Part 19

It is often said that at this time surgery was mainly in the hands of barbers and the ignorant. Henri de Mondeville, however, is a striking example in contradiction of this. He must have had a fine preliminary education and his book shows very wide reading. There is almost no one of any importance who seriously touched upon medicine or surgery before his time whom Mondeville does not quote. Hippocrates, Aristotle, Dioscorides, Pliny, Galen, Rhazes, Ali Abbas, Abulcasis, Avicenna, Constantine Africanus, Averroes, Maimonides, Albertus Magnus, Hugo of Lucca, Theodoric, William of Salicet, Lanfranc are all quoted, and not once or twice but many times. Besides he has quotations from the poets and philosophers, Cato, Diogenes, Horace, Ovid, Plato, Seneca, and others. He was a learned man, devoting himself to surgery.

It is no wonder, then, that he thought that a surgeon should be a scholar, and that he needed to know much more than a physician. One of his characteristic passages is that in which he declares "it is impossible that a surgeon should be expert who does not know not only the principles, but everything worth while knowing about medicine," and then he added, "just as it is impossible for a man to be a good physician who is entirely ignorant of the art of surgery." He says further: "This our art of surgery, which is the third part of medicine (the other two parts were diet and drugs), is, with all due reverence to physicians, considered by us surgeons ourselves and by the non-medical as a more certain, nobler, securer, more perfect, more necessary, and more lucrative art than the other parts of medicine." Surgeons have always been prone to glory in their specialty.

Mondeville had a high idea of the training that a surgeon should possess. He says: "A surgeon who wishes to operate regularly ought first for a long time to frequent places in which skilled surgeons operate often, and he ought to pay careful attention to their operations and commit their technique to memory. Then he ought to associate himself with them in doing operations. A man cannot be a good surgeon unless he knows both the art and science of medicine and especially anatomy. The characteristics of a good surgeon are that he should be moderately bold, not given to disputations before those who do not know medicine, operate with foresight and wisdom, not beginning dangerous operations until he has provided himself with everything necessary for lessening the danger. He should have well-shaped members, especially hands with long, slender fingers, mobile and not tremulous, and with all his members strong and healthy so that he may perform all the good operations without disturbance of mind. He must be highly moral, should care for the poor for God's sake, see that he makes himself well paid by the rich, should comfort his patients by pleasant discourse, and should always accede to their requests if these do not interfere with the cure of the disease." "It follows from this," he says, "that the perfect surgeon is more than the perfect physician, and that while he must know medicine he must in addition know his handicraft."

Thinking thus, it is no wonder that he places his book under as noble patronage as possible. He says in the preface that he "began to write it for the honor and praise of Christ Jesus, of the Virgin Mary, of the Saints and Martyrs, Cosmas and Damian, and of King Philip of France as well as his four children, and on the proposal and request of Master William of Briscia, distinguished professor in the science of medicine and formerly physician to Pope Boniface IV and Benedict and Clement, the present Pope." His first book on anatomy he proposed to found on that of Avicenna and "on his personal experience as he has seen it." The second tractate on the treatments of wounds, contusions, and ulcers was founded on the second book of Theodoric "with whatever by recent study has been newly acquired and brought to light through the experience of modern physicians." He then confesses his obligations to his great master, John Pitard, and adds that all the experience that he has gained while operating, studying, and lecturing for many years on surgery will be made use of in order to enhance the value of the work. He hopes, however, to accomplish all this "briefly, quietly, and above all, charitably." There are many things in the preface that show us the reason for Mondeville's popularity, for they exhibit him as very sympathetically human in his interests.

While Mondeville is devoted to the principle that authority is of great value, he said that there was nothing perfect in things human, and successive generations of younger men often made important additions to what their ancestors had left them. While his work is largely a compilation, nearly everywhere it shows signs of the modification of his predecessors' opinions by the results of his own experience. His method of writing is, as Pagel declares, "always interesting, lively, and often full of meat." He had a teacher's instinct, for in several of the earlier manuscripts his special teaching is put in larger letters in order to attract students' attention.... He seems to have introduced or re-introduced into practice the idea of the use of a large magnet in order to extract portions of iron from the tissues. He made several modifications in needles and thread holders and invented a kind of small derrick for the extraction of arrows with barbs. Besides, he suggested the surrounding of the barbs of the arrows with tubes, to facilitate extraction. In his treatment of wounds, Pagel considers that as a writer and teacher he is far ahead of his predecessors and even of those who came after him in immediately subsequent generations. One of his great merits undoubtedly is that Guy de Chauliac, the father of modern surgery, in his text-book turned to him with a confidence that proclaims his admiration and how much he felt that he had gained from him.

