SURGEONS OUTSIDE OF ITALY: SURGEONS OF THE WEST OF EUROPE
"Sciences are made by addition, and it is not possible that the same
man should begin and finish them...." "We are like infants at the neck
of a giant, for we can see all that the giant sees and something
more."--(GUY DE CHAULIAC, Papal Physician to the Popes at Avignon.)
The very interesting and in many ways astonishing development of surgery
which occurred in Italy in the twelfth and thirteenth centuries, was
followed up by similar developments in the western countries of Europe.
France was the first to fall into the line of progress with important
advances in surgery, and owes her teaching directly to the Italians; but
in Flanders, in England, in Spain, and in Germany, we have records of some
significant advances in surgery, and distinguished surgeons wrote books
that fortunately for the history of surgery were preserved. The most
important of the surgical writings of the time, put in type during the
great nascent period of printing at the Renaissance, have come down to us.
Many of these have been republished in recent years, and as the texts are
now readily available they enable anyone to see for himself just what were
the interests of the surgeons of the later medieval period, their
technique, and their successful applications of great practical principles
to the solution of important surgical problems.
The beginning of French scientific surgery came with the exile from Italy
of Lanfranc, as he is known, though his Italian name was Lanfranchi or
Lanfranco, and he is sometimes spoken of as Alanfrancus. He had practised
as physician and surgeon in Milan until banished from there by Matteo
Visconti, about 1290. He made his way then to Lyons, where he attracted so
much attention by his success as a surgeon that he was offered the chair
of professor of surgery at the University of Paris. "He attracted an
almost incredible number of scholars to his lessons in Paris, and by
hundreds literally they accompanied him to the bedside of his patient and
attended his operations" (Gurlt). Paris was at this time at the very
height of its glory as a University. It had had a series of distinguished
professors whose writings are still known and honoured, Albert the Great,
Thomas Aquinas, Roger Bacon, and Duns Scotus; and during the latter half
of the thirteenth century Louis IX. had encouraged the University in
every way, and had helped in the foundation of the Sorbonne. There were
probably more students in attendance at the University of Paris about the
time that Lanfranc was there than there has ever been in attendance at any
University before or since. The prestige of Lanfranc's position, then, and
his opportunity to impress the world of his time, can be readily
appreciated.
The Dean of the medical faculty of Paris, Jean de Passavant, urged
Lanfranc to write a textbook of surgery, partly for the familiar academic
reason that the students were clamouring for some definite record of his
teaching, but also because the Dean felt that the many copies of these
lessons which the students would take away with them, and which would be
consulted by others, would add greatly to the prestige of the medical
school. Medical school officials are not so different after more than six
and a half centuries. Lanfranc completed his textbook of surgery, called
"Chirurgia Magna," in 1296, and dedicated it to Philippe le Bel, the then
reigning King of France. It is from this work that we are able to judge
exactly what the value of Lanfranc's surgical teaching was.
In the second chapter of his textbook--the first containing the definition
of surgery and a general introduction--Lanfranc devotes some paragraphs to
the surgeon himself, and the qualities that a surgeon should possess if
he is to be successful in his speciality. It is about the sort of advice
that older surgeons are still likely to give young men who are entering on
the practice of the speciality, and more or less what is said at many a
commencement in the modern time when the maker of the address to the
graduates is a surgeon.
"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 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. (What a desideratum for the modern time is thus
outlined!) 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."
Lanfranc was himself a scholar well read in the literature of his
profession, but who had well digested his reading. He quotes altogether
more than a score of writers on surgery who had preceded him, and
evidently was thoroughly familiar with general surgical literature. He is
a particular favourite of Gurlt, the German historian of surgery, who has
devoted more than twenty-five closely printed large octavo pages to the
discussion of this old Paris professor and his work. Lanfranc's discussion
of wounds of nerves is of itself sufficient to show the character of his
work. Many generations after his time have used the word nerves for
tendons, and mistaken the function of these two structures, but Lanfranc
distinguished very clearly between them. He declared that since the nerves
are instruments of sense and motion, wounds of them should be carefully
treated, especially as the sensitiveness of these structures is likely to
cause the patient much subsequent pain if they are neglected. Longitudinal
wounds of nerves are much less dangerous than those across them. When a
nerve is completely divided in cross section Lanfranc was of the opinion,
though Theodoric and some others were opposed to it, that the nerve ends
should be stitched together. He says that the suture insures the
reintegration of the nerve much better. Besides, after this operation the
restoration of the usefulness of the member is more assured and is
commonly more complete.
