The Development of Surgery during the Twelfth through Fourteenth Centuries

Overview

Early in twelfth century pre-Renaissance European surgery and medical practice began to mature, in large part through the heavy influence of ancient Greek texts and the work of Arabic physicians and surgeons. Medical scholarship and practice became centered in southern Italy at Salerno, where a medical school was established in 1140. In the thirteenth century the medical school at Bologna, Italy, was the most influential center of medical expertise, anatomical teaching, and competent surgical practice. Surgeons who trained at Bologna took their practice and scholarship into northern Europe. By the close of the fourteenth century France became the preeminent seat of European surgical practice.

Surgery, as practiced by Theodoric (1205-1296), Guido Lanfranchi (1250-1306), Henri de Mondeville (1260-1320), and Guy de Chauliac (1300-1368), became a respected and important part of medicine rather than the craft of barbers and butchers. The surgical masters of the fourteenth century paved the way for the great European surgeons of the Renaissance and beyond.

Background

In pre-Renaissance Europe surgery was not considered part of legitimate medical practice. Performed by barbers and butchers in Europe, surgery was not even a noble profession. Surgery had, however, been an important aspect in the practice of medicine as conducted by the great Islamic physicians, such as al-Zahrawi (930-1013). Europe's pre-Renaissance surgeons were to be heavily influenced by medicine and surgery as practiced in the Islamic world.

Al-Zahrawi, born near Cordova, Spain, attended the University of Cordova to study medicine. He became a great surgeon and served as court physician to King Abdel-Rahman III. Al-Zahrawi wrote a surgical encyclopedia that influenced surgical practice and training well into the 1600s. In his works he stressed the importance of knowledge of anatomy, particularly the function of organs, along with functional knowledge of bones, nerves, and muscles. He demonstrated and practiced complicated surgical procedures, such as stripping vericose veins (by a procedure not unlike modern practice), closing skull fractures, and performing dental extractions as well as dental implants. In his writing, al-Zahrawi described 200 surgical and dental tools and wrote chapters advising midwives.

Impact

European surgery during the time of al-Zahrawi was still in the Dark Ages. However, in Salerno, Italy, a seaside town long known as a health resort, a school of medicine was established in 1140. The sick (poor and wealthy, young and old), wounded crusaders, and both teachers and students of healing had visited Salerno since the ninth century. The formal school of medicine, Civitas Hippocratica, was established at Salerno by Roger II of Sicily, who introduced the first system of examination for physicians at Salerno. Roger's grandson, Frederic II, later instituted regulations for the practice of medicine and approved a curriculum for medical education.

One legend says that the school at Salerno was created by four masters—a Greek, a Jew, an Arab, and a Latin. Some sources say that the school was heavily influenced by Arab medicine, others contend that its downfall in the thirteenth century was due to the rise of Islamic medicine. The Salerno school reached its zenith during the twelfth century.

At the Salerno school—not far geographically or culturally from Islamic influence—medical texts, such as those written by Al-Zahrawi, and ancient Greek medical texts by Galen (130-200), were translated and widely read. Salerno instructors also produced medical literature, such as the "Regimin Sanitatis Salernitanum" (Salernitan Guide to Health). Roger of Salerno and his star pupil, Roland de Parma, wrote Surgery of the Four Masters, a work that influenced physicians all over Europe.

As the traditions of Arab science and medicine and Greek healing arts were carried on at Salerno during the twelfth century, seats of medical learning, including both anatomical and surgical study and instruction, soon spread northward. One of the first great surgeons of northern Italy was Hugh of Lucca (1160-1257). Influenced by Arab and Greek medicine, Hugh founded what was to become the famous medical school at Bologna, Italy. Most of Hugh's accomplishments and thoughts on surgical practice are best known from accounts written by his student, Theodoric, a cleric-surgeon. Theodoric wrote a book entitled Chirurgia (Surgery) that built upon the teachings of Hugh. It featured a treatise on wound management that debunked the previous century's surgical opinion that the production of pus in a wound was desirable. Hugh and Theodoric felt that wounds should be immediately joined by cautery (the application of a hot blade to seal open wounds), as recommended by Islamic surgeons. Theodoric was also known for experimenting with antiseptics and anesthesia.

