Part 11 (1/2)

In the next chapter there is an account of the treatment of a remarkable case of abscess of the uvula. In the following chapter the swelling of cervical glands is taken up. In his experience expectant treatment of these was best. He advises internal medication with the building up of the general health, or suggests allowing the inflamed glands to empty themselves after pustulation. After much meddlesome surgery we are almost back to his methods again. He did not hesitate to treat goitre surgically, though he considered there were certain internal remedies that would benefit it. In obstinate cases he suggests the complete extirpation of cystic goitre, but if the sac is allowed to remain it should be thoroughly rubbed over on the inside with green ointment. He warns about the necessity for avoiding the veins and arteries in this operation, and says that ”in this affection many large veins make their appearance and they find their way everywhere through the fleshy ma.s.s.”

What I have given here is to be found in a little more than half a page of Gurlt's abstract of the first twenty chapters of Salicet's first book. Altogether Gurlt has more than ten pages of rather small print with regard to William; most of it is as interesting and as practical and as representative of antic.i.p.ations of what is done in the modern time as what I have here quoted. William, as I have said, depended much more upon his own experience than upon what was to be found in text-books. He knew the old text-books very well however, but as a rule did not quote from them unless he had tried the recommendations for himself, or unless similar cases to these mentioned had come under his own observation. He was evidently a thoroughly observant physician, a skilled surgeon who was practical enough to see the simplest way to do things, and he proceeded to do them. It is no wonder that he influenced succeeding generations so much, nor that his great pupil, Lanfranc, continuing his tradition, founded a school of surgery in Paris, the influence of which was to endure almost down to our time, and give France a primacy in surgery until the nineteenth century.

LANFRANC

After Salicet's lifetime the focus of interest in surgery changes from Italy to France, and what is still more complimentary to William, it is through a favorite disciple of his that the change takes place. This was Lanfranchi, or Lanfranco, sometimes spoken of as Alanfrancus, who practised as physician and surgeon in Milan until banished from there by Matteo Visconti about 1290. He then went to Lyons, where in the course of his practice he attracted so much attention that he was offered the opportunity to teach surgery in Paris. He attracted what Gurlt calls an almost incredible number of scholars to his lessons in Paris, and by hundreds they accompanied him to the bedside of his patients and attended his operations. The dean of the medical faculty, Jean de Pa.s.savant, urged him to write a text-book of surgery, not only for the benefit of his students at Paris but for the sake of the prestige which this would confer on the medical school. Deans still urge the same reasons for writing. Lanfranc completed his surgery, called ”Chirurgia Magna,” in 1296, and dedicated it to Philippe le Bel, the then reigning French King. Ten years later he died, but in the meantime he had transferred Italian prestige in surgery from Italy to France and laid the foundations in Paris of a thoroughly scientific as well as a practical surgery, though this department of the medical school had been in a sadly backward state when he came.

In the second chapter of this text-book, the first containing the definition of surgery and general introduction, Lanfranc describes the qualities that in his opinion a surgeon should possess. He says, ”It is necessary that a surgeon should have a temperate and moderate disposition. That he should have well-formed hands, long slender fingers, a strong body, not inclined to tremble and with all his members trained to the capable fulfilment of the wishes of his mind. He should be of deep intelligence and of a simple, humble, brave, but not audacious disposition. He should be well grounded in natural science, and should know not only medicine but every part of philosophy; should know logic well, so as to be able to understand what is written, to talk properly, and to support what he has to say by good reasons.” He suggests that it would be well for the surgeon to have spent some time teaching grammar and dialectics and rhetoric, especially if he is to teach others in surgery, for this practice will add greatly to his teaching power. Some of his expressions might well be repeated to young surgeons in the modern time. ”The surgeon should not love difficult cases and should not allow himself to be tempted to undertake those that are desperate. He should help the poor as far as he can, but he should not hesitate to ask for good fees from the rich.”

Many generations since Lanfranc's time have used the word nerves for tendons. Lanfranc, however, made no such mistake. He says that the wounds of nerves, since the nerve is an instrument of sense and motion, are, on account of the greater sensitiveness which these structures possess, likely to involve much pain. Wounds along the length of the nerves are less dangerous than those across them. When a nerve is completely divided by a cross wound Lanfranc is of the opinion, though Theodoric and some others are opposed to it, that the nerve ends should be st.i.tched together. He says that this suture insures the redintegration of the nerve much better. After this operation the restoration of the usefulness of the member is more complete and a.s.sured.

His description of the treatment of the bite of a rabid dog is interesting. A large cupping gla.s.s should be applied over the wound so as to draw out as much blood as possible. After this the wound should be dilated and thoroughly cauterized to its depths with a hot iron. It should then be covered with various substances that were supposed to draw, in order as far as possible to remove the poison. His description of how one may recognize a rabid animal is rather striking in the light of our present knowledge, for he seems to have realized that the main diagnostic element is a change in the disposition of the animal, but above all a definite tendency to lack playfulness. Lanfranc had seen a number of cases of true rabies, and describes and suggests treatment for them, though evidently without very much confidence in the success of the treatment.