After Lanfranc at Paris came Henri de Mondeville, whom Latin writers
usually quote as _Henricus_. At least a dozen variants of the second
portion of his name are found in literature, from Armondeville to
Hermondaville. 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 in the latter half 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, and then 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
practice 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.
There is an historical tradition which has led many to believe that the
surgery of the fourteenth century was mainly in the hands of the barber
surgeons--ignorant men who plied a rude handicraft in connection with some
conventional use of the lancet--and that the physicians quite despised
their surgical colleagues. Mondeville is a striking contradiction of this.
He was a scholarly man, who quotes not only all the distinguished
contributors to medicine and surgery before his time, the Greeks and
Latins, the Arabs, and his Italian masters, but who also has quotations
from poets and philosophers, Aristotle, Plato, Diogenes, Cato, Horace,
Ovid, Seneca, and others.
The Regius Professors of Medicine at both Oxford and Cambridge in our
generation are on record with the declaration that medicine and surgery
have been allowed to drift too far apart, and that above all the physician
should see more of surgical operations for the confirmation of diagnoses,
for they are real bioscopys. It is rather interesting to find, then, that
Mondeville felt the necessity in his time for close relations between
physicians and surgeons, and said:
"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 deference 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 speciality.
Mondeville is particularly interesting for the history of surgery because
he himself ventured to trace some of the recent history of the development
of his speciality. Following Galen's example, who had divided the
physicians of the world into three sects, the Methodists, the Empirics,
and the Rationalists, 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 Ugo
da Lucca and his son Theodoric and their modern [_sic_] disciples.
The characteristics of these three sects are in brief. The first limited
patients' diet, used no stimulants, dilated all wounds and looked for
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. Almost needless to
say, his critical discussion of the three schools is extremely
interesting.
Mondeville was himself a broadly educated scholar, who considered that the
surgeon should know everything worth while knowing about medicine, for his
work was greater than that of the physician. While he had high ideas,
however, of the value of theoretic knowledge, he insisted above all on the
value of practical training. He said, in his textbook on surgery, as to
what the training of the surgeon should be:
"A surgeon who wishes to operate regularly ought first for a long time
to frequent places in which skilled surgeons often operate, 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 proper
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."
The other great French surgeon of the fourteenth century was Guy de
Chauliac, who well deserves the name of father of modern surgery. He was
educated in a little town in the South of France, made his medical studies
at Montpellier, and then went on a journey of hundreds of miles to Italy
in order to make his postgraduate studies. While it is not generally
realized, for some seven centuries before the nineteenth Italy was the
home of graduate teaching in all departments. Whenever a man in any
country in Europe, from the beginning of the twelfth until the end of the
eighteenth century, wanted to secure opportunities for the higher
education that were not available in his home country, he went down into
Italy. At the beginning of the nineteenth century France usurped
Italy's place for half a century, and Germany pre-empted the position to a
great degree during the latter half of the nineteenth. The journey to
Italy in the Middle Ages was more difficult, and involved more expense and
time, than would even the voyage from America to Europe in our time; yet
many a student from France, Germany, and England made it for the sake of
the postgraduate opportunities, and it is matter for professional pride
that this was particularly true of our medieval colleagues in medicine and
surgery.
[Illustration: SURGICAL INSTRUMENTS OF GUY DE CHAULIAC, NOS. 1, 2, 3, AND
4 (FOURTEENTH CENTURY); AND SURGICAL APPARATUS OF HANS VON GERSSDORFF,
NOS. 5, 6 AND 7 (FIFTEENTH CENTURY)
_After plates in Gurlt's "Geschichte der Chirurgie"_
1. Trepan
2. Balista used for extraction of arrows
3. Cauterizing shears with cannula for cauterization of the uvula
4. Bistoury
5. Extension arrangement for reducing upper arm dislocations, called
"The Fool"
6. Screwpiece for extending a knee contracture
7. Extension apparatus in the form of armour-arm and armour-leg plates
("harness instruments") for contractures of the elbow and knee joints]
To know Guy de Chauliac's works well is to have ready contradictions at
hand to practically all of the objections so frequently repeated as to the
lack of scholarly work during the Middle Ages. For instance, Guy de
Chauliac insisted on the value of experience rather than authority, and of
original work rather than mere copying. He criticized in bitter satire
John of Gaddesden's book on medicine, called after the fashion of the time
by the poetical title "Rosa Anglica," of which he said: "Last of all
bloomed the scentless Rose of England, which on its being sent to me I
hoped to find bearing the odour of sweet originality. But instead of that
I encountered only the fictions of Hispanus, of Gilbert, and of
Theodoric." His mode of satirical expression is all the more interesting
and significant, because it shows that the men of the time were
critically minded enough as regards many of the passages in the writings
of their predecessors with which fault has been found in the modern time,
though we have usually been inclined to think that medieval readers
accepted them quite uncritically. Chauliac's 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 description of the methods of anæsthesia practised by the
surgeons of his time, especially in cases of amputation, is particularly
interesting to us because the anæsthetic was administered by inhalation.
