came just at the end of the Middle Ages, dentistry shared to such degree that some of the text-books of the writers on surgery of this time furnish abundant evidence of anticipations of many of the supposedly most modern developments of dentistry.

There are a number of historical traditions with regard to dentistry and the treatment of the teeth in Egypt that can be traced back to good authorities in Egyptology of a generation or more ago, but it is rather hard to confirm the accounts we have by actual specimens; either none were found or for some reason those actually discovered are now not readily available for study. Among the Phenicians however, though we have good reasons to think that they learned their arts and crafts from the Egyptians, there is convincing evidence of a high development of dentistry. M. Ernest Renan, during an exploring expedition in Phenicia, found in the old necropolis at Sidon a set of teeth wired together, two of which were artificial. It was a striking example of bridgework, very well done, and may now be seen in the Louvre. It would be more than a little surprising, from what we know of the lack of inventiveness on the part of the Phenicians and their tendency to acquire their arts by imitation, if they had reached such a climax of invention by themselves. Since they adapted and adopted most of their arts and crafts from Egypt, with which they were in close commercial relations, it has been argued with some plausibility that the Egyptians may have had many modes of dental prosthesis, but removed all artificial teeth and dental appliances from the mouth of corpses before embalming them, in preparation for the next world, because there was some religious objection to such human handiwork being left in place for the hereafter, as they hoped for it.

There is a well-authenticated tradition of intimate intercourse in a commercial way between the old Etruscans who inhabited the Italian hill country and the Phenicians, so that it is no surprise to find that the oldest of Etruscan tombs contain some fine examples of bridgework. An improvement has come over Phenician work however, and bands of gold instead of wire are used for holding artificial teeth in place. Guerini, whose "History of Dentistry" is the standard work on the subject, on a commission from the Italian government, carefully studied these specimens of Etruscan dental work in the museums of Italy, and has made some interesting observations on them. In one specimen, which is especially notable, two incisor teeth are replaced by a single tooth from a calf. This was grooved in such a way as to make it seem like two separate teeth. Guerini suggests a very interesting and quite unexpected source for this. While examining the specimen he wondered where the old Etruscan dentist had obtained a calf's tooth without a trace of wear on it. He came to the conclusion that he must have cut into the gums of a young calf before the permanent tooth was erupted in order to get this structure absolutely unworn for his purpose. A number of examples of bridgework have been found in the old Etruscan tombs. The dates of their construction are probably not later than 500 B.C., and some of them are perhaps earlier than 700 B.C.

The Etruscans affected the old Romans in the matter of dentistry, so that it is easy to understand the passage in the "Laws of the Twelve Tables," issued about 450 B.C., which, while forbidding the burial of gold with corpses, made a special exception for such gold as was fastened to the teeth. Gold was rare at Rome, and care was exercised not to allow any unnecessary decrease of the visible supply almost in the same way as governments now protect their gold reserves. It may seem like comparing little things with great, but the underlying principle is the same. Hence this special law and its quite natural exception.

In Pope Julius' Museum in Rome there is a specimen of a gold cap made of two plates of gold riveted together and also riveted to bands of metal which were fastened around the neighboring teeth in order to hold the cap in place. This is from later Republican times at Rome. At the end of the Republic and the beginning of the Empire there appear to have been many forms of dental appliances. Martial says that the reason why one lady's teeth—whose name he does not conceal—are white and another's—name also given—were dark, was that the first one bought hers and the second still had her own. In another satiric poem he describes an elderly woman as so much frightened that when she ran away her teeth fell out, while her friends lost their false hair. Fillings of many kinds were used, dentrifices of nearly every kind were invented, and dentistry evidently reached a high stage of development, though we have nowhere a special name for dentist, and the work seems to have been done by physicians, who took this as a specialty.

