Читать книгу The Greatest Benefit to Mankind: A Medical History of Humanity - Roy Porter - Страница 38

The great age of hospital building from around 1200 coincided with the flourishing of universities in Italy, Spain, France and England, sustained by the new wealth and confidence of the High Middle Ages. Paris was founded in 1110; Bologna in 1158; Oxford in 1167, Montpellier in 1181, Cambridge in 1209, Padua in 1222 and Naples in 1224. The universities extended the work of Salerno in medical education. By the 1230s Montpellier was drawing medical students from afar; there, as in Paris, Bologna, Oxford and other centres, medical teaching initially developed informally, but teachers later banded themselves into an official faculty.

There were some differences between the clerically dominated universities of the north like Paris, Cologne and Oxford, where the theology faculty was supreme, and the more secular ones of Montpellier and Italy, where arts and law faculties led; but all had much in common. The Bachelor of Medicine (MB) took around seven years of study, including a preliminary Arts training; a medical doctorate (MD) was awarded after around ten years’ study. Hence there were hardly swarms of medical students: Bologna granted 65 degrees in medicine and only one in surgery between 1419 and 1434; Turin a mere 13 between 1426 and 1462. The single big school and true centre of excellence was Padua, where medical students comprised one tenth of the student population. Its medical faculty was unusually large, numbering 16 in 1436 – Oxford had only a single MD teaching.

Following the model established in universities at large, medical education was based on set books, usually parts of the Articella and Avicenna’s Canon, expounded in lectures. It was also heavily influenced by the new Aristotelianism associated with Thomas Aquinas (1226–74) and Albertus Magnus (1200–80). A Dominican monk who taught at the new university of Cologne, Albert was wrongly credited with many medicinal recipes and occult treatises, as well as with the De secretis mulierum [On the Secrets of Women], all of which blocked his canonization until 1931.

After perhaps seven years’ study beyond the Arts degree, doctoral graduation rested on having attended the requisite lectures, disputations and oral examinations and – at some universities, including Bologna and Paris – on having worked under a physician (such clinical experience had to be acquired extra-murally). From about 1300 at Bologna and a generation later at Montpellier, university requirements further demanded that students attend a dissection, to supplement traditional anatomical lessons on dead animals. The academic justification of a medical education lay in the acquisition of rational knowledge (scientia) within a natural philosophical framework. Medical professors aimed to prove that their discipline formed a noble chapel of the temple of science and philosophy; the learned physician who knew the reasons for things would not be mistaken for the hireling with a knack for healing.

Renaissance humanists and subsequent historians have sneered at medieval academic medicine for its Galenolatry and its abstract disputation topics (‘Can sleep be harmful?’). But formulaic teaching was unavoidable in an age when books were few. And if much of the knowledge seems rather formal, this is because the student had to understand the medieval forerunner of what is now prized as ‘basic science’: the theory of the physical world and its laws and purposes. Grasp of universal truths was needed to comprehend individual cases, and the ability to reason and cite chapter and verse raised the true physician above the empiric.

Graduates got the pick of the patients; princes and patricians in Italy, France and Spain welcomed cultured doctors who could explain the whys and wherefores. The duties of physicians in the service of King Edward III of England were clearly laid down:

And muche he should talke with the steward, chamberlayn, assewer, and the maister cooke, to devyse by counsayle what metes and drinkes is best according with the Kinge.… Also hym ought to espie if any of this courte be infected with leperiz or pestylence, and to warn the soveraynes of hym, till he be purged clene, to keepe hym oute of courte.

The learned physician claimed, in the Hippocratic manner, to prevent disorders or restore health by dietetics and drugs. For that he would need to form a diagnosis. Feeling the pulse and scrutinizing urine (uroscopy) were routine, and the doctor’s consilium (advice) would be a personal prognosis based on a patient’s history. Drug prescriptions were also personalized, involving compound mixtures (polypharmacy), often called ‘Galenicals’.

Highly prized was medical mathematics, which sought to achieve an understanding of the significance for health of the motions of the heavens, in a tradition going back to the Hippocratic Epidemics and embracing subsequent developments in Ptolemaic astronomy and astrology. Following Galen, disease was enumerated as involving sequences of ‘critical days’ when an illness would reach crisis point and then either subside or prove fatal. The physician on Chaucer’s Canterbury pilgrimage was proud of his astrological learning:

With us ther was a DOCTOUR OF PHISYK,

In al this world ne was ther noon him lyk

To speke of phisik and of surgerye;

For he was grounded in astronomye.

He kepte his pacient a full greet del

In houres, by his magik naturel.

Wel coude he fortunen the ascendent

Of his images for his pacient.

He knew the case of everich maladye,

Were it of hoot or cold, or moiste, or drye,

And where engendred, and of what humour;

He was a verrey parfit practisour.

Medical astrology might require arcane and labyrinthine calculations, but there were handy charts to illustrate planetary influences over the organs of the body and their maladies. Princely courts often housed a physician-astrologer, though it could prove a risky trade: the physician John of Toledo (d. 1275) was accused of dabbling in necromancy, and thrown into prison.