Chauliac says:
"Some surgeons prescribe medicaments, such as opium, the juice of the
morel, hyoscyamus, mandrake, ivy, hemlock, lettuce, which send the
patient to sleep, so that the incision may not be felt. A new sponge
is soaked by them in the juice of these and left to dry in the sun;
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."[10]
Chauliac was particularly interested in the radical cure of hernia, and he
discusses six different operations for this purpose. Gurlt points out that
Chauliac's criticism of these operations is quite modern in its viewpoint.
He declared that practically 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 as a support; it
was to be left in the tissues, and was 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 criticizes the operation in this respect, but says
that he has "seen many cases in which men possessed of but one testicle
have procreated, and this is a problem where the lesser of two evils is
to be chosen."
While he discussed hernia operations so freely, the great French surgeon
did not believe that everyone who suffered from a hernia ought to be
submitted to an operation. He quite agreed with Mondeville who, in the
preceding generation, declared that many operations for hernia were done
not for the benefit of the patient but for the benefit of the surgeon--a
mode of expression that is likely to strike a sympathetic chord in some
physicians' minds even at the present time. Chauliac's rule was that no
operation should be attempted unless the patient's life was put in danger
by the hernia, but that a truss should be worn to retain it. He emphasized
that trusses should not be made according to rule, but must be adapted to
each individual, and he invented several forms of trusses himself. He
developed the method of taxis by which hernias might be reduced, suggested
an exaggerated Trendelenburg position for operations for hernia and for
the manipulations necessary for the reduction of hernia.
The technique of some of these old surgeons is a never-ending source for
surprise. The exaggerated Trendelenburg position in the operation for the
radical cure of hernia--the patient being fastened on an inclined board,
head down, so that the intestines would fall away from the site of
operation--was used by Guy de Chauliac, who probably obtained a hint of it
from Italy. He also employed extension in the treatment of fracture of the
thigh, inventing an apparatus by which this might be continued for a long
time until the muscles were relaxed from overtiredness. He made use for
this purpose of a weight suspended on a cord which ran over rollers. He
also adapted stiffened bandages of various kinds, especially employing
white of egg for this, and sometimes moulding bandages to the limbs in
cases of fracture. Yperman, the Flemish surgeon of this time, knew and
used the oesophagus tube for artificial feeding, and a number of various
kinds of instruments were invented for the urethra, including bougies of
wax, tin, and silver. In diseases of the bladder and in gonorrhoea John
Ardern employed astringent injections.
Probably what ought to be considered the most important work of the French
surgeons of the Middle Ages has been quite misunderstood until recent
years. In his paper on "The Origin of Syphilis," at the Seventeenth
International Congress of Medicine (London, 1913), Professor Karl Südhoff
of Leipzig (see Transactions) reviewed the use of mercury in the form of
mercurial ointment during the later Middle Ages, and the reputation that
it had acquired for the cure of ulcers, skin eruptions of various kinds,
and other distinctly objective lesions. It is perfectly clear now that the
success of this form of therapy was due to the fact that syphilis was
being treated. The French surgeons of the South of France developed the
empiric discovery of the value of this remedy, the first hint of which had
probably come to them from the Italians. It is one of the few specifics in
the history of medicine. Needless to say, it is still with us, and still
the accepted medication in spite, as Professor Südhoff notes, of the
often-attempted replacement of it down the centuries by some form or other
of arsenic treatment, though this has always been afterwards abandoned,
and it would seem as though our generation might furnish another instance
of the triumph of the medieval mercurial treatment over arsenic.
