HENRI de MONDEVILLE (on surgery)
and  ARNALD of VILLANOVA (on medicine)

HENRI de MONDEVILLE 

on the Morals and Etiquette of Surgeons (c. 1306-1320)

Reprinted from D’Arcy Power, ed., Treatises of Fistula in Ano, by John Arderne (London: Kegan Paul, Trench, Trubner & Co., 1910), pp. 20-22.

“A Surgeon ought to be fairly bold. He ought not to quarrel before the laity, and although he should operate wisely and prudently, he should never undertake any dangerous operation unless he is sure that it is the only way to avoid a greater danger. His limbs, and especially his hands, should be well-shaped with long, delicate and supple fingers which must not be tremulous. He ought to promise a cure to every patient, but he should tell the parents or the friends if there is any danger. He should refuse as far as possible all difficult cases, and he should never mix himself up with desperate ones. He may give advice to the poor for the love of God only, but the wealthy should be made to pay well. He should neither praise himself nor blame others, and he should not hate any of his colleagues. He ought to sympathise with his patients in their distress and fall in with their lawful requests so far as they do not interfere with the treatment.

Patients, on the other hand, should obey their surgeons implicitly in everything appertaining to their cure. The surgeon’s assistants must be loyal to their surgeon and friendly to his patients. They should not tell the patient what the surgeon said unless the news is pleasant, and they should always appear cheerful. They must agree amongst themselves as well as with the patients, and they must not be always grumbling, because this inspires fear and doubt in the patient.... ”

De Mondeville then shows how an honest surgeon may be replaced and damaged by one who is less conscientious, for he says

“A rich man has the beginning of an inflammation. He calls in an upright surgeon, who says after examining him, ‘Seigneur, there is no need for any operation here, because nature will relieve herself, etc.; but if the inflammation gets worse, send for me.’ It then happens that the patient calls in another man who is a quack, and he is told, ‘Seigneur, you have a great deal of inflammation, I can feel it inside, and if you are not treated at once you will certainly regret it.’ This surgeon then sets to work and makes an inflammation, which he afterwards cures, so that the whole proceeding redounds to his credit and profit, for he discovered an inflammation which did not exist, whilst the first surgeon is damaged both in his reputation and his pocket because he did not find out what was not there.”

“Then again, one of these second-rate surgeons will come to a sick man who is wealthy, and will say to him, with the voice of an archangel-taking care that no witnesses are present ‘Seigneur, you must remember that you are the one who is ill and in pain. It is not your son or your nephew. It is you who are kept awake by the pain whilst your friends and servants sleep. Others won’t take care of you if you don’t care of yourself. You are rich enough to get advice and to buy health and whatever else you want if you choose to do so. Riches are not more than health, nor is poverty worse than sickness. Have you not made the greater part of your money yourself and for yourself, so that if you are not a miser you can apply it to relieve your wants? Would to God that those who look after you so badly had your complaint. But all this is between ourselves, and what I tell you is only out of pity for you and for your good,’ Then, in the absence of the patient, he speaks to the relatives and says, ‘Seigneurs, this man has the greatest confidence in you, and, truly, if you lose him, you will lose an excellent friend. It is not to your credit either to let him go without advice, for if he died without advice you would be blamed everlastingly, even if it made him as poor as Job. He is really in great danger, and it is a serious case, but nature sometimes does better than we have any right to expect. He is sure to die if no one treats him, but if he is properly treated it is just possible that he will escape and not die. If he dies it won’t be the result of the treatment, because he is nearly dead already, his only chance is to have a consultation, etc. I am speaking to you as a friend and not as a doctor.’

“But it is quite another matter when this same surgeon has to treat a poor man, for he says, ‘I am really sorry for you, and I would gladly help you for the love of God only. But I am very busy just now with a lot of difficult cases, and, besides, the season is not a very favorable one for an operation. You can’t afford to buy what is necessary for your case, such as drugs and dressings, so I would put it off until the summer. You will then be able to get the herbs and whatever else is wanted and so save expense. The summer, too, is the best time for the poor.’ When the same pauper comes back in the summer the surgeon says to him, ‘I am very sorry that I put you off in the winter and told you to wait until the summer, because the winter is really the best time. Summer is too hot and there is a fear of stirring up the disease. I should advise you to wait until the hot weather is over.’ And this goes on everlastingly, for this kind of surgeon never finds time to operate upon a pauper.”