The treatment of snake bites and the bites of other poisonous animals was supposed to follow the principles laid down for the bite of a mad dog, especially as regards the encouragement of free bleeding and the use of the cautery.

Lanfranc has many other expressions that one is tempted to quote, because they show a thinking surgeon of the old time, antic.i.p.ating many supposedly modern ideas and conclusions. He is a particular favorite of Gurlt's, who has more than twenty-five large octavo, closely printed pages with regard to him. There is scarcely any development in our modern surgery that Lanfranc has not at least a hint of, certainly nothing in the surgery of a generation ago that does not find a mention in his book. On most subjects he has practical observations from his own experience to add to what was in surgical literature before his time. He quotes altogether more than a score of writers on surgery who had preceded him and evidently was thoroughly familiar with general surgical literature. There is scarcely an important surgical topic on which Gurlt does not find some interesting and personal remarks made by Lanfranc.

All that we can do here is refer those who are interested in Lanfranc to his own works or Gurlt.

MONDEVILLE

The next of the important surgeons who were to bring such distinction to French surgery for five centuries was Henri de Mondeville. Writers usually quote him as Henricus. His latter name is only the place of his birth, which was probably not far from Caen in Normandy. It is spelled in so many different ways, however, by different writers that it is well to realize that almost anything that looks like Mondeville probably refers to him. Such variants as Mundeville, Hermondaville, Amondaville, Amundaville, Amandaville, Mandeville, Armandaville, Armendaville, Amandavilla occur. We owe a large amount of our information with regard to him to Professor Pagel, who issued the first edition of his book ever published (Berlin, 1892). It may seem surprising that Mondeville's work should have been left thus long without publication, but unfortunately he did not live long enough to finish it. He was one of the victims that tuberculosis claimed among physicians in the midst of their work. Though there are a great number of ma.n.u.script copies of his book, somehow Renaissance interest in it in its incompleted state was never aroused sufficiently to bring about a printed edition. Certainly it was not because of any lack of interest on the part of his contemporaries or any lack of significance in the work itself, for its printing has been one of the surprises afforded us in the modern time as showing how thoroughly a great writer on surgery did his work at the beginning of the fourteenth century. Gurlt, in his ”History of Surgery,” has given over forty pages, much of it small type, with regard to Mondeville, because of the special interest there is in his writing.[20]

His life is of particular interest for other reasons besides his subsequent success as a surgeon. He was another of the university men of this time who wandered far for opportunities in education. Though born in the north of France and receiving his preliminary education there, he made his medical studies towards the end of the thirteenth century under Theodoric in Italy. Afterwards he studied medicine in Montpellier and surgery in Paris. Later he gave at least one course of lectures at Montpellier himself and a series of lectures in Paris, attracting to both universities during his professors.h.i.+p a crowd of students from every part of Europe. One of his teachers at Paris had been his compatriot, Jean Pitard, the surgeon of Philippe le Bel, of whom he speaks as ”most skilful and expert in the art of surgery,” and it was doubtless to Pitard's friends.h.i.+p that he owed his appointment as one of the four surgeons and three physicians who accompanied the King into Flanders.

Besides his lectures, Mondeville had a large consultant practice and also had to accompany the King on his campaigns. This made it extremely difficult for him to keep continuously at the writing of his book. It was delayed in spite of his good intentions, and we have the picture that is so familiar in the modern time of a busy man trying to steal or make time for his writing. Unfortunately, in addition to other obstacles, Mondeville showed probably before he was forty the first symptoms of a serious pulmonary disease, presumably tuberculosis. He bravely fought it and went on with his work. As his end approached he sketched in lightly what he had hoped to treat much more formally, and then turned to what was to have been the last chapter of his book, the Antidotarium or suggestions of practical remedies against diseases of various kinds because his students and physician friends were urging him to complete this portion for them. We of the modern time are much less interested in that than we would have been in some of the portions of the work that Mondeville neglected in order to provide therapeutic hints for his disciples. But then the students and young physicians have always clamored for the practical--which so far at least in medical history has always proved of only pa.s.sing interest.

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 Africa.n.u.s, 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 pa.s.sages 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, n.o.bler, securer, more perfect, more necessary, and more lucrative art than the other parts of medicine.” Surgeons have always been p.r.o.ne 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 a.s.sociate 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 G.o.d'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 n.o.ble 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 ma.n.u.scripts 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 p.r.o.ne to object to nearly everything that the surgeon wants to do, and who often seem to think that they surpa.s.s 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 a.s.sistants 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 p.r.o.ne 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 a.s.sistants 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.