The real reason then, it would seem, why syphilis came to be called the
_morbus Gallicus_, or French Disease, was because when knowledge of its
differential diagnosis was generalized, physicians at the same time
learned of the remedy which could be so successfully employed for its
treatment, the value of which had been determined as the result of the
careful observations of the surgeons of South France. It is probable, as I
have said, that the original idea for this form of treatment came from
the Italian surgical traditions brought over from Italy by Lanfranc and
his contemporaries at the end of the thirteenth century. There can be no
doubt at all, however, of the power of clinical observation of the
medieval surgeons who gave us this wonderful advance in therapeutics.
The most distinguished pupil of Guy de Chauliac was Pietro d'Argelata, who
died about 1423 as a professor at Bologna, but whose textbook, "The
Cirurgia," was among the first of medical books to be printed at Venice in
1480. His teaching was still a living force at that time, and it is
evident that he had attracted wide attention in his own generation. He
taught the dry treatment of wounds, suggesting various powders to be
employed on them, and gave his experience with sutures and drainage tubes
in wounds.
Ligatures are often supposed to have been invented much later. They have
been attributed to Ambroise Paré and other surgeons of the Renaissance
period, but were probably used at many times during the Middle Ages, and
had been invented and frequently employed by the Greeks. They invariably
went out of use after a time, however, and had to be reinvented. As I said
in "Old-Time Makers of Medicine":
"It is hard to understand how so useful an auxiliary to the surgeon as
the ligature--it seems indispensable to us--could possibly be allowed
to go out of use and even be forgotten. It will not be difficult,
however, for anyone who recalls the conditions that obtained in
old-time surgery to understand the succession of events. The ligature
is a most satisfying immediate resource in stopping bleeding from an
artery, but a septic ligature inevitably causes suppuration, and
almost inevitably leads to secondary hæmorrhage. In the old days of
septic surgery, secondary hæmorrhage was the surgeon's greatest and
most dreaded bane. Some time from the fifth to the ninth day a septic
ligature came away under conditions such that inflammatory disturbance
had prevented sealing of the vessel. If the vessel was large, the
hæmorrhage was fast and furious, and the patient died in a few
minutes. After a surgeon had had a few deaths of this kind he dreaded
the ligature.
"Eventually he abandoned its use, and took kindly even to such methods
as the actual cautery, red-hot knives for amputations and the like,
that would sear the surfaces of tissues, and the bloodvessels, and not
give rise to secondary hæmorrhage. A little later, however, someone
not familiar with the secondary risks would reinvent the ligature. If
he were cleanly in his methods, and, above all, if he were doing his
work in a new hospital, the ligature worked very well for a while. If
not, it soon fell into innocuous desuetude again. In any case, it was
only a question of time until it would be abandoned."
There was at least one, and probably a number of English surgeons who were
doing excellent work in the latter part of the Middle Ages, but John of
Ardern wrote a book which has come down to us, and from him we may judge
the character of his contemporaries. He was educated at Montpellier, and
practised surgery for a time in France. About the middle of the fourteenth
century, according to Pagel, he went back to his native land and settled
for some twenty years at Newark in Nottinghamshire; and for nearly thirty
years longer, until near the end of the century, practised in London.
Ardern's speciality was diseases of the rectum, but he made special
studies in the treatment of fistulas everywhere in the body. He was an
expert operator, and seems to have had excellent success in this field. He
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 some new instruments and of a clyster
apparatus. We know something also about his fees, and there is no doubt
that he obtained quite as good fees in proportion to the value of money as
even any specialist of the modern time.
Ardern gives many evidences of his power of clinical observation, and
incidentally makes it very clear that the eyes of the men of his time were
not so held from seeing the things that lay before them as is often
assumed. Mr. D'Arcy Power, in the paper on "The Lesser Writings of John
Ardern" which he read before the section on the History of Medicine at the
Seventeenth International Congress (see Transactions), has quoted a series
of paragraphs from Ardern which make it very clear how accurate an
observer this fourteenth-century Englishman was. Here, for instance, is
his description of epidemic sore throat in his time, probably diphtheria,
for the death within five days through strangling would seem to point to
this:
"And note diligently that in the sqwynancy [quinsy] and in all the
swellynges of the throte and the nekke and in all the lettynges and
swolowynge as whanne the pacient thereof is oftetymys dysposyd to the
deeth withinne schort time and I have seye manye deyed thereof within
v dayes thorough stranglynge. To the weche it is to know that ther is
nothynge more profytablere therefore thane to use glysteryes of
malowys, mercurye [cheno-podium?] branne and oyle or buttre, hony and
Sal gemme or comone salt. This operacione draweth the wykkyd humours
to the inner partyes that causeth the syknesse and so it helpeth the
sqwynnancye."