Surgery and wound management was also the central concern of other Bologna-trained Italian surgeons, such as Mondino dei Liucci (1270-1326) and William of Saliceto (1210-1277). Anatomy and surgery were separate chairs at Bologna. Mondino, famous for teaching anatomy through public dissection, is credited for having revived the art of dissection as practiced by Islamic anatomists. William of Saliceto, who hoped to unify the practice of medicine and surgery, taught surgery at Bologna and later practiced medicine in Verona. William described the difference between venous and arterial hemorrhage and discouraged cautery. He wrote on both internal medicine and surgery, with a book on surgery published in 1275. William also taught two notable students—Lanfranchi and Henri de Mondeville.

Lanfranchi was part of a movement that saw the "capital" of surgical study and practice shift from Italy to France. Born in Milan, Italy, Lanfranchi studied under William of Saliceto at Bologna but fled to France after civil war in Italy in 1290, settling in Lyon to practice surgery before finally taking residence in Paris in 1295, where he died in 1306. In his last 20 years, Lanfranchi was credited for writing his Chirurgia Parva (Little Surgery) and teaching the next generation of surgeons.

Lanfranchi tried to unify surgery and medicine, asserting that "no man can be a good physician who knows no surgery and no one can be a good surgeon without a knowledge of medicine." Yet, Lanfranchi's surgery has been considered "conservative." For example, he did not believe in surgery for a hernia, preferring trusses and bandages. He preferred to surgically remove bladder stones only as a last resort, yet was considered the father of French surgery.

No French surgeon (save his successor, Guy de Chauliac) is more important to the history and development of surgery than Henri de Mondeville. Remembered as the "first great French master of surgery," Henri, after learning surgery from Theodoric in Bologna, served Louis X, taught anatomy at the school at Montpellier, and was the first French surgeon to write a book on surgery. In Chirgurie, written between 1306 and 1320, Henri cites Theodoric on the treatment of wounds and Lanfranchi on the treatment of ulcers and other diseases. Henri's teaching was largely about the treatment of wounds.

Like Theodoric, Henri taught that the production of pus in a wound was not desirable. He preferred to remove foreign bodies from wounds, control bleeding by any means possible (usually cautery), and to close a wound as quickly as possible by bandages or suture. Henri's later books focused on surgical problems other than wound management and influenced the next generation of French surgeons, most importantly Guy de Chauliac.

Guy de Chauliac is often considered the second great French surgeon of the pre-Renaissance. Born near Avignon, France, Guy became the physician and surgeon to the popes who established residency at Avignon during this period. Guy studied medicine at Montpellier and is best known for his huge text Chirurgie Magna (Grand Surgery). In its many chapters, Guy discussed anatomy as indispensable for the surgeon's art, quoting Mondeville, but going into greater anatomical detail. To his credit, Guy stayed in Avignon rather than flee when bubonic plague, or Black Death, ravaged Europe in 1348 and 1360. Though infected by the plague, he survived and wrote objective accounts of its symptoms and kept track or mortality figures.

A proponent of Mondevillian methods of wound treatment, Guy went further—and many of his contemporaries and successors thought too far—in his treatment of wounds. His practice was often characterized as "meddlesome." Guy advocated removing foreign bodies from wounds, cleaning them with preparations of wine, turpentine, or brandy, packing or draining wounds, cauterization to close wounds, and bandaging or suturing when advisable. He also differentiated types of wounds, such as those "altered by air," contusion wounds, abscessed wounds, and even bites. Guy shocked the fourteenth-century medical world by stating that it took more than nature to heal wounds.

Jean Yperman (1260-1310), a Belgian student of Lanfranchi in Paris, practiced both medicine and surgery and, after returning to his native town of Ypres, was often called to serve as a military surgeon. Because of his military service, he became an expert in the ligature of arteries. Although he left no disciples, he is regarded as the father of Flemish surgery, having invented and developed techniques for ligature that two centuries later were attributed to French master surgeon Ambroise Paré (1510-1590).

The first great English surgeon was John of Arderne (1306-1390). Although the source of his training is not known, John served as a military surgeon during the Hundred Years War, during which time gunpowder was first used. After his military service, John began practicing in Nottinghamshire, where records show he specialized in diseases of the rectum, using surgery to repair anal fistulas, hemorrhoids, and to treat cancer. Records show that John did not use harsh suppositories after his surgery, preferring simple cleansing. Later in his career he moved to London where he was admitted to the Guild of Surgeons. In London, toward the end of his career, he wrote on medical practice.

RANDOLPH FILLMORE