While in the Middle Ages there was, owing to conditions, a loss of much of this knowledge of antiquity with regard to dentistry, or an obscuration of it, it never disappeared completely, and whenever men have written seriously about medicine, above all about surgery in relation to the face and the mouth, the teeth have come in for their share of scientific and practical consideration. Aetius, the first important Christian writer on medicine and surgery, discusses, as we have seen in the sketch of him, the nutrition of the teeth, their nerves, "which came from the third pair and entered the teeth by a small hole existing at the end of the root," and other interesting details of anatomy and physiology. He knows much about the hygiene of the teeth, discusses extraction and the cure of fistula and other details. Paul of AEgina in the next century has much more, and while they both quote mainly from older authors there seems no doubt that they themselves had made not a few observations and had practical experience.

It was from these men that the Arabian physicians and surgeons obtained their traditions of medicine, and so it is not surprising to find that they discuss dental diseases and their treatment rationally and in considerable detail. Abulcasis particularly has much that is of significance and interest. We have pictures of two score of dental instruments that were used by them. The Arabs not only treated and filled carious teeth and even replaced those that were lost, but they also corrected deformities of the mouth and of the dental arches. Orthodontia is sometimes said to be of much later origin and to begin many centuries after Abulcasis' time, yet no one who knows of his work can speak of Orthodontia as an invention after him. In this, however, as in most of the departments of medicine and surgery, the Arabs were merely imitators, though probably they expanded somewhat the practical knowledge that had come to them.

When the great revival in surgery came in the twelfth and thirteenth centuries it is not surprising that there should also have been an important renewal of interest in dentistry. A detailed review of this would take us too far afield, but at least something may be said of two or three of the great representative surgical writers who touched on this specialty.

About the middle of the fourteenth century that prince of surgeons, and model of surgical writers, Guy de Chauliac, wrote his great text-book of surgery, "Le Grande Chirurgie." An extremely interesting feature of this work is to be found in the chapters that treat of diseases of the teeth. These are not very comprehensive, and are evidently not so much the result of his experience, as the fruit of his reading, yet they contain many practical valuable ideas that are supposed to be ever so much later than the middle of the fourteenth century. His anatomy and physiology at least are not without many errors. His rules for the preservation of the teeth show that the ordinary causes of dental decay were well recognized even as early as this. Emphasis was laid on not taking foods too hot or too cold, and above all not to follow either hot or cold food by something very different from it in temperature. The breaking of hard things with the teeth was recognized as one of the most frequent causes of such deterioration of the enamel as gives opportunity for the development of decay. The eating of sweets, and especially the sticky sweets—preserves and the like—was recognized as an important source of caries. The teeth were supposed to be cleaned frequently, and not to be cleaned too roughly, for this would do more harm than good. We find these rules repeated by succeeding writers on general surgery, who touch upon dentistry, or at least the care of the teeth, and they were not original with Guy de Chauliac, but part of the tradition of surgery.

As noted by Guerini in his "History of Dentistry," the translation of which was published under the auspices of the National Dental Association of the United States of America,[28] Chauliac recognized the dentists as specialists. Besides, it should be added, as is evident from his enumeration of the surgical instruments which he declares necessary for them, they were not as we might easily think in the modern time mere tooth pullers, but at least the best among them treated teeth as far as their limited knowledge and means at command enabled them to do so, and these means were much more elaborate than we have been led to think, and much more detailed than we have reason to know that they were at certain subsequent periods.

In fact, though Guy de Chauliac frankly confesses that he touches on the subject of dentistry only in order to complete his presentation of the subject of surgery and not because he has anything of his own to say with regard to the subject, there is much that is of present-day interest in his brief paragraphs. He observes that operations on the teeth are special and belong to the dentatores, or dentists, to whom doctors had given them over. He considers, however, that the operations in the mouth should be performed under the direction of a physician. It is in order to give physicians the general principles with which they may be able to judge of the advisability or necessity for dental operations that his short chapters are written. If their advice is to be of value, physicians should know the various methods of treatment suitable for dental diseases, including mouth washes, gargles, masticatories, anointments, rubbings, fumigations, cauterizations, fillings, filings, and the various manual operations. He says that the dentator must be provided with the appropriate instruments, among which he names scrapers, rasps, straight and curved spatumina, elevators, simple and with two branches, toothed tenacula, and many different forms of probes and canulas. He should also have small scalpels, tooth trephines, and files.

