James J. Walsh

Strange as it may appear to those who have not watched the development of our knowledge of the Middle Ages in recent years the most interesting feature in the medical departments and, indeed, of the post-graduate work generally of the medieval universities, is that in surgery. There is a very general impression that this department of medicine did not develop until quite recent years, and that particularly it failed to develop to any extent in the Middle Ages. A good many of the historians of this period, indeed, though never the special historians of medicine, have even gone far afield in order to find some reason why surgery did not develop at this time. They have insisted that the Church by its prohibition of the shedding of blood, first to monks and friars, and then to the secular clergy, prevented the normal development of surgery. Besides they add that Church opposition to anatomy completely precluded all possibility of any genuine natural evolution of surgery as a science.

There is probably no more amusing feature of quite a number of supposedly respectable and presumably authoritative historical works written in English than this assumption with regard to the absence of surgery during the later Middle Ages. Only the most complete ignorance of the actual history of medicine and surgery can account for it. The writers who make such assertions must never have opened an authoritative medical history. Nothing illustrates so well the expression of the editors of the "Cambridge Modern History" referred to more than once in these pages that "in view of changes and of gains such as these [the jointing of original documents] it has become impossible for historical writers of the present day to trust without reserve even to the most respected secondary authority. The honest student finds himself continually deserted, retarded, misled by the classics of historical literature." Fortunately for us this sweeping condemnation does not hold to any great extent for the medical historical classics. All of the classic historians of medicine tell us much of the surgery of the thirteenth and fourteenth centuries, and in recent years the republication of old texts and the further study of manuscript documents of various kinds have made it very clear that there is almost no period in the history of the world when surgery was so thoroughly and successfully cultivated as during the rise and development of the universities and their medical schools in the thirteenth and fourteenth centuries.

It is interesting to trace the succession of great contributors to surgery during these two centuries. We know their teaching not from tradition, but from their text-books so faithfully preserved for us by their devoted students, who must have begrudged no time and spared no labor in copying, for many of the books are large, yet exist in many manuscript copies.

Modern surgery may be said to owe its origin to a school of surgeons, the leaders of whom were educated at Salerno in the early part of the thirteenth century, and who, teaching at various north Italian universities, wrote out their surgical principles and experiences in a series of important contributions to that department of medical science. The fact that the origin of the school was at Salerno, where, as is well known, Arabian influence counted for much and for which Constantine's translations of Arabian works proved such a stimulus a century before, makes most students conclude that this later medieval surgical development is simply a continuation of the Arabian surgery that, as we have seen, developed very interestingly during the earlier Middle Ages. Any such idea, however, is not founded on the realities of the situation, but on an assumption with regard to the extent of Arabian influence. Gurlt in his "History of Surgery" (Vol. I, page 701) completely contradicts this idea, and says with regard to the first of the great Italian writers on surgery, Rogero, that "though Arabian works on surgery had been brought over to Italy by Constantine Africanus a hundred years before Roger's time, these exercised no influence over Italian surgery in the next century, and there is scarcely a trace of the surgical knowledge of the Arabs to be found in Roger's works."

It is in the history of medicine particularly that it is possible to trace the true influence of the Arabs on European thought in the later Middle Ages. We have already seen in the chapter on Salerno that Arabian influence did harm to Salernitan medical teaching. The school of Salerno itself had developed simple, dietetic, hygienic, and general remedial measures that included the use of only a comparatively small amount of drugs. Its teachers emphasized nature's curative powers. With Arabian influence came polypharmacy, distrust of nature, and attempts to cure disease rather than help nature. In surgery, which developed very wonderfully in the thirteenth and fourteenth centuries, Salerno must be credited with the incentive that led up to the marvellous development that came. With this, however, Arabian influence has nothing to do. Gurlt, besides calling attention to the fact that the author of the first great text-book on the subject not only did not draw his inspiration from Arab sources, insisted that "instead of any Arabisms being found in his [Roger's] writings many GrÆcisms occur." The Salernitan school of surgery drank at the fountain-head of Greek surgery. Apart from Greek sources Roger's book rests entirely upon his own experiences, those of his teachers and his colleagues, and the tradition in surgery that had developed at Salerno. This tradition was entirely from the Greek. Roger himself says in one place, "We have resolved to write out deliberately our methods of operation such as they have been derived from our own experience and that of our colleagues and illustrious men."