One of the most interesting features of Mondeville's work is his insistence on the influence of the mind on the body and the importance of using this influence to the best advantage. It is especially important in Mondeville's opinion to keep a surgical patient from being moody. "Let the surgeon," says he, "take care to regulate the whole regimen of the patient's life for joy and happiness by promising that he will soon be well, by allowing his relatives and special friends to cheer him and by having someone to tell him jokes, and let him be solaced also by music on the viol or psaltery. The surgeon must forbid anger, hatred, and sadness in the patient, and remind him that the body grows fat from joy and thin from sadness. He must insist on the patient obeying him faithfully in all things." He repeats with approval the expression of Avicenna that "often the confidence of the patient in his physician does more for the cure of his disease than the physician with all his remedies." Obstinate and conceited patients prone to object to nearly everything that the surgeon wants to do, and who often seem to think that they surpass Galen and Hippocrates in science and wisdom, are likely to delay their cure very much, and they represent the cases with which the surgeon has much difficulty.

Mondeville thought that nursing was extremely important and that without it surgery often failed of its purpose. He says, "For if the assistants are not solicitous and faithful, and obedient to the surgeons in each and every thing which may make for the cure of the disease, they put obstacles and difficulties in the way of the surgeon." It is especially important that the patient's nutrition should be cared for and that the bandages should be managed exactly as the surgeon directs. He has no use for garrulous, talkative nurses, and does not hesitate to say that sometimes near relatives are particularly likely to disturb patients. "Especially are they prone to let drop some hint of bad news which the surgeon may have revealed to them in secret, or even the reports that they may hear from others, friends or enemies, and this provokes the patient to anger or anxiety and is likely to give him fever. If the assistants quarrel among themselves, or are heard murmuring, or if they draw long faces, all of these things will disturb the patients and produce worry and anxiety or fear. The surgeon therefore must be careful in the selection of his nurses, for some of them obey very well while he is present, but do as they like and often just exactly the opposite of what he has directed when he is away."

We do not know enough of the details of Mondeville's life to be sure whether he was married or not. It is probable that he was not, for all of these surgeons of the thirteenth century before Mondeville's time, Theodoric, William of Salicet, Lanfranc, and Guy de Chauliac, after him belonged to the clerical order; Theodoric was a bishop; the others, however, seem only to have been in minor orders. It is therefore from the standpoint of a man who views married life from without that Mondeville makes his remarks as to the difficulty often encountered when wives nurse their husbands. He says that the surgeon has difficulty oftener when husbands or wives care for their spouses than at other times. This is much more likely to take place when the wives are caring for the husbands. "In our days," he says, "in this Gallican part of the world, wives rule their husbands, and the men for the most part permit themselves to be ruled. Whatever a surgeon may order for the cure of a husband then will often seem to the wives to be a waste of good material, though the men seem to be quite willing to get anything that may be ordered for the cure of their wives. The whole cause of this seems to be that every woman seems to think that her husband is not as good as those of other women whom she sees around her." It would be interesting to know how Mondeville was brought to a conclusion so different from modern experience in the matter.

For those who are particularly interested in medical history one of the sections of Henry's book has a special appeal, because he gives in it a sketch of the history of surgery. We are little likely to think, as a rule, that at this time, full two centuries before the close of the Middle Ages, men were interested enough in the doings of those who had gone before them to try to trace the history of the development of their specialty. It is characteristic of the way that the scholarly Mondeville views his own life work that he should have wanted to know something about his predecessors and teach others with regard to them. He begins with Galen, and as Galen divides the famous physicians of the world into three sects, the Methodists, the Empirics, and the Rationalists, so Mondeville divides modern surgery into three sects: first, that of the Salernitans, with Roger, Roland, and the Four Masters; second, that of William of Salicet and Lanfranc; and third, that of Hugo de Lucca and his brother Theodoric and their modern disciples. He states briefly the characteristics of these three sects. The first limited patients' diet, used no stimulants, dilated all wounds, and got union only after pus formation. The second allowed a liberal diet to weak patients, though not to the strong, but generally interfered with wounds too much. The third believed in a liberal diet, never dilated wounds, never inserted tents, and its members were extremely careful not to complicate wounds of the head by unwise interference. His critical discussion of the three schools is extremely interesting.