Chauliac is particularly emphatic in his insistence on not permitting alimentary materials to remain in cavities, and suggests that if cavities between the teeth tend to retain food material they should even be filed in such a way as to prevent these accumulations. His directions for cleansing the teeth were rather detailed. His favorite treatment for wounds was wine, and he knew that he succeeded by means of it in securing union by first intention. It is not surprising, then, to find that he recommends rinsing of the mouth with wine as a precaution against dental decay. A vinous decoction of wild mint and of pepper he considered particularly beneficial, though he thought that dentifrices, either powder or liquid, should also be used. He seems to recommend the powder dentifrices as more efficacious. His favorite prescription for a tooth powder, while more elaborate, resembles to such an extent, at least some, if not indeed most of those, that are used at the present time, that it seems worth while giving his directions for it. He took equal parts of cuttle bone, small white sea-shells, pumice stone, burnt stag's horn, nitre, alum, rock salt, burnt roots of iris, aristolochia, and reeds. All of these substances should be carefully reduced to powder and then mixed. His favorite liquid dentifrice contained the following ingredients,—half a pound each of sal ammoniac and rock salt, and a quarter of a pound of sacharin alum. All these were to be reduced to powder and placed in a glass alembic and dissolved. The teeth should be rubbed with it, using a little scarlet cloth for the purpose. Just why this particular color of cleansing cloth was recommended is not quite clear.

He recognized, however, that cleansing of the teeth properly often became impossible by any scrubbing method, no matter what the dentifrice used, because of the presence of what we call tartar and what he called hardened limosity or limyness (limosite endurcie). When that condition is present he suggests the use of rasps and spatumina and other instrumental means of removing the tartar.

Evidently he did not believe in the removal of the teeth unless this was absolutely necessary and no other method of treatment would avail to save the patient from continuous distress. He summarizes the authorities with regard to the extraction of teeth and the removal of dental fragments and roots. He evidently knew of the many methods suggested before his time of removing teeth without recourse to instrumental extraction. There were a number of applications to the gums that were claimed by older authors to remove the teeth without the need of metal instruments. We might expect that Chauliac would detect the fallacy with regard to these and expose it. He says that while much is claimed for these methods he has never seen them work in practice and he distrusts them entirely.

The most interesting phase of what Guy de Chauliac has to say with regard to dentistry is of course to be found in his paragraphs on the artificial replacement of lost teeth and the subject of dental prosthesis generally. When teeth become loose he advises that they be fastened to the healthy ones with a gold chain. Guerini suggests that he evidently means a gold wire. If the teeth fall out they may be replaced by the teeth of another person or with artificial teeth made from oxbone, which may be fixed in place by a fine metal ligature. He says that such teeth may be serviceable for a long while. This is a rather curt way of treating so large a subject as dental prosthesis, but it contains a lot of suggestive material. He was quoting mainly the Arabian authors, and especially Abulcasis and Ali Abbas and Rhazes, and these of course, as we have said, mentioned many methods of artificially replacing teeth as also of transplantation and of treatment of the deformities of the dental arches.

On the whole, however, it must be confessed that we have here in the middle of the fourteenth century a rather surprising anticipation of the knowledge of a special department of medicine which is usually considered to be distinctly modern, and indeed as having only attracted attention seriously in comparatively recent times.

After Guy de Chauliac the next important contributor to dentistry is Giovanni of Arcoli, often better known by his Latin name, Johannes Arculanus, who was a professor of medicine and surgery at Bologna and afterwards at Padua, just before and after the middle of the fifteenth century, and who died in 1484. He is famous principally for being the first we know who mentions the filling of teeth with gold.

