Popular Science Monthly/Volume 51/September 1897/Fourteenth-Century Doctors
DAREMBERG says, in his Histoire des Sciences médicales, that the custom of consultations among doctors was extended in the thirteenth century; but it is probable that the usage existed in previous stages of civilization. There have always been grave maladies and hard diagnoses and cases involving considerable responsibilities, for which a meeting of doctors was desirable; and there have always been patients in considerable social station who liked to be taken care of by several doctors at once. Consultations, therefore, have not all the same origin or the same purpose, but the proceedings in them are always the same—examination for what is the matter with the patient, and discussion concerning it and concerning the treatment to be adopted.
On this subject, we have but few documents from antiquity and the middle ages, and of these the work of Mondeville gives the most information. His work relates to other subjects than surgery, and might, without straining words, be styled Memoirs. Under Philippe the Fair money was scarce, and the doctor and the surgeon were but poorly paid even by the king. "I have never," Mondeville says, "found a man rich enough or honest enough, of whatever condition, religious or other, willing to pay what he had promised without being pressed or forced to do it." His rancor against these patients is so great that he is ready to excuse and counsel even means which we would incontinently reject at this time, to compel them to pay acceptable fees. He does not seem to have put these measures into practice, for he had no fortune; but the fact that a king's surgeon should venture to speak as he does on so delicate a subject casts a curious light on the society of his day and its want of order; on the other hand, his remarks can not be generalized and applied wholesale to the period in which he lived.
Coming to Mondeville's exposition of the method of holding a discussion, we find his description almost a story of what might take place to-day. "First," he says, "we should inquire into the nature of the disease, examining carefully and feeling, because the diagnosis is made by touching with the hand and observing with the eye. All the consultants engage in turn in the examination. Then, if the case demands it, they make a new examination all together, pointing out to one another the symptoms of disease and the special or remarkable features either in the patient or the disease. Then one of them, the highest in rank, says to the patient, ‘Sir, we perceive very clearly what is the matter with you, and you ought to have full confidence in us. and be glad that there are so many of us here, and such doctors—enough for a king—and to believe that the youngest of us is competent to prescribe and carry on your treatment and bring it to a good result.’ Then he interrogates the patient about the circumstances of his attack: ‘Sir, do not be displeased or take it ill, but when did your illness begin?’ following this with many other questions, the answers to which are recorded as indications furnished by the patient.
"When all the questions called for by the case have been asked, the consultants retire to another room, where they will be alone; for in all consultations the masters dispute with one another in order the better to discuss the truth, and sometimes they come to a pass in the heat of discussion which would cause strangers witnessing their proceeding to suppose there were discord and strife among them. This is sometimes the case.
"The oldest, the most eminent, or the most illustrious of the doctors, if there is any such among them, a king's or a Pope's doctor, should propose that they all speak in turn. If they are all silent, as they would be in the presence of so eminent a chief, he should take the floor and question them, one after another, beginning with the youngest and least famous, and so on, passing always from the inferior to the superior. If the older ones spoke first, the younger and less considerable would have nothing to add, and the consultation would thus be of no effect; while, whatever the younger doctors might say, the older ones would have opportunity, which would be valuable in some cases, to correct it, add to it, subtract, oppose, or applaud it. He should ask them concerning the character of the disease, what it is called, what the experience of experts has been with it, what authors mention it, and in what part of their works. These questions being answered, he should inquire whether the disease is curable or not, and how. For a simple example in surgery," says Mondeville, "to show better how the thing is done, suppose a tumor on a fleshy part, the shoulder or the thigh, is to be treated: the doctor should inquire of what matter or humor it is formed; whether of the blood, for example. He should then inform himself concerning the disease, its beginning and progress, and ask if an evacuation is not desirable. This being decided upon, of what kind—a bleeding? If yes, in what limb or what vein, when and where; for the practice varies according to the season and the habits of the patients, and according to the aspects of the moon and the heavenly bodies and an infinite variety of things." Such is the regular, decorous consultation, but things did not always go on thus smoothly.
Before repeating what Mondeville says concerning the incidents of consultations, I will expound the sage precepts he lays down for consultation at a distance, a subject to which he devoted a whole notable. This is an important point when we recollect that at that time, and thence on down to the sixteenth century, the doctor often gave his advice without leaving his office, without seeing the patient, by examining his fluids and asking some questions of the messenger. It is not worth while to give all that Mondeville says, but only the principal parts of his chapter, omitting the arguments which he draws from the authors that preceded him. It was one of the characteristics of the period, as I have already remarked, that authors generally rested their opinions, not principally on their own experience and studies, but on what Galen and some Arabian authors said. The respect of some for their predecessors was absolute, and they cared for nothing besides what rested on the authority of these. Mondeville rose bravely above this principle, but yielded sometimes to its influence, and also called the Arabians to his aid.