Ardern's description of rabies, its fatality, and of how a mad dog acts,
exemplifies still further his accuracy of clinical observation. Only one
who had seen many cases and understood them, and had had many mad dogs
under observation, could have given the details he does. A single
paragraph confirms the idea that the medieval surgeons had very clearly
recognized the disease, and knew as much about it as was known until our
own generation added something of more definite knowledge of the affection
than could be gained by mere clinical observation. Ardern says:
"The bytynge of a wood [mad] dogge is more venemous and perilous thane
it is of a serpente, ffor the venyme of a wood dogge ys hydd often
tymes by the hole yere togydere and other whyle by the ii [two] yere
and after some auctours it wole endure vii yere or it sle [slay] a
man. And note wheyther it be longe tyme hydd or schorte or that it
slee ther comene tofore to the pacient thes tokenys medlynge and
chaungynge of wytte and resone and abhominacione and lothsomnesse of
cold water that is clene and pure. And whane suche sygnys fallen to
him that is byten of a wood hound schall unnethe or ellys [seldom or
never] escape it.
"The tokenys of a wood dogge ben these; the furste is he knoweth not
his lord ne his mayster and he falleth into a voyd goyinge allone with
boowynge of his heed and hangynge of the erys [ears] as other wyse
than ne he hadde hemin his helthe and the yene [eyes] of him ben rede
and the fome cometh out at the mowth and he wole berke at his oune
schadowe and he hath ane hos [hoarse] berkynge, and other houndes
fleene from hyme and berken towardys hyme. And yf a schyvere [slice]
of breed be folden or wette in the bytynge of the sore and yoven a
dogge to ete, yf that he ete it, it is a token that the dogge is not
wood, for and the dogge be wood tha other dogge that the breed is
yoven to wole not ete it, but that he be over moche hungry, and yf he
denye to ete the seyde breed, out-take [unless on] the condicione
aforeseyd, thane is the dogge wood."
Ardern's description of a case of traumatic tetanus is very interesting,
because it contains so many elements that are familiar in the history of
this affection. The fact that it occurred in a gardener from a hook, so
likely to be infected with tetanus bacilli from hay or grass, and that the
wound was made where the thumb joins the hand and where, as we know now,
the construction of the tissues is so favourable to that burying of the
tetanus bacilli away from the free oxygen of the air, giving it a chance
to grow anaerobically, all show the disease exactly as in our own time.
The other details of the case probably indicate a wound of an important
bloodvessel, secondary hæmorrhage after suppuration had been established,
and then the development of fatal subacute tetanus.
"A gardinere whyle that he wrowghte in the vynes kytte his owne hande
with ane hooke uppone a ffryday after the ffeste of Seynt Thomas of
Caunterbury in somere so that the thoombe was altogydere departyd from
the hande saff only in the juncture that was joyned to the hande, and
he myghte boowe bakward the thoombe to his arme and ther stremyd out
therof moche blood.
"And so touchynge to the cure. The thoombe was furst reduced in to his
furste ordre and sowyd and the blood was restreyned with the reed
pouder of launfrankes [Lanfranc's red powder] and with the heerys
[hairs] of ane hare and it was not remevyd une-to the iiide day when
it was remevyd tther apperyd no blood. Thanne was ther putte therto
tho medicines that engendren blood, every day ones repeyrynge the
wounde, and tho it begane to purge itselffe and to gadere mater. And
in the iiiithe nyght after the blood brak out abowte mydnyght in the
wheyghte of ii poundes. And whane the blod was restreyned the wounde
was repeyred frome day to day as it was furste.