It might possibly be suggested that coming at this time Arculanus should rather be reckoned as a Maker of Medicine in the Renaissance than as belonging to the Middle Ages and its influences. His education, however, was entirely completed before the earliest date at which the Renaissance movement is usually said to begin, that is with the fall of Constantinople in 1452, and he was dead before the other date, that of the discovery of America in 1492, which the Germans have in recent years come to set down as the end of the Middle Ages. Besides, what he has to say about dentistry occurs in typical medieval form. It is found in a commentary on Rhazes, written just about the middle of the fifteenth century. In the later true Renaissance such a commentary would have been on a Greek author. In his commentary Arculanus touches on most of the features of medicine and surgery from the standpoint of his own experience as well as from what he knows of the writings of his predecessors and contemporaries. With the rest he has a series of chapters on diseases of the teeth. Guerini in his "History of Dentistry" says that "this subject [dentistry] is treated rather fully, and with great accuracy." Even some short references to it will, I think, demonstrate this rather readily.[29]

Arculanus is particularly full in his directions for the preservation of the teeth. We are rather prone to think that prophylaxis is comparatively a modern idea, and that most of the principles of conservation of human tissues and the prevention of deterioration and disease are distinctly modern. It needs only a little consideration of Arculanus' instruction in the matter of the teeth, however, to undo any such false impression. For obvious reasons I prefer to quote Guerini's summation of this medieval student of dentistry's rules for dental hygiene:

"For the preservation of teeth—considered by him, quite rightly, a matter of great importance—Giovanni of Arcoli repeats the various counsels given on the subject by preceding writers, but he gives them as ten distinct canons or rules, creating in this way a kind of decalogue of dental hygiene. These rules are: (1) It is necessary to guard against the corruption of food and drink within the stomach; therefore, easily corruptible food—milk, salt fish, etc.—must not be partaken of, and after meals all excessive movement, running exercises, bathing, coitus, and other causes that impair the digestion, must also be avoided. (2) Everything must be avoided that may provoke vomiting. (3) Sweet and viscous food—such as dried figs, preserves made with honey, etc.—must not be partaken of. (4) Hard things must not be broken with the teeth. (5) All food, drink, and other substances that set the teeth on edge must be avoided. (6) Food that is too hot or too cold must be avoided, and especially the rapid succession of hot and cold, and vice versa. (7) Leeks must not be eaten, as such a food, by its own nature, is injurious to the teeth. (8) The teeth must be cleaned at once, after every meal, from the particles of food left in them; and for this purpose thin pieces of wood should be used, somewhat broad at the ends, but not sharp-pointed or edged; and preference should be given to small cypress twigs, to the wood of aloes, or pine, rosemary, or juniper and similar sorts of wood which are rather bitter and styptic; care must, however, be taken not to search too long in the dental interstices and not to injure the gums or shake the teeth. (9) After this it is necessary to rinse the mouth by using by preference a vinous decoction of sage, or one of cinnamon, mastich, gallia, moschata, cubeb, juniper seeds, root of cyperus, and rosemary leaves. (10) The teeth must be rubbed with suitable dentrifices before going to bed, or else in the morning before breakfast. Although Avicenna recommended various oils for this purpose, Giovanni of Arcoli appears very hostile to oleaginous frictions, because he considers them very injurious to the stomach. He observes, besides, that whilst moderate frictions of brief duration are helpful to the teeth, strengthen the gums, prevent the formation of tartar, and sweeten the breath, too rough or too prolonged rubbing is, on the contrary, harmful to the teeth, and makes them liable to many diseases."

All this is so modern in many ways that we might expect a detailed exact knowledge of the anatomy of the teeth and even something of their embryology from Arculanus. It must not be forgotten, however, that coming as he does before the Renaissance, the medical sciences in the true sense of the word are as yet unborn. Men are accumulating information for practical purposes but not for the classification and co-ordination that was to make possible the scientific development of their knowledge.