ROGER, ROLAND, AND THE FOUR MASTERS

Ruggero, or Rogero, who is also known as Rogerio and Rogerus with the adjective Parmensis, or Salernitanus, of Parma or of Salerno, and often in German and English history simply as Roger, lived at the end of the twelfth or the beginning of the thirteenth century and probably wrote his text-book about 1180. This text-book was, according to tradition, originally drafted for his lessons in surgery at Salerno. It attracted much attention and after being commented on by his pupil Rolando, the work of both of them being subsequently annotated by the Four Masters, this combined work became the basis of modern surgery. Roger was probably born either in Palermo or Parma. There are traditions of his having taught for a while at Paris and at the University of Montpellier, though these are not substantiated. His book was printed at Venice in 1546, and has been lately reprinted by De Renzi in his "Collectio Salernitana."

Roland was a pupil of Roger's, and the two names that often occur in medieval romance became associated in a great historic reality as a consequence of Roland's commentary on his master's work, which was a favorite text-book in surgery for a good while in the thirteenth century at Salerno. Some space will be given to the consideration of their surgical teaching after a few words with regard to some disciples who made a second commentary, adding to the value of the original work.

This is the well-known commentary of the Four Masters, a text-book of surgery written somewhat in the way that we now make text-books in various departments of medicine, that is, by asking men who have made specialties of certain subjects to write on that subject and then bind them all together in a single volume. It represents but another striking reminder that most of our methods are old, not new as we are likely to imagine them. The Four Masters took the works of Roger and Rolando, acknowledged their indebtedness much more completely than do our modern writers on all occasions, I fear, and added their commentaries.

Gurlt says ("Geschichte der Chirurgie," Vol. I, p. 703) that "in spite of the fact that there is some doubt about the names of the authors, this volume constitutes one of the most important sources for the history of surgery of the later Middle Ages and makes it very clear that these writers drew their opinions from a rich experience." It is rather easy to illustrate from the quotations given in Gurlt or from the accounts of their teaching in Daremberg or De Renzi some features of this experience that can scarcely fail to be surprising to modern surgeons. For instance, what is to be found in this old text-book of surgery with regard to fractures of the skull is likely to be very interesting to surgeons at all times. One might be tempted to say that fewer men would die every year in prison cells who ought to be in hospitals, if the old-time teaching was taken to heart. For there are rather emphatic directions not to conclude because the scalp is unwounded that there can be no fracture of the skull. Where nothing can be felt care must be exercised in getting the history of the case. For instance, if a man is hit by a metal instrument shaped like the clapper of a bell or by a heavy key, or by a rounded instrument made of lead—this would remind one very much of the lead pipe of the modern time, so fruitful of mistakes of diagnosis in head injuries—special care must be taken to look for symptoms in spite of the lack of an external penetrating wound. Where there is good reason to suspect a fracture because of the severity of the injury, the scalp should be incised and a fracture of the cranium looked for carefully. That is carrying the exploratory incision pretty far. If a fracture is found the surgeon should trephine so as to relieve the brain of any pressure of blood that might be affecting it.

There are many warnings, however, of the danger of opening the skull and of the necessity for definitely deciding beforehand that there is good reason for so doing. How carefully their observations had been made and how well they had taken advantage of their opportunities, which were, of course, very frequent in those warlike times when firearms were unknown, hand-to-hand conflict common, and blunt weapons were often used, can be appreciated very well from some of the directions. For instance, they knew of the possibility of fracture by contrecoup. They say that "quite frequently though the percussion comes in the anterior part of the cranium, the cranium is fractured on the opposite part."[18] They even seem to have known of accidents such as we now discuss in connection with the laceration of the middle meningeal artery. They warn surgeons of the possibilities of these cases. They tell the story of "a youth who had a very small wound made by a thrown stone and there seemed no serious results or bad signs. He died the next day, however. His cranium was opened and a large amount of black blood was found coagulated about his dura mater."