[De Mondeville classifies his patients according to their ability to pay fees]:.

 “The first class are paupers who must be treated for nothing; the second class are a little better off, and may send presents of fowls and ducks; they pay in kind. The third class are friends and relations who pay no fixed fee, but send victuals or presents in token of gratitude, but no money. Our assistants ought to suggest the presents to this class, saying behind our backs, and as if we knew nothing about it, when anything is said about money, ‘No, indeed, the Master would not like it, and you would do much better to make him a little present, though I am sure that he does not expect anything.’ Indeed, a sharp assistant sometimes makes more by such suggestions than the Master does by his operation, and it is just like doubling the fee on account of the horse when the Master makes his visits on horseback. Then there is a class embracing those who are notoriously bad payers, such as our nobility and their households, government officials, judges, baillies and lawyers, whom we are obliged to treat because we dare not offend them. In fact, the longer we treat these people the more we lose. It is best to cure them as quickly as possible, and to give them the best medicines. Lastly, there is a class who pay in full and in advance, and they should be prevented from getting ill at all, because we are paid a salary to keep them in health.”

[The difficulty of obtaining payment for operations in the fourteenth century must have been very great, for De Mondeville still further emphasizes it and says],

“The chief object of the patient, and the one idea which dominates all his actions, is to get cured, and when once he is cured fie forgets his own obligation and omits to pay; the object of the surgeon, on the other hand, is to obtain his money, and he should never be satisfied with a promise or a pledge, but he should either have the money in advance or take a bond for it. As the poet says, ‘Saepe fides data fallit, plegius plaidit, vadium valet-The promise is often broken, the security is worthless, the bond alone holds good,”

Arnald of Villanova: [1245-1311?]

On the Precautions That Physicians Must Observe”

Reprinted with permission of the publisher from “Bedside Manners in the Middle Ages: The Treatise De Cautelis Medicorum Attributed to Arnald of Villanova,” trans. Henry E. Sigerist, Quarterly Bulletin of Northwestern University Medical School, vol. 20, 1946, pp. 139-142.

[Arnald of Villanova was born in the year 1245, and studied medicine with great success in the University of Paris.  He afterwards travelled for twenty years in Italy and Germany, where he made acquaintance with Pietro d’Apone; a man of a character akin to his own, and addicted to the same pursuits.  As a physician, he was thought, in his own lifetime, to be the most able the world had ever seen. Like all the learned men of that day, he dabbled in astrology and alchymy, and was thought to have made immense quantities of gold from lead and copper.  When Pietro d’Apone was arrested in Italy, and brought to trial as a sorcerer, a similar accusation was made against Arnold; but he managed to leave the country in time and escape the fate of his unfortunate friend. He lost some credit by predicting the end of the world, but afterwards regained it.  The time of his death is not exactly known; but it must have been prior to the year 1311, when Pope Clement V. wrote a circular letter to all the clergy of Europe who lived under his obedience, praying them to use their utmost efforts to discover the famous treatise of Arnold on “The Practice of Medicine.” The author had promised, during his lifetime, to make a present of the work to the Holy See, but died without fulfilling it.

]

We must consider the precautions with regard to urines, by which we can protect ourselves against people who Wish to deceive us. The very first shall consist in finding out whether the urine he of man or of another animal or another fluid; and if it is human urine it is diagnosed in four ways.

The second precaution is with regard to the individual who brings the urine. You must look at him sharply and keep your eyes straight on him or on his face; and if he wishes to deceive you he will start laughing or the color of his face will change, and then you must curse him forever and in all eternity.

The third precaution is also with regard to the individual who brings the urine, whether man or woman, for you must see whether he or she is pale, and after you have ascertained that this is the individual’s urine, say to him: “Verily, this urine resembles you,” and talk about the pallor, because immediately you will hear all about his illness. It commonly happens with poor people and those of moderate means that they go to the doctor when they are afflicted very seriously.

