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 anticipations 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
Passavant, 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 stitched 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
assured.
His description of the treatment of the bite of a rabid dog is
interesting. A large cupping glass 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, anticipating 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 manuscript 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 professorship 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 friendship 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 passing 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 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.