SURGERY IN THE MIDDLE AGES

12 May

One problem  exacerbated  during  the Middle  Ages was the separation between surgery and medicine. Although  the leech of the early medieval period  was both  physician and surgeon,  his surgery was generally lim- ited  to  simple  emergency  measures,  such  as phlebotomy  (therapeutic bloodletting), cupping (applying evacuated  glass cups to intact or scari- fied skin  in order  to  draw  blood  towards  the  surface),  cauterization, and simple emergency measures for coping with the usual run of burns, bruises,  wounds,  ulcers, sprains,  dislocations,  toothaches, and  broken bones.  A few more  daring  practitioners had  the  special skills needed for  couching  cataracts,   tooth  extraction,   and  lithotomy  (the  surgical removal of stones in the urinary  bladder).

Modern  specialists might be surprised  to find their medieval coun-

terparts  among the lowly oculists, bone setters, tooth  extractors,  cutters of the stone, and other empirics, rather  than in the company  of learned physicians.  Nevertheless,  during  the Middle  Ages, ambitious  surgeons were trying  to  win a more  respectable  professional  status  for  surgery as  a  branch  of  knowledge  with  its  own  body  of  technical  writings, as well as an eminently useful occupation. The specialized literature  of surgery was growing by the thirteenth century,  but  glimpses of earlier surgical traditions have survived in epic poetry  and mythology.

Because the need for surgeons is a common  byproduct of warfare,

semilegendary  stories of great  heroes and  battles  may reflect the con- ditions of battlefield surgical practice with more immediacy than learned texts.  According  to  Scandinavian epic  poets,  if professional  doctors were not available, the men with the softest hands were assigned to care for the wounded.  Many famous physicians were said to have descended from warriors  with gentle hands.  Truly heroic warriors  bound  up their own wounds and returned  to the battle. Sometimes women cared for the wounded   in  a  special  tent  or  house  near  the  battlefield.   One  saga described a woman who cleaned wounds with warm water and extracted arrows with tongs. When the woman could not find the tip of the arrow, she made the patient  eat boiled leeks. Then, the hidden wound could be located  because it smelled of leeks.

Although  epic heroes  apparently emerged  from  crude  battlefield

surgery  completely  healed  and  eager  to  fight,  the  subjects  of  more mundane  operations often succumbed to bleeding, shock, and infection. Despite  their  familiarity  with the soporific  effects of poppy,  henbane, and  mandrake, surgeons  did  not  routinely  use these  drugs  before  an operation. Potions  made  of wine, eggs, honey,  and  beer were used to wash and  dress wounds.  A dressing for burns  might be as gentle as a mixture  of egg whites, fats, and  herbs,  or it might be strengthened by the addition  of goat droppings.

Despite  the  low  status   of  most  medieval  surgeons,   some  dis- tinguished  practitioners deplored  the separation between medicine and surgery.  The  learned  doctors   of  Salerno,  the  most  famous  Western medical  school  of  the  Middle  Ages,  maintained  high  standards  of surgery  and  taught   anatomy   and  surgical  technique   by  dissections of animals.  Medieval  authors  created  simplified Latin  texts  by fusing the work of doctors  at Salerno with excerpts from the Arabic literature. A treatise  on  surgery,  based  on  the  lectures  of Roger  Frugard,  who taught  and practiced  surgery at Parma  in northern Italy, was prepared about  1180 by his colleague Guido  Arezzo, the Younger.  Roger’s influ- ential  and  often  copied Surgery  described  methods  of wound  closure, trephination, and  lithotomy  and  recommended  mercury  for  skin  dis- eases and seaweed for goiter.

In  the  mid-thirteenth  century,   Roland   of  Parma   produced   an important new edition  of Roger’s surgical treatise  that  became known as  the  Rolandina.  Roland, who  taught  at  the  new  medical  center  in Bologna,  based  his teaching  and  practice  on  Roger’s  methods.  Even as late as the sixteenth century, after newer Latin texts and translations of Galenic and Arabic texts became available,  Roger’s treatise was still respectfully  studied.  By the beginning  of the fourteenth century,  texts for surgeons who were literate but had not mastered Latin were appear- ing in vernacular  languages.  These simplified texts  provided  practical information on medicine and surgery and collections of remedies.

Hugh of Lucca (ca. 1160–1257), town surgeon of Bologna, and his

son Theodoric,  Bishop of Cervia (1210–1298), may have been the most ingenious of medieval surgeons.  Theodoric  is said to have attacked  the two great enemies of surgery—infection and pain—and  rejected the idea that the formation of pus was a natural and necessary stage in the heal- ing of wounds.  Indeed,  Theodoric  realized that  the generation  of pus, sometimes   deliberately   provoked   by  surgeons,   actually   obstructed wound  healing.  He  also  objected  to  the  use of complex  and  noxious wound  dressings.

To overcome the pain caused by surgery, Theodoric  attempted to

induce  narcosis  by the  use of a  ‘‘soporific sponge’’ containing  drugs known to produce a sleep-like state. Just how effective his methods were in practice is unclear. Sponges were prepared  by soaking them in a mix- ture  of  extracts  from  mandrake, poppy,  henbane,   and  other  herbs. Before surgery began, dried sponges were soaked in hot water and the patient  was allowed to  chew on the sponge  and  inhale  the vapors.  If the process was successful, the patient  would fall asleep and remember nothing  of the operation—if he woke up again.

Sometime  in the  early  fourteenth century,  Henri  de Mondeville, surgeon  to  Philip  the  Fair  of France,  began  writing  a major  treatise on surgery.  The text was still unfinished  when Henri  died. Moreover, Henri’s text was polemical  in style, highly argumentative, and  hostile

to the medical authorities. Proud  of his skills and accomplishments  as a surgeon,  Henri  protested  the disastrous  results of separating  surgery from  medicine.  By the  end  of the  century,  the  physicians  comprising the Faculty  of Medicine  in Paris were demanding  that  graduates  take an oath  that  they would not  perform  any surgical procedures.  Henri’s work was gradually  forgotten  and his text was not  printed  until 1892. Eventually,   the  title  ‘‘father  of  French   surgery’’  was  bestowed  on Henri’s  student  Guy  de Chauliac  (ca.  1298–1368), eminent  physician and surgeon and author of a treatise on surgery that  was still in use in the   eighteenth   century.   Guy’s   treatise,   composed   about   1363,  is generally considered  the most valuable  surgical text of its time. For  at least  two  centuries,  most  of  the  Latin  and  vernacular  texts  on  sur- gery produced  in Europe  were based  on  the  work  of Roger  Frugard and Guy de Chauliac.

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