There are many interesting things said with regard to depressed fractures and the necessity for elevating the bone. If the depressed portion is wedged then an opening should be made with the trephine and an elevating instrument called a spatumen used to relieve the pressure. Great care should be taken, however, in carrying out this procedure lest the bone of the cranium itself, in being lifted, should injure the soft structures within. The dura mater should be carefully protected from injury as well as the pin. Care should especially be exercised at the brow and the rear of the head and at the commissures (proram et pupim et commissuras), since at these points the dura mater is likely to be adherent. Perhaps the most striking expression, the word infect being italicized by Gurlt, is: "In elevating the cranium be solicitous lest you should infect or injure the dura mater."

For wounds of the scalp sutures of silk are recommended because this resists putrefaction and holds the wound edges together. Interrupted sutures about a finger-breadth apart are recommended. "The lower part of the wound should be left open so that the cure may proceed properly." Red powder was strewed over the wound and the leaf of a plant set above it. In the lower angle of the wound a pledget of lint for drainage purposes was inlaid. Hemorrhage was prevented by pressure, by the binding on of burnt wool firmly, and by the ligature of veins and by the cautery.

There are rather interesting discussions of the prognosis of wounds of the head, especially such as may be determined from general symptoms in this commentary of the Four Masters on Roger's and Rolando's treatises. If an acute febrile condition develops, the wound is mortal. If the patient loses the use of the hands and feet or if he loses his power of direction, or his sensation, the wound is mortal. If a universal paralysis comes on, the wound is mortal. For the treatment of all these wounds careful precautions are suggested. Cold was supposed to be particularly noxious to them. Operations on the head were not to be done in cold weather and, above all, not in cold places. The air where such operations were done must be warmed artificially. Hot plates should surround the patient's head while the operation was being performed. If this were not possible they were to be done by candlelight, the candle being held as close as possible in a warm room. These precautions are interesting as foreshadowing many ideas of much more modern time and especially indicating how old is the idea that cold may be taken in wounds. In popular medicine this still has its place. Whenever a wound does badly in the winter time patients are sure that they have taken cold. Such popular medical ideas are always derived from supposedly scientific medicine, and until we learned about microbes physicians used the same expressions. We have not got entirely away from them yet.

These old surgeons must have had many experiences with fractures at the base of the skull. Hemorrhages from the mouth and nose, for instance, and from the ears were considered bad signs. They were inclined to suggest that openings into the skull should be discovered by efforts to demonstrate a connection between the mouth and nares and the brain cavity. For instance, in their commentary the Four Masters said: "Let the patient hold his mouth and nostrils tight shut and blow strongly." If there was any lessening of the pressure or any appearance of air in the wound in the scalp, then a connection between the mouth and nose was diagnosticated. This is ingenious but eminently dangerous because of the infectious material contained in the nasal and oral cavities, so likely to be forced by such pressure into the skull. They were particularly anxious to detect linear fractures. One of their methods of negative diagnosis for fractures of the skull was that if the patient were able to bring his teeth together strongly, or to crack a nut without pain, then there was no fracture present. One of the commentators, however, adds to this "sed hoc aliquando fallit—but this sign sometimes fails." Split or crack fractures were also diagnosticated by the method suggested by Hippocrates of pouring some colored fluid over the skull after the bone was exposed, when the linear fracture would show by coloration. The Four Masters suggest a sort of red ink for this purpose.