The fourth precaution is with regard to sex. An old woman wants to have your opinion. You inquire whose urine it is, and the old woman will say to you: “Don’t you know it?” Then look at her in a certain way from the corner of your eye, and ask: “What relation is it of yours?” Arid if she is not too crooked, she will say that the patient is a male or female relation, or something from which you can distinguish the sex. Should she say; “We are not related,” then ask what the patient used to do when he was in good health, and from the patient’s doing you can recognize or deduce the sex.

The fifth precaution is that you must ask if the patient is old. If the messenger says yes, you must say that he greatly suffers from the stomach, and that he spits a lot, and in the morning more than at any other time, for old people have by nature a cold stomach.

The sixth precaution: whether this illness has lasted for a long time or not. if the messenger says that it has, you must say that the patient is altogether irritable and that one can help him, or some such talk. It he says no, you must say that the patient is altogether oppressed because in the beginnings of diseases there is much matter that oppresses the organ.

There is a seventh precaution, and it is a very general one; you may not find nut anything about the case, then say that he has an obstruction in the liver. He may say: “No, sir, on the contrary he has pains in the head, or in the legs or in other organs.” You must say that this comes from the liver or from the stomach; and particularly use the word, obstruction, because they do not understand what it means, and it helps greatly that a term is not understood by the people.

The eighth precaution is with regard to conception. An old woman consults you because the patient cannot become pregnant. Perhaps you do not know the cause but say that she cannot hold her husband’s sperm which she could have done very well if she had been well disposed.

The ninth precaution is with regard to a woman, whether she is old or young; and this you shall find out from what is told you. Should she be very old, say that she has all the evils that old women have, and also that she has many superfluities in the womb. Should she, however, he young say that she suffers from the stomach, and whenever she has a pain further down, say that it comes from the womb or the kidneys; and whenever she has it in the anterior part of the head, then it comes from the stomach; and whenever on the left side, then it comes from the spleen; whenever to the right, then it comes from the liver; and when it is worse and almost impedes her eyesight, say that she has pains or feels a heaviness in the legs, particularly when she exerts herself.

The tenth precaution: you must keep yourself very busy spitting or blowing your nose and if the old woman pesters you with the urine say quite casually: “What concern is this of yours?” or “Why do you pester me so much?” If she says: “Yes, it concerns me,” then you shall know the sex. If she says, no, ask as has been explained under the fourth precaution.

The eleventh precaution is taken with regard to white or yellow wine. If you have any doubts in this respect, be cautious and put the lid of the urinal down and pour out a little of the content in such a way that the wine in being poured out touches your finger. Then you must give her the urinal and act as if you were going to blow your nose whereby you put the finger that has been dipped in, on or next to your nose; then you will smell the odor of wine, whereupon you must take the urinal again and say to her: “Get away and be ashamed of yourself!”

The twelfth precaution is taken with respect to fluid made from figs and also nettles. Although you could recognize this under the first precaution, yet you will clearly see that the residue extends in the form of a circle touching the urinal and does not make a rotundity or pine cone like a true sediment.

The thirteenth precaution: whenever the old woman asks what disease the patient has, you must say: “You would not understand me if I told you, and it would be better for you to ask what he should do.” And then she will see that you have judgment in the matter and will keep quiet. But perhaps she will say: “Sir, he is very hot; therefore he seems to have a fever.”-”Thus it seems to you and other lay people who do not know how to distinguish between fever and other diseases.”

The fourteenth precaution: When you have been called to a patient, feel the pulse before you examine the urine and make them [sic] talk so that the condition of the animal virtue becomes apparent to you. After having recognized these factors you will be able to evaluate the urine better and with more certainty and you may proceed thus.

The fifteenth precaution is: should the patient be in a bad condition so that you think that he may die the following day, do not go to him but send your servant to bring you the urine, or tell them to bring it to-morrow in the early morning because you wish that they prepare for the meal and that after you have seen the urine you will tell what they shall administer. And so from the report of the person who brings the urine you will be able to form an opinion about the patient, whether he is in good or bad condition.

The sixteenth precaution is that when you come to a patient you should always do something new lest they say that you cannot do anything without the books.

The seventeenth precaution is that if by hard luck you come to the home of the patient and find him dead and

somebody perhaps says: “Sir, what have you come for?” You shall say that you have not come for that, and say that you well knew that he was going to die that night but that you wanted to know at what hour he had died.