Giovanni of Arcoli's acquaintance with the anatomy of the teeth was rather sadly lacking. He does not know even with certainty the number of roots that the teeth have. This has been attributed to the fact that he obtained most of his information from books, and had not the time to verify descriptions that he had found. It has been argued from this that he was himself probably not a practical dentist, and turned to that specialty only as a portion of his work as a general surgeon, and that consequently he was not sufficiently interested to verify his statements. His chapters on dentistry would seem to bear out this conclusion to some extent, though the very fact that one who was himself not specially interested in dental surgery should have succeeded in gathering together so much that anticipates modern ideas in dentistry, is of itself a proof of how much knowledge of the subject there was available for a serious student of that time. The anatomy of the teeth continued to be rather vague until about the middle of the next century when Eustachius, whose investigations of the anatomy of the head have deservedly brought him fame and the attachment of his name to the Eustachian canal, wrote his "Libellus de Dentibus—Manual of the Teeth," which is quite full, accurate, and detailed. Very little has been added to the microscopic anatomy of the teeth since Eustachius' time. He had the advantage, of course, of being intimately in contact with the great group of Renaissance anatomists,—Vesalius, Columbus, Varolius, Fallopius, and the others, the great fathers of anatomy. Besides, his position as Papal Physician and Professor of Anatomy at the Papal Medical School at Rome gave him opportunities for original investigation, such as were not easily obtained elsewhere.

Arculanus can scarcely be blamed, therefore, for not having anticipated the Renaissance, and we must take him as merely the culmination of medieval knowledge with regard to anatomy and surgery. Medieval medical men did not have the time nor apparently the incentive to make formal medical science, though it must not be forgotten, as has been said, that they did use the knowledge they obtained by their own and others' observation to excellent advantage for the practical benefit of ailing humanity. The sciences related to medicine are conscious developments that follow the evolution of practical medicine, nor must it be forgotten that far from always serving as an auxiliary to applied medical science, often indeed in the history of medicine scientific pursuits have led men away into side issues from which they had to be brought back by some genius medical observer. As might be expected, then, it is with regard to the practical treatment and general consideration of ailments of the teeth that Giovanni of Arcoli is most interesting. In this some of his chapters contain a marvellous series of surprises.

Arculanus was probably born towards the end of the fourteenth century. The date of his death is variously placed as either 1460 or 1484, with the probability in favor of the former. From 1412 to 1427 he was professor at Bologna, where in accordance with the non-specializing tendencies of the time he did not occupy a single chair but several in succession. He seems first to have taught Logic, then Moral Philosophy, and finally Medicine. His reputation in medicine drew many students to the university, and his fame spread all over Italy. The rival University of Padua then secured him, and he seems to have been for some twenty years there. Later apparently he accepted a professor's chair at Ferrara, where the D'Estes were trying to bring their university into prominence. It was at Ferrara that he died. He was a man of wide reading, of extensive experience, both of men and medicine, and one of the scholars of his time. His works are, as we have said, mainly excerpts from earlier writers and particularly the Arabians, but they contain enough of hints drawn from his own observation and experience to make his work of great value.

While, as Gurlt remarks in his "History of Surgery," Arculanus' name is one of those scarcely known—he is usually considered just one of many obscure writers of the end of the Middle Ages—his writings deserve a better fate. They contain much that is interesting and a great deal that must have been of the highest practical value to his contemporaries. They attracted wide attention in his own and immediately succeeding generations. The proof of this is that they exist in a large number of manuscript copies. Just as soon as printing was introduced his books appeared in edition after edition. His "Practica" was printed in no less than seven editions in Venice. Three of them appeared before the end of the fifteenth century, which places them among the incunabula of printing.

Probably nothing in the history of human intellectual interest is more striking than the excellent judgment displayed by the editors who selected the works to be printed at this time. Very few of them were trivial or insignificant. Fewer still were idle speculations, and most of them were almost of classical import for literature and science. Four editions of this work were printed in Venice in the sixteenth century, one of them as late as 1560, when the work done by such men as Vesalius, Columbus, Eustachius, and Fallopius would seem to have made Arculanus out of date. The dates of the various editions are Venice, 1483, 1493, 1497, 1504, 1542, 1557, and 1560. Besides there was an edition printed at Basel in 1540.