Another phase of Mondeville's work that is sympathetic to the moderns is his discussion of the irregular practice of medicine and surgery as it existed in his time. Most of our modern medicine and surgery was anticipated in the olden time; but it may be said that all of the modes of the quack are as old as humanity. Galen's description of the travelling charlatan who settled down in his front yard, not knowing that it belonged to a physician, shows this very well. There were evidently as many of them and as many different kinds in Mondeville's time as in our own. In discussing the opposition that had arisen between physicians and surgeons in his time and their failure to realize that they were both members of a great profession, he enumerates the many different kinds of opponents that the medical profession had. There were "barbers, soothsayers, loan agents, falsifiers, alchemists, meretrices, midwives, old women, converted Jews, Saracens, and indeed most of those who, having wasted their substance foolishly, now proceed to make physicians or surgeons of themselves in order to make their living under the cloak of healing."

What surprises Mondeville however, as it has always surprised every physician who knows the situation, is that so many educated, or at least supposedly well-informed people of the better classes, indeed even of the so-called best classes, allow themselves to be influenced by these quacks. And it is even more surprising to him that so many well-to-do, intelligent people should, for no reason, though without knowledge, presume to give advice in medical matters and especially in even dangerous surgical diseases, and in such delicate affections as diseases of the eyes. "It thus often happens that diseases in themselves curable grow to be simply incurable or are made much worse than they were before." He says that some of the clergymen of his time seemed to think that a knowledge of medicine is infused into them with the sacrament of Holy Orders. He was himself probably a clergyman, and I have in the modern time more than once known of teachers in the clerical seminaries emphasizing this same idea for the clerical students. It is very evident that the world has not changed very much, and that to know any time reasonably well is to find in it comments on the morning paper. We are in the midst of just such a series of interferences with medicine on the part of the clergy as this wise, common-sense surgeon of the thirteenth century deprecated.

In every way Mondeville had the instincts of a teacher. He took advantage of every aid. He was probably the first to use illustrations in teaching anatomy. Guy de Chauliac, whose teacher in anatomy for some time Mondeville was, says in the first chapter of his "Chirurgia Magna" that pictures do not suffice for the teaching of anatomy and that actual dissection is necessary. The passage runs as follows: "In the bodies of men, of apes, and of pigs, and of many other animals, tissues should be studied by dissections and not by pictures, as did Henricus, who was seen to demonstrate anatomy with thirteen pictures."[21] What Chauliac blames is the attempt to replace dissections by pictorial demonstrations. Hyrtl, however, suggests that this invention of Mondeville's was probably very helpful, and was brought about by the impossibility of preserving bodies for long periods as well as the difficulty of obtaining them.

YPERMAN

One of the maxims of the old Greek philosophers was that good is diffusive of itself. As the scholastics put it, _bonum est diffusivum sui_. This proved to be eminently true of the old universities also, and especially of their training in medicine and in surgery. We have the accounts of men from many nations who went to the universities and returned to benefit their own people. Early in the thirteenth century Richard the Englishman was in Italy, having previously been in Paris and probably at Montpellier. Bernard Gordon, probably also an Englishman, was one of the great lights in medicine down at Montpellier, and his book, "Lilium De Medicina," is well known. Two distinguished surgeons whose names have come down to us, having studied in Paris after Lanfranc had created the tradition of great surgical teaching there, came to their homes to be centres of beneficent influence among their people in this matter. One was Yperman, of the town of Ypres in Belgium; the other Ardern of England. Yperman was sent by his fellow-townsmen to Paris in order to study surgery, because they wanted to have a good surgeon in their town and Paris seemed the best school at that time. Ypres was at this period one of the greatest commercial cities of Europe, and probably had a couple of hundred thousand inhabitants. The great hall of the cloth gild, which has been such an attraction for visitors ever since, was built shortly before the town determined upon the very sensible procedure of securing good surgery beyond all doubt by having a townsman specially educated for that purpose.