The eighteenth precaution is that if you have a competitor whom you believe to be a shameless crook, be careful when you go to the house of the patient; perhaps he will stir up the urine for you and you will not be able to form a certain judgment from it.

The nineteenth precaution is the following: if two urines of the same patient are presented to you and you wish to know which was the first, ask at what time of the night he got up, for if he did at dawn or after digestion had taken place that urine which is more digested and red will be the first, if it has sediment. If, however, he got up before midnight or around that time, you may judge that the less digested and less red urine is the first.

No other deception can occur outside of these, but these points must be kept in mind, and you must be cautious because the physician is greatly honored if he knows how to be cautious, for he is asked questions many times.

II

Note that the physician must be learned in diagnosing, careful and accurate in prescribing, circumspect and cautious in answering questions, ambiguous in making a prognosis, just in making promises; and he should not promise health because in doing so he would assume a divine function and insult God. He should rather promise loyalty and attentiveness, should be discreet in making calls, and he must be careful in speech, modest in behavior and kind to the patient.

III

Physician! When you shall be called to a sick man, in the name of God seek the assistance of the Angel who has attended the action of the mind and from inside shall attend departures of the body.’ You must know from the beginning how long the sick has been laboring, and in what way the illness has befallen him, and by inquiring about the symptoms, if it can be done, ascertain what the disease is. This is necessary because after having seen the faeces and urine and the condition of the pulse you may not he able to diagnose the disease, but if you can announce the symptoms the patient will have confidence in you as in the author of his health and therefore one must devote greatest pains to knowing the symptoms.

Therefore, when you come to a house, inquire before you go to the sick whether he has confessed, and if he has not, he should confess immediately or promise’ you that he will confess immediately, and this must not be neglected because many illnesses originate on account of sin and are cured by the Supreme Physician after having been purified from squalor by the tears of contrition, according to what is said in the Gospel: “Go, and sin no more, lest something worse happens to you.”‘

Entering the sickroom do not appear very haughty or over-zealous, and return, with the simple gesture, the greetings of those who rise to greet you. After they have seated themselves you finally sit down facing the sick; ask him how he feels and reach out for his arm, and all that we shall say is necessary so that through your entire behavior you obtain the favor of the people who are around the sick. And because the trip to the patient has sharpened your sensitivity, and the sick rejoices at your coming or because he has already become stingy and has various thoughts about the fee, therefore by your fault as well as his the pulse is affected, is different and impetuous from the motion of the spirits. When it has quieted down on both parts, you shall examine the pulse in the left arm because although the right side would he satisfactory, yet it is easier to diagnose the motion of the heart in the left arm on account of its vicinity to the heart. Be careful that the patient does not lie on the right side because the compression would hinder the sense motion, nor should he stretch the fingers or make a fist. While you apply the fingers of your right hand you shall support with the left the patient’s arm, because from greater sensibility you will distinguish the different and various motions more easily, and also because the patient’s arm being so to say weak requires your support. If the arm is very full and fleshy you must press your fingers hard so as to get into the depth; if it is weak and lean you can feel the pulse sufficiently on the surface. You must examine the pulse to a hundred beats at the very least, so that you may form an opinion on the various kinds of pulses, and the patient’s people should receive your words as the result of a long examination of the heart beat.

Finally you request to have the urine brought, and if the change in pulse indicates that the individual is sick, the kind of disease is still better indicated by the urine, but they will believe you to indicate and diagnose the disease not only from the urine but also from the pulse. While you look at the urine for a long time you pay attention to its color, substance and quantity and to its contents from the diversity of which you will diagnose the different kinds of diseases, as is taught in the Treatise on Urines, whereupon you promise health to the patient who is hanging on your lips. When you have left him say a few words to the members of the household, say that he is very sick, for if he recovers you will be praised more for your art; should he die his friends will testify that you had given him up.

Let me give you one more warning: do not look at a maid, or a daughter or a wife with an improper or covetous eye and do not let yourself be entangled in woman affairs-for there are medical operations that excite the helper’s mind; otherwise your judgment is affected, you become harmful to the patient and people will expect less from you. And so, be pleasant in your speech, diligent and careful in your medical dealings, eager to help. And adhere to this without fallacy.

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