Arculanus is said to have re-introduced the use of the seton, that is the method of producing intense counter-irritation by the introduction of some foreign body into an incision in the skin. We owe to him, too, according to Pagel in the chapters on medieval medicine in Puschmann's "Handbook of the History of Medicine," an excellent description of alcoholic insanity.

His directions for the treatment of conditions in the mouth and nose apart from the teeth are quite as explicit and practical, and in many ways quite as great an anticipation of some of our modern notions as what he has to say with regard to the teeth. For instance, in the treatment of polyps he says that they should be incised and cauterized. Soft polyps should be drawn out with a toothed tenaculum as far as can be without risk of breaking them off. The incision should be made at the root so that nothing or just as little as possible of the pathological structure be allowed to remain. It should be cut off with a fine scissors, or with a narrow file just small enough to permit its ingress into the nostrils, or with a scalpel without cutting edges on the sides, but only at its extremity, and this cutting edge should be broad and well sharpened. If there is danger of hemorrhage, or if there is fear of it, the instruments with which dissection is made should be fired (igniantur), that is, heated at least to a dull redness. Afterwards the stump, if any remains, should be touched with a hot iron or else with cauterizing agents so that as far as possible it should be obliterated.

After the operation a pledget of cotton dipped in the green ointment described by Rhazes should be placed in the nose. This pledget should have a string fastened to it, hanging from the nose in order that it may be easily removed. At times it may be necessary to touch the root of the polyp with a stylet on which cotton has been placed that has been dipped in aqua fortis (nitric acid). It is important that this cauterizing fluid should be rather strong so that after a certain number of touches a rather firm eschar is produced. In all these manipulations in the nose Arculanus recommends that the nose should be held well open by means of a nasal speculum. Pictures of all these instruments occur in his extant works, and indeed this constitutes one of their most interesting and valuable features. They are to be seen in Gurlt's "History of Surgery."

In some cases he had seen the polyp was so difficult to get at or was situated so far back in the nose that it could not be reached by means of a tenaculum or scissors, or even the special knife devised for that purpose. For these patients Arculanus describes an operation that is to be found in the older writers on surgery, Paul of AEgina (AEginetus), Avicenna, and some of the other Arabian surgeons. For this three horse-tail hairs are twisted together and knotted in three or four places, and one end is passed through the nostrils and out through the mouth. The ends of this are then pulled on backward and forward after the fashion of a saw. Arculanus remarks evidently with the air of a man who has tried it and not been satisfied that this operation is quite uncertain, and seems to depend a great deal on chance, and much reliance must not be placed on it. Arculanus suggests a substitute method by which latent polyps or occult polyps as he calls them may be removed.

There is scarcely an important disease for which Arculanus has not some interesting suggestions, and the more one reads of him the more is one surprised to find how many things that we might think of as coming into the purview of medicine long after his time or at least as having been neglected from the time of the Greeks almost down to our own time are here treated explicitly, definitely, and with excellent practical suggestions. He has a good deal to say with regard to the treatment of angina, which he calls synanche, or synanchia, or cynanche, or angina. Parasynanche is a synonymous term, but refers to a milder synanche. He distinguished four forms of it. In one called canine angina, because the patient's tongue hangs out of his mouth, somewhat the same as from an overheated dog in the summer time, while at the same time the mouth is held open and he draws his breath pantingly, Arculanus suggests an unfavorable prognosis, and would seem to refer to those cases of Ludwig's angina in which there is involvement of the tongue and in which our prognosis continues to be of the very worst even to our own day. At times the angina causes such swelling in the throat that the breathing is interfered with completely. For this Arculanus' master, Rhazes, advised tracheotomy. Arculanus himself, however, apparently hesitated about that.