While they have so much to say about fractures of the skull and insist, over and over again, that though all depressed fractures need treatment and many fissure fractures require trepanation, still great care must be exercised in the selection of cases. They say, for instance, that surgeons who in every serious wound of the head have recourse to the trephine must be looked upon as "fools and idiots" (idioti et stolidi). In the light of what we now know about the necessity for absolute cleanliness,—asepsis as we have come to call it,—it is rather startling to note the directions that are given to a surgeon to be observed on the day when he is to do a trepanation. For obvious reasons I prefer to quote it in the Latin: "Et nota quod die ilia cavendum est medico a coitu et malis cibis aera corrumpentibus, ut sunt allia, cepe, et hujusmodi, et colloquio mulieris menstruosÆ, et manus ejus debent esse mundÆ, etc." My quotation is from Gurlt, Vol. I, p. 707. The directions are most interesting. The surgeon's hands must be clean, he must avoid the taking of food that may corrupt the air, such as onions, leeks, and the like; must avoid menstruating and other women, and in general must keep himself in a state of absolute cleanliness.

To read a passage like this separated from its context and without knowing anything about the wonderful powers of observation of the men from whom it comes, it would be very easy to think that it is merely a set of general directions which they had made on some general principle, perhaps quite foolish in itself. We know, however, that these men had by observation detected nearly every feature of importance in fractures of the skull, their indications and contra-indications for operation and their prognosis. They had anticipated nearly everything of importance that has come to be insisted on even in our own time in the handling of these difficult cases. It is not unlikely, therefore, that they had also arrived at the recognition by observations on many patients that the satisfactory after-course of these cases which were operated on by the surgeon after due regard to such meticulous cleanliness as is suggested in the paragraph I have quoted, made it very clear that these aseptic precautions, as we would call them, were extremely important for the outcome of the case and, therefore, were well worth the surgeon's attention, though they must have required very careful precautions and considerable self-denial. Indeed this whole subject, the virtual anticipation of our nineteenth-century principles of aseptic surgery in the thirteenth century, is not a dream nor a far-fetched explanation when one knows enough about the directions that were laid down in the surgical text-books of that time.

THE NORTH ITALIAN SURGEONS

After Roger and Rolando and the Four Masters, who owe the inspiration for their work to Salerno and the south of Italy, comes a group of north Italian surgeons: Bruno da Longoburgo, usually called simply Bruno; Theodoric and his father, Hugo of Lucca, and William of Salicet. Immediately following them come two names that belong, one almost feels, to a more modern period: Mondino, the author of the first text-book on dissection, and Lanfranc (the disciple of William of Salicet), who taught at Paris and "gave that primacy to French surgery which it maintained all the centuries down to the nineteenth" (Pagel). It might very well be thought that this group of Italian surgeons had very little in their writings that would be of any more than antiquarian interest for the modern time. It needs but a little knowledge of their writings as they have come down to us to show how utterly false any such opinion is. To Hugo da Lucca and his son Theodoric we owe the introduction and the gradual bringing into practical use of various methods of anÆsthesia. They used opium and mandragora for this purpose and later employed an inhalant mixture, the composition of which is not absolutely known. They seem, however, to have been very successful in producing insensibility to pain for even rather serious and complicated and somewhat lengthy operations. Indeed it is to this that must be attributed most of their surprising success as surgeons at this early date.

We are so accustomed to think that anÆsthesia was discovered about the middle of the nineteenth century in America that we forget that literature is full of references in Tom Middleton's (seventeenth century) phrase to "the mercies of old surgeons who put their patients to sleep before they cut them." AnÆsthetics were experimented with almost as zealously, during the latter half of the thirteenth century at least, as during the latter half of the nineteenth century. They were probably not as successful as we are, but they did succeed in producing insensibility to pain, otherwise they could never have operated to the extent they did. Moreover the traditions show that the Da Luccas particularly had invented a method that left very little to be desired in this matter of anÆsthesia. A reference to the sketch of Guy de Chauliac in this volume will show how practical the method was in his time.

Nearly the same story as with regard to anÆsthetics has to be repeated for what are deemed so surely modern developments,—asepsis and antisepsis. I have already suggested that Roger seems to have known how extremely important it was to approach operations upon the skull with the most absolute cleanliness. There are many hints of the same kind in other writers which show that this was no mere accidental remark, but was a definite conclusion derived from experience and careful observation of results. We find much more with regard to this same subject in the writings of the group of northern Italian surgeons and especially in the group of those associated with William of Salicet. Professor Clifford Allbutt, Regius Professor of Medicine at the University of Cambridge, England, in his address before the St. Louis World's Fair Congress of Arts and Science in 1904, did not hesitate to declare that William discussed the causes for union by first intention and the modes by which it might be obtained. He, too, insisted on cleanliness as the most important factor in having good surgical results, and all of this group of men, in operating upon septic cases, used stronger wine as a dressing. This exerted, as will be readily understood, a very definite antiseptic quality.