Zodiacs and nativities were also used to ascertain the right time for blood-letting. Recommended in spring and the beginning of September, its benefits, according to the Salernitan Rule of Health, included sound sleep, toning up the spirits, calmness, and better sight and hearing. Bleeding was left mainly to surgeons and barber-surgeons, who also cupped, pulled teeth, leeched, gave enemas, curetted fistulas, applied ointments, drained running sores, sutured wounds, removed superficial tumours and stopped haemorrhaging. Descriptions of trusses and eyeglasses began to appear in the thirteenth century.

Dietetics, by contrast, was the main therapeutic recourse of the physician regulating lifestyle in accordance with the six non-naturals. Spurred by the revival of international commerce, pharmacy also developed, especially in Venice, where drugs imported from the East were traded in large stores (apothecai), which came to mean a druggist’s shop.

Relations between physicians and surgeons were not always plain-sailing, especially with eminent surgeons like Henri de Mondeville, Guy de Chauliac and John of Arderne (c. 1307–70) laying claim to learning as well as a good eye, a steady hand and a sharp blade. According to de Mondeville, ‘it is impossible to be a good surgeon if one is not familiar with the foundations and general rules of medicine [and] it is impossible for anyone to be a good physician who is absolutely ignorant of the art of surgery.’

Among the famous early surgical writers was Lanfranc of Milan (c. 1250–1306). Italian by birth, he settled in Paris where he wrote his Chirurgia magna, an expansion of his more popular Chirurgia parva. They were both translated into French, Italian, Spanish, German, English, Dutch and Hebrew. The Grand Surgery is divided into sections on general principles, and on anatomy, embryology, ulcers, fistulas, fractures and luxations, baldness and skin diseases, phlebotomy and scarification, cautery and diseases of various organs. There is also a lengthy section on herbs and pharmacy. Lanfranc was valued by his distinguished successors, de Mondeville and de Chauliac.

Henri de Mondeville (c. 1260-f. 1320) was born in Normandy, studying at Montpellier, Paris and Bologna. Travelling widely, he spent some time as a military surgeon to the French royal family, and lectured in surgery and anatomy at Montpellier and Paris. He planned his Cyrurgia (begun in 1306 but never completed) along traditional lines, opening with anatomy and moving on to wounds. Attention was paid to the contentious topic of wound treatment. Mondeville advocated simple bathing of wounds and immediate closure, followed by dry dressings with minimal loss of flesh or skin. His preference was for dry healing without pus formation, a view contradicting Hippocratic wisdom but already advocated by Hugo of Lucca (c. 1160–1257) and his disciple, Theoderic (1205–96), who had boldly maintained in his Chirurgia (1267) that ‘it is not necessary that pus be formed in wounds’.

This new approach met opposition from supporters of conventional wound salves: plasters and powders designed to promote suppuration; since Greek times it had been taught that certain types of pus (known as ‘laudable pus’) were beneficial, conveying poisoned blood out of the body. The Salernitan school had thus recommended keeping wounds open to allow for suppuration and healing per intentio secundam (by second intention), from the base of the wound up.

The most prominent surgeon of the next generation was Guy de Chauliac (1298–1368), educated at Montpellier and Bologna. His great work, the Chirurgia magna, was fully comprehensive, covering anatomy, inflammation, wounds, ulcers, fractures, dislocations and miscellaneous diseases belonging to surgery. An astonishing exercise in surgical erudition, it contains no fewer than 3299 references to other works, including 890 quotations from Galen. This parade of sources was calculated, since Chauliac was concerned to show surgery to be a learned art:

The conditions necessary for the surgeon are four: first, he should be learned, second, he should be expert: third, he must be ingenious, and fourth, he should be able to adapt himself. It is required for the first that the surgeon should know not only the principles of surgery, but also those of medicine in theory and practice.

Chauliac’s Chirurgia was translated into several languages. In the pus bonum et laudibile debate, he did not exactly take sides, though he appears to have been hostile to traditional wound salves, judging they did more harm than good. The work also contains fascinating details about his own times, including first-hand reports of the Black Death, descriptions of surgical instruments and operations, and his often damning judgments on his contemporaries. Like most medieval practitioners, he offered a pot-pourri of Hippocratic treatments and ones of a magico-religious flavour. Epileptics, for instance, were to write in their own blood on a piece of parchment the names of the Three Wise Men, and to recite three Pater Nosters and three Ave Marias daily for three months.

The most distinguished English surgeon was John of Arderne, who served under John of Gaunt in the Hundred Years War and produced a Treatment of Anal Fistulas. For this operation, his technique was to place the patient in the lithotomy position. Four ligatures were taken up through the fistula, and their ends, drawn down through the anus, were knotted to stop the bleeding. Next, he pushed one grooved instrument through the fistula into the rectum, where it made contact with another. He then made a bold cut with his scalpel to remove the whole intervening segment, and stopped the bleeding between the ligatures with a hot sponge. The wound was cared for by cleaning and the patient was given daily enemas.