"Also in the xithe nyght abowte the forseyd oure the blood brake owt
ayene [again] in more quantyte thane it dyde afore tyme, nevertheless
the blood was staunched, and by the morne the pacient was so taken
with the crampe in the chekes [cheeks] and in the arme that he myght
resseyve no mete in-to his mowth ne neyther opene the mowyth (lockjaw)
and so vexynge the pacient in the xv day the blood brake out ayene owt
of mesure and alwey the crampe endured forth and in the xx day he
dyde."
Another important surgeon of the West of Europe whose book has come down
to us was John Yperman, who owes his name to the fact that he was a native
of the town of Ypres (in Flemish Ypern) in Flanders. Yperman was sent by
his fellow-townsmen to Paris in order to study surgery, apparently at the
expense of the municipality, because they wanted to have a good surgeon
in their town, and Paris seemed the best school at that time. Ypres, so
familiar now as the scene of bloody battles, had become even before the
war one of the less important cities even of Belgium, with less than
20,000 people. It was in the thirteenth century one of the greatest
commercial cities of Europe, and probably had several hundred thousand
inhabitants. The great hall of the Cloth Guild, one of the architectural
triumphs of the time, and such an attraction for visitors to the town ever
since (destroyed in the war) was built at this time, and is another
tribute to the community feeling of the citizens, who determined upon the
very sensible procedure of assuring the best possible surgery for
themselves and fellow-citizens by having one of their townsmen specially
educated for that purpose. Yperman's book on surgery was well known in his
own time, but remained unprinted until about half a century ago (1854),
when Carolus of Ghent issued an edition. Subsequent editions were issued
by Broeckx, the Belgian historian (Antwerp, 1863), and by van Leersum
(1913), who gathered some details of the great Flemish surgeon's life.
After his return from Paris, Yperman obtained great renown, which
maintains 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 tuberculous, tysiken), apoplexy, epilepsy,
frenzy, lethargy, fallen palate, cough, shortness of breath, lung abscess,
hæmorrhage, blood-spitting, liver abscess, hardening of the spleen,
affections of the kidney, bloody urine, diabetes, incontinence of urine,
dysuria, strangury, gonorrhoea, and involuntary seminal emissions--all
these terms are quoted directly from Pagel's account of his work.
There is not much to be said of the surgery of Germany during the Middle
Ages, though toward the end of this period a series of important documents
for the history of surgery were written which serve to show how much was
being accomplished, though the subsequent religious and political
disturbances in Germany doubtless led to the destruction of many other
documents that would have supplied valuable information. Heinrich von
Pfolspeundt's book, which is a work on bandaging--"Bundth-Ertzney"--was
published in 1460, and the experience for it was therefore all obtained
in the Middle Ages. While its main purpose is bandaging, it contains many
hints of the surgical knowledge of the time. There are chapters devoted to
injuries and wounds, though it is distinctly stated that the book is for
"wound physicians" (_Wund Aertzte_) and not for cutting physicians
(_Schneide Aertzte_)--that is, for those who do operations apart from
wounds. There are two operations described, however, that have particular
interest. One of them involves the plastic surgery of the nose, and the
other the repair of a hare-lip.
Pfolspeundt suggested that stitches should be placed on the mucous surface
as well as on the skin surface, after the edges of the cleft in hare-lip
had been freshened in order to be brought closely together for healing
with as little deformity as possible. Perhaps his most interesting
surgical hint for us is a description of a silver tube with flanges to be
inserted in the intestines whenever there were large wounds, or when the
intestines had been divided. The ends of the gut were brought together
carefully over the tube and stitched together, the tube being allowed to
remain _in situ_. Pfolspeundt says that he had often seen these tubes used
and the patient live for many years afterwards. While this resembles some
of the mechanical aids to surgery of the intestines that have been
suggested in our time, this was not the first mechanical device of this
kind that had been thought of. One of the later medieval surgeons in
Italy, one of the Brancas, had employed the trachea of an animal as the
tube over which the wounded intestines were brought together. This had the
advantage of not having to be passed, for after a time it became
disintegrated in the secretions, but it remained intact until after
thorough agglutination of the intestines had occurred.
[Illustration: BRUNSCHWIG'S SURGICAL ARMAMENTARIUM
_From Gurlt's "Geschichte der Chirurgie"_]
Hans von Gerssdorff and Hieronymus Brunschwig, who flourished in the
latter half of the fifteenth century in Germany, have both left early
printed treatises on Surgery which give excellent woodcuts showing
pictures of instruments, operations, and costumes, at the end of the
medieval period.