Evidently some details of the teaching of this group of great surgeons in northern Italy in the second half of the thirteenth century will make clearer to us how much the rising universities of the time were accomplishing in medicine and surgery as well as in their other departments. The dates of the origin of some of these universities should perhaps be recalled so as to remind readers how closely related they are to this great group of surgical teachers. Salerno was founded very early, probably in the tenth century, Bologna, Reggio, and Modena came into existence toward the end of the twelfth century; Vicenza, Padua, Naples, Vercelli, and Piacenza, as well as Arezzo, during the first half of the thirteenth century; Rome, Perugia, Trevizo, Pisa, Florence, Sienna, Lucca, Pavia, and Ferrara during the next century. The thirteenth century was the special flourishing period of the universities, and the medical departments, far from being behind, were leaders in accomplishment. (See my "The Thirteenth Greatest of Centuries," N.Y., 1908.)

BRUNO DA LONGOBURGO

The first of this important group of north Italian surgeons who taught at these universities was Bruno of Longoburgo. While he was born in Calabria, and probably studied in Salerno, his work was done at Vicenza, Padua, and Verona. His text-book, the "Chirurgia Magna," dedicated to his friend Andrew of Piacenza, was completed at Padua in January, 1252. Gurlt notes that he is the first of the Italian surgeons who quotes, besides the Greeks, the Arabian writers on surgery. Eclecticism had definitely come into vogue to replace exclusive devotion to the Greek authors, and men were taking what was good wherever they found it. Gurlt tells us that Bruno owed much of what he wrote to his own experience and observation. He begins his work by a definition of surgery, chirurgia, tracing it to the Greek and emphasizing that it means handwork. He then declares that it is the last instrument of medicine to be used only when the other two instruments, diet and potions, have failed. He insists that surgeons must learn by seeing surgical operations and watching them long and diligently. They must be neither rash nor over bold and should be extremely cautious about operating. While he says that he does not object to a surgeon taking a glass of wine, the followers of this specialty must not drink to such an extent as to disturb their command over themselves, and they must not be habitual drinkers. While all that is necessary for their art cannot be learned out of books, they must not despise books however, for many things can be learned readily from books, even about the most difficult parts of surgery. Three things the surgeon has to do:—"to bring together separated parts, to separate those that have become abnormally united, and to extirpate what is superfluous."

In his second chapter on healing he talks about healing by first and second intention. Wounds must be more carefully looked to in summer than in winter, because putrefactio est major in aestate quam in hyeme, putrefaction is greater in summer than in winter. For proper union care must be exercised to bring the wound edges accurately together and not allow hair, or oil, or dressings to come between them. In large wounds he considers stitching indispensable, and recommends for this a fine, square needle. The preferable suture material in his experience was silk or linen.

The end of the wound was to remain open in order that lint might be placed therein in order to draw off any objectionable material. He is particularly insistent on the necessity for drainage. In deep wounds special provision must be made, and in wounds of extremities the limb must be so placed as to encourage drainage. If drainage does not take place, then either the wound must be thoroughly opened, or if necessary a counter opening must be made to provide drainage. All his treatment of wounds is dry, however. Water, he considered, always did harm. We can readily understand that the water generally available and especially as surgeons saw it in camps and on the battlefield, was likely to do much more harm than good. In penetrating wounds of the belly cavity, if there was difficulty in bringing about the reposition of the intestines, they were first to be pressed back with a sponge soaked in warm wine. Other manipulations are suggested, and if necessary the wound must be enlarged. If the omentum finds its way out of the wound, all of it that is black or green must be cut off. In cases where the intestines are wounded they are to be sewed with a small needle and a silk thread and care is to be exercised in bringing about complete closure of the wound. This much will give a good idea of Bruno's thoroughness. Altogether, Gurlt, in his "History of Surgery," gives about fifteen large octavo pages of rather small type to a brief compendium of Bruno's teachings.

