The Greatest Benefit to Mankind: A Medical History of Humanity. Roy Porter

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СКАЧАТЬ 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.

      MEDICINE AND THE PEOPLE

      From the twelfth century, Europe blossomed: population rose, trade boomed, and courts and cities acquired a new sophistication. Such circumstances helped medicine. Though learned physicians were at the top of the tree, they constituted only a small fraction of all those offering medical services, and larger towns attracted a diversity of healers. Around 1400 Florence boasted not only graduates of Padua and Bologna, but bone-setters from Rome and families specializing in eye-diseases, hernia and the stone. Herbalists, midwives and pedlars of folk remedies thrived, and parish priests plied pious cures.

      With numbers rising, medicine needed to organize itself. This happened first in urban Italy, where medical guilds assumed responsibilities for apprenticeship, examination of candidates, location of pharmacists and supervision of drugs, food and herbs. As early as 1236 Florentine physicians and pharmacists grouped into a single guild, recognized as one of the city’s seven major crafts.

      Medical organization took various forms. In southern Europe there was no great gulf between surgeon and physician: surgery was a desirable skill for a physician to acquire. In Frederick II’s regulations for the Kingdom of Sicily (c. 12 31), a licence to practice medicine could be gained only after five years of study which included surgery, and in Italy the chance to learn surgery at university helped to prevent professional rancour between the two branches. Elsewhere the gap widened, however, for beyond Italy surgery was excluded from the academic curriculum. In northern Europe surgical training and practice were organized on a guild basis, through apprenticeship, and so were regarded by physicians as infra dig.

      In Paris, the surgeons’ organization began in 1210 when the College of St Cosme (Côme or Cosmas) was established. Its members were divided into the long- and the short-robed, only the former being entitled to operate. Training was mainly practical and the college granted three degrees: a bachelor’s, a licence and a master’s. A three-cornered tussle developed between physicians of the faculty, the surgeons of the college, and the barbers, who did bleeding and the like. The introduction of anatomy added to the confusion, for dissections were under the direction of a physician but the knife-work was performed by a surgeon. Not till 1516 was the conflict resolved, with the surgeons ceding precedence to the physicians, for both could unite in antipathy towards the ‘ignorant’ barbers. In the German states and England, the barber-surgeon became typical, but in Italy, Spain and southern France, that hybrid occupation never gained prominence.

      In London, the Fellowship of Surgeons came into being in 1368–9, and a Company of Barbers was chartered in 1376. The tiny band of university-trained physicians did not organize themselves until 1423, when a group led by the cleric and court physician, Gilbert Kymer (c. 1385–1463) petitioned for a joint college ‘for the better education and control of physicians and surgeons practising in the city’. Not until the founding of the College of Physicians of London in 1518 could the physicians regulate metropolitan practice. Though intra-professional conflicts flared, they were not universal. In small cities like Bristol or Norwich, physicians, surgeons and barbers found strength in unity. And, in any event, professional tussles in the late medieval centuries reflect the surging number of healers and their dawning sense of civic standing.

      This proliferation provoked attempts by princes and city authorities at regulation and ‘protection’. In the Kingdom of Sicily the royal physician took charge of licensing, while in the 1340s the Aragonese King Peter licensed Jewish practitioners who had been denied medical degrees from Christian universities. Church authorities often licensed midwives, on the grounds that their morals needed to be impeccable.

      Urban expansion also explains the emergence, initially in northern Italy, of community-employed public physicians. The earliest known public contracts for such medici condotti were at Reggio in 1211 and in neighbouring Bologna in 1214, where the appointee was to treat soldiers as well as citizens. Contracts typically imposed a residence requirement, balanced the doctor’s private and public duties, and set scales of fees. Especially in time of plague, the civic doctor was to assist at inquests and trials, to attend hospitals, and to tend injuries resulting from judicial torture.

      This system spread. By 1300, public physicians were found in all the large towns of northern Italy; a century later the office was almost universal in northern and central Italy and in the Venetian territories in Dalmatia and Greece, and it had also been adopted in major centres in Provence, Aragon and Valencia. By 1500 civic doctors were being appointed in northern France, Flanders and many German cities, though Britain lagged behind.

      Meanwhile rising urban populations contributed to overcrowding and worsening sanitary problems, due to the contamination of drinking water and food, waste accumulation and the keeping of livestock. Water began to be piped into towns, and by 1300 Bruges had built a municipal water system. Many towns СКАЧАТЬ