Yperman's work was practically unknown to us until Broeck, the Belgian historian, discovered manuscript copies of his book on surgery and gathered some details of his life. After his return from Paris, Yperman obtained great renown, which maintained itself in the custom extant in that part of the country even yet of calling an expert surgeon an Yperman. He is the author of two works in Flemish. One of these is a smaller compendium of internal medicine, which is very interesting, however, because it shows the many subjects that were occupying physicians' minds at that time. He treats of dropsy, rheumatism, under which occur the terms coryza and catarrh (the flowing diseases), icterus, phthisis (he calls the tuberculosis, tysiken), apoplexy, epilepsy, frenzy, lethargy, fallen palate, cough, shortness of breath, lung abscess, hemorrhage, blood-spitting, liver abscess, hardening of the spleen, affections of the kidney, bloody urine, diabetes, incontinence of urine, dysuria, strangury, gonorrhea, and involuntary seminal emissions--all these terms are quoted directly from Pagel's account of his work; the original is not available in this country.

JOHN ARDERN

In English-speaking countries of course we are interested in what was done by Englishmen at this time. Fortunately we have the record of one great English surgeon of the period worthy to be placed beside even the writers already mentioned. This is John Ardern, whose name is probably a modification of the more familiar Arden, whose career well deserves attention. I have given a sketch of his work in "The Popes and Science."[22] He was educated at Montpellier, and practised surgery for a time in France. About the middle of the century however, according to Pagel, he went back to his native land and settled for some twenty years at Newark, in Nottinghamshire, and then for nearly thirty years longer, until about the end of the century, was in London. He is the chief representative of English surgery during the Middle Ages. His "Practica," as yet unprinted, contains, according to Pagel, a short sketch of internal medicine, but is mainly devoted to surgery. Contrary to the usual impression with regard to works in medicine and surgery at this time, the book abounds in references to case histories which Ardern had gathered, partly from his own and partly from others' experience. The therapeutic measures that he suggests are usually very simple, in the majority of cases quite rational, though, of course, there are many superstitions among them; but Ardern always furnished a number of suggestions from which to choose. He must have been an expert operator, and had excellent success in the treatment of diseases of the rectum. He seems to have been the first operator who made careful statistics of his cases, and was quite as proud as any modern surgeon of the large numbers that he had operated on, which he gives very exactly. He was the inventor of a new clyster apparatus.

Fortunately we possess here in America, in the Surgeon General's Library at Washington, a very interesting manuscript containing Ardern's surgical writings, though it has not yet been published. Even a little study of this and of the notes on it prepared by an English bibliophile before its purchase by the Surgeon General's Library, serves to show how valuable the work is in the history of surgery. There are illustrations scarcely less interesting than the text. Some of these illustrations were inserted by the original writer or copyist, and some of them later. In general, however, they show a rather high development of the mechanics of surgery at that time. Some of the pages have spaces for illustrations left unfilled, so that evidently the copyist did not complete his work. The titles of certain of the chapters are interesting, as illustrating the fact that our medical and surgical problems were stated clearly in the olden time, and thinking physicians, even six centuries ago, met them quite rationally. There is, for instance, a chapter headed "Against Colic and the Iliac Passion," immediately followed by the subheading, "Method of Administering Clysters." The iliac passion, _passio iliaca_ of the old Latin, is usually taken to signify some obstruction of the intestines causing severe pain, vomiting, and eventually fecal vomiting. A good many different forms of severe painful conditions, especially all those complicated by peritonitis, were included under the term, and the modern student of surgery is likely to wonder whether these old observers had not noted that the right iliac region was particularly prone to be the source of fatal conditions. There is a chapter entitled "Against Pain in the Loins and the Kidneys," followed by the chapter subheading, "Against Stone in the Kidneys." There is a chapter with the title, "Against Ulceration of the Bladder or the Kidneys." Another one, with the title "Against Burning of the Urine and Excoriation of the Lower Part of the Yard." Gonorrhea is frankly treated under the name _Shawdepisse_, evidently an English alliteration of the corresponding French word. As to the instrumentation of such conditions and for probing in general, Ardern suggests the use of a lead probe, because it may readily be made to bend any way and not injure the tissues.

MEDIEVAL SURGERY