One or two other remarks of Bruno are rather interesting in the light of modern developments in medicine. For instance, he suggests the possibility of being able to feel a stone in the bladder by means of bimanual palpation. He teaches that mothers may often be able to cure hernias, both umbilical and inguinal, in children by promptly taking up the treatment of them as soon as noticed, bringing the edges of the hernial opening together by bandages and then preventing the reopening of the hernia by prohibiting wrestling and loud crying and violent motion. He has seen overgrowth of the mamma in men, and declares that it is due to nothing else but fat, as a rule. He suggests if it should hang down and be in the way on account of its size it should be extirpated. He seems to have known considerable about the lipomas and advises that they need only be removed in case they become bothersomely large. The removal is easy, and any bleeding that takes place may be stopped by means of the cautery. He divides rectal fistulÆ into penetrating and non-penetrating, and suggests salves for the non-penetrating and the actual cautery for those that penetrate. He warns against the possibility of producing incontinence by the incision of deep fistulÆ, for this would leave the patient in a worse state than before.

HUGH OF LUCCA

Bruno brought up with him the methods and principles of surgery from the south of Italy, but there seems to have been already in the north at least one distinguished surgeon who had made his mark. This was Ugo da Lucca or Ugo Luccanus, sometimes known in the modern times in German histories of medicine as Hugo da Lucca and in English, Hugh of Lucca. He flourished early in the thirteenth century. In 1214 he was called to Bologna to become the city physician, and joined the Bolognese volunteers in the crusade in 1218, being present at the siege of Damietta. He returned to Bologna in 1221 and was given the post of legal physician to the city. The civic statutes of Bologna are, according to Gurlt, the oldest monument of legal medicine in the Middle Ages. Ugo died not long after the middle of the century, and is said to have been nearly one hundred years old. Of his five sons, three became physicians. The most celebrated of these was Theodoric, who wrote a text-book of surgery in which are set down the traditions of surgery that had been practised in his father's life. Theodoric is especially enthusiastic in praise of his father, because he succeeded in bringing about such perfect healing of wounds with only wine and water and the ligature and without the employment of any ointments.

Ugo seems to have occupied himself much with chemistry. To him we owe a series of discoveries with regard to anodyne and anÆsthetizing drugs. He is said to have been the first who taught the sublimation of arsenic. Unfortunately he left no writings after him, and all that we know of him we owe to the filial devotion of his son Theodoric.

THEODORIC

This son, after having completed his medical studies at the age of about twenty-three, entered the Dominican Order, then only recently established, but continued his practice of medicine undisturbed. His ecclesiastical preferment was rapid. He attracted the attention of the Bishop of Valencia, and became his chaplain in Rome. At the age of about fifty he was made a bishop in South Italy and later transferred to the Bishopric of Cervia, not far from Ravenna. Most of his life seems to have been passed in Bologna however, and he continued to practise medicine, devoting his fees, however, entirely to charity. His text-book of surgery was written about 1266 and is signed with his full name and title as Bishop of Cervia. Even at this time however, he still retained the custom of designating himself as a member of the Dominican Order.

The most interesting thing in the first book of his surgery is undoubtedly his declaration that all wounds should be treated only with wine and bandaging. Wine he insists on as the best possible dressing for wounds. It was the most readily available antiseptic that they had at that time, and undoubtedly both his father's recommendation of it and his own favorable experience with it were due to this quality. It must have acted as an excellent inhibitive agent of many of the simple forms of pus formation. At the conclusion of this first book he emphasizes that it is extremely important for the healing of wounds that the patient should have good blood, and this can only be obtained from suitable nutrition. It is essential therefore for the physician to be familiar with the foods which produce good blood in order that his wounded patients may be fed appropriately. He suggests, then, a number of articles of diet which are particularly useful in producing such a favorable state of the tissues as will bring about the rebirth of flesh and the adhesion of wound surfaces. Shortly before he emphasizes the necessity for not injuring nerves, though if nerves have been cut they should be brought together as carefully as possible, the wound edges being then approximated.