It is not surprising, then, to find that Arculanus is very explicit in his treatment of affections of the uvula. He divides its affections into apostema, ulcus, putredo sive corrosio, et casus. Apostema was abscess, ulcus any rather deep erosion, putredo a gangrenous condition, and casus the fall of the uvula. This is the notorious falling of the soft palate which has always been in popular medical literature at least. Arculanus describes it as a preternatural elongation of the uvula which sometimes goes to such an extent as to make it resemble the tail of a mouse. For shorter elongations he suggests the cautery; for longer, excision followed by the cautery so that the greater portion of the extending part may be cut off. If people fear the knife he suggests following Rhazes, the application of an astringent powder directly to the part by blowing through a tube. His directions for the removal of the uvula are very definite. Seat the patient upon a stool in a bright light while an assistant holds the head; after the tongue has been firmly depressed by means of a speculum let the assistant hold this speculum in place. With the left hand then insert an instrument, a stilus, by which the uvula is pulled forward, and then remove the end of it by means of a heated knife or some other process of cauterization. The mouth should afterwards be washed out with fresh milk.

The application of a cauterizing solution by means of a cotton swab wrapped round the end of a sound may be of service in patients who refuse the actual cautery. To be successful the application must be firmly made and must be frequently repeated.

After this it is not surprising to find that Arculanus has very practical chapters on all the other ordinary surgical affections. Empyema is treated very thoroughly, liver abscess, ascites, which he warns must be emptied slowly, ileus especially when it reaches stercoraceous vomiting, and the various difficulties of urination, he divides them into dysuria, ischuria, and stranguria, are all discussed in quite modern fashion. He gives seven causes for difficulty of urination. One, some injury of the bladder; two, some lesion of the urethra; three, some pathological condition in the power to make the bladder contract; four, some injury of the muscle of the neck of the bladder; five, some pathological condition of the urine; six, some kidney trouble, and seven, some pathological condition of the general system. He takes up each one of these and discusses the various phases, causes, disposition, and predispositions that bring them about. One thing these men of the Middle Ages could do, they reasoned logically, they ordered what they had to say well, and they wrote it out straightforwardly.

That Arculanus' work with regard to dentistry was no mere chance and not solely theoretic can be understood very well from his predecessors, and that it formed a link in a continuous tradition which was well preserved we may judge from what is to be found in the writings of his great successor, Giovanni or John de Vigo, who is considered one of the great surgeons of the early Renaissance, and to whom we owe what is probably the earliest treatise on "Gun-shot Wounds." John of Vigo was a Papal physician and surgeon, generally considered one of the most distinguished members of the medical profession of his time. Two features of his writing on dental diseases deserve mention. He insists that abscesses of the gums shall be treated as other abscesses by being encouraged to come to maturity and then being opened. If they do not close promptly, an irritant Egyptian ointment containing verdigris and alum among other things should be applied to them. In the cure of old fistulous tracts near the teeth he employs not only this Egyptian ointment but also arsenic and corrosive sublimate. What he has to say with regard to the filling of the teeth is, however, most important. He says it with extreme brevity, but with the manner of a man thoroughly accustomed to doing it. "By means of a drill or file the putrefied or corroded part of the tooth should be completely removed. The cavity left should then be filled with gold leaf." It is evident that the members of the Papal court, the Cardinals and the Pope himself, had the advantage of rather good dentistry at John de Vigo's hands even as early as the beginning of the sixteenth century.

John de Vigo, however, is not medieval. He lived on into the sixteenth century and was influenced deeply by the Renaissance. He counts among the makers of modern medicine and surgery, as his authorship of the treatise on gun-shot wounds makes clear. He comes in a period that will be treated of in a later volume of this series on "Our Forefathers in Medicine."