Probably the most interesting feature for our generation of the great text-books of the surgeons of the medieval universities is the occurrence in them of definite directions for securing union in surgical wounds, at least by first intention and their insistence on keeping wounds clear. The expression union by first intention comes to us from the olden time. They even boasted that the scars left after their incisions were often so small as to be scarcely noticeable. Such expressions of course could only have come from men who had succeeded in solving some of the problems of antisepsis that were solved once more in the generation preceding our own. With regard to their treatment of wounds, Professor Clifford Allbutt says:[19]

"They washed the wound with wine, scrupulously removing every foreign particle; then they brought the edges together, not allowing wine nor anything else to remain within—dry adhesive surfaces were their desire. Nature, they said, produces the means of union in a viscous exudation, or natural balm, as it was afterwards called by Paracelsus, ParÉ, and Wurtz. In older wounds they did their best to obtain union by cleansing, desiccation, and refreshing of the edges. Upon the outer surface they laid only lint steeped in wine. Powders they regarded as too desiccating, for powder shuts in decomposing matters wine after washing, purifying, and drying the raw surfaces evaporates."

Theodoric comes nearest to us of all these old surgeons. The surgeon who in 1266 wrote: "For it is not necessary, as Roger and Roland have written, as many of their disciples teach, and as all modern surgeons profess, that pus should be generated in wounds. No error can be greater than this. Such a practice is indeed to hinder nature, to prolong the disease, and to prevent the conglutination and consolidation of the wound" was more than half a millennium ahead of his time. The italics in the word modern are mine, but might well have been used by some early advocate of antisepsis or even by Lord Lister himself. Just six centuries almost to the year would separate the two declarations, yet they would be just as true at one time as at another. When we learn that Theodoric was proud of the beautiful cicatrices which he obtained without the use of any ointment, pulcherrimas cicatrices sine unguento aliquo inducebat, then further that he impugned the use of poultices and of oils on wounds, while powders were too drying and besides had a tendency to prevent drainage, the literal meaning of the Latin words saniem incarcerare is to "incarcerate sanious material," it is easy to understand that the claim that antiseptic surgery was anticipated six centuries ago is no exaggeration and no far-fetched explanation with modern ideas in mind of certain clever modes of dressing hit upon accidentally by medieval surgeons.

Theodoric's treatment of many practical problems is interesting for the modern time. For instance, in his discussion of cancer he says that there are two forms of the affection. One of them is due to a melancholy humor, a constitutional tendency as it were, and occurs especially in the breasts of women or latent in the womb. This is difficult of treatment and usually fatal. The other class consists of a deep ulcer with undermined edges, occurring particularly on the legs, difficult to cure and ready of relapse, but for which the outlook is not so bad. His description of noli me tangere and of lupus is rather practical. Lupus is "eating herpes," occurs mainly on the nose, or around the mouth, slowly increases, and either follows a preceding erysipelas or comes from some internal cause. Noli me tangere is a corroding ulcer, so called perhaps because irritation of it causes it to spread more rapidly. He thinks that deep cauterization of it is the best treatment. Since these are in the department of skin diseases this seems the place to mention that Theodoric describes salivation as occurring after the use of mercury for certain skin diseases. He has already shown that he knows of certain genital ulcers and sores on the genital regions and of distinctions between them.

WILLIAM OF SALICET

The third of the great surgeons in northern Italy was William of Salicet. He was a pupil of Bruno's and the master of Lanfranc. The first part of his life was passed at Bologna and the latter part as the municipal and hospital physician of Verona. He probably died about 1280. He was a physician as well as a surgeon and was one of those who insisted that the two modes of practising medicine should not be separated, or if they were both medicine and surgery would suffer. He thought that the physician learned much by seeing the interior of the body during life, while the surgeon was more conservative if he were a physician. It is curiously interesting to find that the Regius Professors at both Oxford and Cambridge in our time have expressed themselves somewhat similarly. Professor Clifford Allbutt is quite emphatic in this matter and Professor Osler is on record to the same effect. Following Theodoric, William of Salicet did much to get away from the Arabic abuse of the cautery and brought the knife back to its proper place again as the ideal surgical instrument. Unlike those who had written before him, William quoted very little from preceding writers. Whenever he quotes his contemporaries it is in order to criticise them. He depended on his own experience and considered that it was only what he had actually learned from experience that he should publish for the benefit of others.

A very good idea of the sort of surgery that William of Salicet practised may be obtained even from the beginning of the first chapter of his first book. This is all with regard to surgery of the head. He begins with the treatment of hydrocephalus or, as he calls it, "water collected in the heads of children newly born." He rejects opening of the head by an incision because of the danger of it. In a number of cases, however, he had had success by puncturing the scalp and membranes with a cautery, though but a very small opening was made and the fluid was allowed to escape only drop by drop. He then takes up eye diseases, a department of surgery rather well developed at that time, as can be seen from our account of the work of Pope John XXI as an ophthalmologist during the thirteenth century. See Ophthalmology (January, 1909), reprinted in "Catholic Churchmen in Science," Philadelphia, The Dolphin Press, 1909.

William devotes six chapters to the diseases of the eyes and the eyelids. Then there are two chapters on affections of the ears. Foreign bodies and an accumulation of ear wax are removed by means of instruments. A polyp is either cut off or its pedicle bound with a ligature, and it is allowed to shrivel. The next chapter is on the nose. Nasal polyps were to be grasped with a sharp tenaculum, cum tenacillis acutis, and either wholly or partially extracted. Ranula was treated by being lifted well forward by means of a sharp iron hook and then split with a razor. It is evident that the tendency of these to fill up again was recognized, and accordingly it was recommended that vitriol powder, or alum with salt, be placed in the cavity for a time after evacuation in order to produce adhesive inflammation.

In the same chapter on the mouth one finds that William did not hesitate to perform what cannot but be considered rather extensive operations within the oral cavity. For instance, he tells of removing a large epulis and gives an account in detail of the case. To quote his own words: "I cured a certain woman from Piacenza who was suffering from fleshy tumor on the gums of the upper jaw, the tumor having grown to such a size above the teeth and the gums that it was as large or perhaps larger than a hen's egg. I removed it at four operations by means of heated iron instruments. At the last operation I removed the teeth that were loose with certain parts of the jawbone."

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 mass."

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 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, AverroËs, 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

Even this brief account of the surgeons who taught and studied at the medieval universities demonstrates what fine work they did. It is surely not too much to say that the chapter on university education mainly concerned with them is one of the most interesting in the whole history of the universities. Their story alone is quite enough to refute most of the prevalent impressions and patronizing expressions with regard to medieval education. Their careers serve to show how interested were the men of many nations in the development of an extremely important application of science for the benefit of suffering humanity. Their work utterly contradicts the idea so frequently emphasized that the great students of the Middle Ages were lacking in practicalness. Besides, they make very clear that we have been prone to judge the Middle Ages too much from its speculative philosophies. It has been the custom to say that speculation ruled men's minds and prevented them from making observations, developing science, or applying scientific principles. There was much speculation during the Middle Ages, but probably not any more in proportion than exists at the present day. We were either not acquainted with, or failed to appreciate properly, until comparatively recent years, the other side of medieval accomplishment. Our ignorance led us into misunderstanding of what these generations really did. It was our own fault, because during the Renaissance practically all of these books were edited and printed under the direction of the great scholars of the time in fine editions, but during the eighteenth century nearly all interest was lost in them, and we are only now beginning to get back a certain amount of the precious knowledge that they had in the Renaissance period of this other side of medieval life. We have learned so much about surgery because distinguished scholars devoted themselves to this phase of the history of science. Doubtless there are many other phases of the history of science which suffered the same fate of neglect and with regard to which the future will bring us equally startling revelations. For this reason this marvellous chapter in the history of surgery is a warning as well as a startling record of a marvellous epoch of human progress.