XIII

CUSANUS AND THE FIRST SUGGESTION OF LABORATORY METHODS IN MEDICINE

As illustrating how, as we know more about the details of medical history, the beginnings of medical science and medical practice are pushed back farther and farther, a discussion in the Berliner klinische Wochenschrift a dozen years ago is of interest. Professor Ernest von Leyden, in sketching the history of the taking of the pulse as an important aid in diagnostics, said that John Floyer was usually referred to as the man who introduced the practice of determining the pulse rate by means of the watch. His work was done about the beginning of the eighteenth century. Professor von Leyden suggested, however, that William Harvey, the English physiologist, to whom is usually attributed the discovery of the circulation of the blood, had emphasized the value of the pulse in medical diagnosis, and also suggested the use of the watch in counting the pulse. Professor Carl Binz, of the University of Bonn, commenting on these remarks of Professor von Leyden, called attention to the fact that more than a century before the birth of either of these men, even the earlier, to whom the careful measurement of the pulse rate is thus attributed as a discovery, a distinguished German churchman, who died shortly after the middle of the fifteenth century, had suggested a method of accurate estimation of the pulse that deserves a place in medical history.

This suggestion is so much in accord with modern demands for greater accuracy in diagnosis that it seems not inappropriate to talk of it as the first definite attempt at laboratory methods in the department of medicine. The maker of the suggestion, curiously enough, was not a practising physician, but a mathematician and scholar, Cardinal Nicholas of Cusa, who is known in history as Cusanus from the Latin name of the town Cues on the Moselle River, some twenty-five miles south of Treves, where he was born. His family name, Nicholas Krebs, has been entirely lost sight of in the name derived from his native town, which is the only reason why most of the world knows anything about that town. Cardinal Cusanus suggested that in various forms of disease and at various times of life, as in childhood, boyhood, manhood, and old age, the pulse was very different. It would be extremely valuable to have some method of accurately estimating, measuring, and recording these differences for medical purposes. At that time watches had not yet been invented, and it would have been very difficult to have estimated the time by the clocks, for almost the only clocks in existence were those in the towers of the cathedrals and of the public buildings. The first watches, Nuremberg eggs, as they were called, were not made by Peter Henlein until well on into the next century. The only method of measuring time with any accuracy in private houses was the clepsydra or water-clock, which measured the time intervals by the flow of a definite amount of water. Cardinal Cusanus suggested then that the water-clock should be employed for estimating the pulse frequency. His idea was that the amount of water which flowed while a hundred beats of the pulse were counted, should be weighed, and this weight compared with that of the average weight of water which flowed while a hundred beats of the normal pulse of a number of individuals of the same age and constitution were being counted.

This was a very single and a very ingenious suggestion. We have no means of knowing now whether it was adopted to any extent or not. It may seem rather surprising that a cardinal should have been the one to make such a suggestion. Cusanus, however, was very much interested in mathematics and in the natural sciences, and we have many wonderful suggestions from his pen. He was the first, for instance, to suggest, more than a century before Copernicus, that the earth was not the centre of the universe, and that it would not be absolutely at rest or, as he said, devoid of all motion. His words are: "Terra igitur, quae centrum esse nequit, motu omni carere non potest." He described very clearly how the earth moved round its own axis, and then he added, what cannot fail to be a surprising declaration for those in the modern times who think such an idea of much later origin, that he considered that the earth itself cannot be fixed, but moves as do the other stars in the heavens. The expression is so astonishing at that time in the world's history that it seems worth the while to give it in its original form, so that it may be seen clearly that it is not any subsequent far-fetched interpretation of his opinion, but the actual words themselves, that convey this idea. He said: "Consideravi quod terra ista non potest esse fixa, sed movetur ut aliae stellae."

How clearly Cusanus anticipated another phase of our modern views may be judged from what he has to say in "De Docta Ignorantia" with regard to the constitution of the sun. It is all the more surprising that he should by some form of intuition reach such a conclusion, for the ordinary sources of information with regard to the sun would not suggest such an expression except to a genius, whose intuition outran by far the knowledge of his time. The Cardinal said: "To a spectator on the surface of the sun the splendor which appears to us would be invisible, since it contains, as it were, an earth for its central mass, with a circumferential envelope of light and heat, and between the two an atmosphere of water and clouds and of ambient air." After reading that bit of precious astronomical science announced nearly five centuries ago, it is easy to understand how Copernicus could have anticipated other phases of our knowledge, as he did in his declarations that the figure of the earth is not a sphere, but is somewhat irregular, and that the orbit of the earth is not circular.