On the subject of consultation at a distance, he observes that "people have often asked counsel of us surgeons on the treatment of diseases that we have not seen and can not see, because of the absence and distance of patients who can not be brought to us, while we can no more go to them. Under such conditions, it is neither safe nor conformable to the precepts of the art and of a good conscience to make out a prescription of curative treatment for diseases hard to cure, like cancers, fistulas, etc. It is, however, permissible, after having legitimately excused one's self, to prescribe a palliative treatment. In diseases easy to cure, in recent small wounds—for example, boils, tumors, slight contusions, etc.—we may give a curative prescription to absent persons. We should laugh indeed at surgeons," he adds, "if the patient had to appear personally before them for a light disease as well as for a serious one.
"Possibly the messengers from persons seriously ill will tell us that they know as well as the patient himself all the details of the disease; but this is not possible, for no one can extract facts as appropriate and useful in the particular case as the doctor. The patient would not pay due heed to the questions if they did not come from the doctor; and even if the messengers did exactly describe the condition of the patient as it was—and even this is not possible—they would be wholly, or to a large extent, ignorant of his present state, for it would have changed in the interim." In the proceedings just described things were done correctly, as in our own time, but it was not always so; and there are some statements in Mondeville that throw a curious light on the manners of the fourteenth century.
He represents many persons as choosing their doctor without troubling themselves to know whether he was well taught and experienced; others were not satisfied till they had as many doctors around them as possible. "There are frequently," he says, "Parisians who, when ill, call together a great many doctors of different sects, to consult with them. Some think that the more surgeons they have, the sooner their disease will be cured—the same, for example, as ten masons working together on a wall will accomplish as much in one day as one mason can in ten days. Patients who know how to distinguish among surgeons the one who has the best training and experience prefer to have only one"—and that is Mondeville's advice.
But if complications arise, as a fourth day of fever, it will be preferable to call two surgeons, "and if possible, let them be friends, of the same sect, and agreeing in opinion; if two such can not be found, then a third should be taken in, in order solely to make the others agree after they have discussed the matter." Mondeville is not a partisan of a large number of consultants. He found many inconveniences and few advantages for the patient at the numerous meetings which he attended as king's surgeon. He then makes an irreverent comparison, of the patient to a dog and the surgeons to its hair: "We are," he says, "like the hairs of a dog: the longer and coarser they are, the more they annoy the animal, because they overload him and furnish a harbor for lice, and are of no use in any way, for dogs seldom die of cold. . . . The more numerous we are," he adds, "the less each one of us feels himself responsible. Each says that no larger part of the treatment fell upon him than upon the others. Hence, the more doctors the sick man has the more he finds that he has few or none. If affairs go ill, every doctor excuses himself, and holds that he is absolved. In this way it often happens that wealthy patients are less effectively treated than poor ones, because of the number of doctors they have around them. On the other hand, a large number of consultants embarrasses the attending doctor, and prevents his following his habitual practice; while, if he does not pay strict attention to the observations of the others, they regard him as a disagreeable, proud, self-conceited man."
The experienced surgeon, when he is alone, uses processes which he is not willing to reveal to the others (every one keeps his secrets, and every one pretended to have them in those days), or he is afraid that they will reject his remedy, as some do, who will nevertheless make a note of it to use it on occasion. Or, again, if his remedy is accepted, each of them will want to add something to it—one rose, another melilot, a third camomile—whereby the medicine will lose its virtue and the surgeon will not accomplish his purpose, and will be exposed to reproach from the very persons who have nullified his remedy. And, lastly, when the surgeon reveals to others, who knew nothing about them, the conclusions to which his experience has led him, they will say, "That is what I observed a long time ago," or "That is what I was just going to say."
Another argument adduced by Mondeville against a large number of doctors is that an experienced doctor is really seldom mistaken, while it is impossible, when several doctors have come together, for them all to be agreed as to the cause of the disease, its nature, symptoms, and treatment, for there will be as many
opinions as there are heads. If by chance they should agree upon the purpose to be effected, they will differ concerning the details. One will propose, for example, in the treatment of a tumor, to make it ripen, while another, who had intended to prescribe the same, will say althea and a third ursine, and so on with the others, if there are a thousand of them; then all these drugs will be mixed in the same medicine, although mallows alone would have been the best.
An anecdote is related by Mondeville in illustration of the desire that prevailed in those days to appear to be doing something. During a consultation, when a number of the best doctors in Paris had just formulated a prescription for a sirup, a belated colleague came in. After carefully examining the prescription, he added a berry. On the others expressing surprise, he exclaimed: "Mutton-heads and oxen! why are you looking at me so? How could I conscientiously take my part of the fees if I did not put something in the sirup?"
If the consultants do not dispute over some definite object, they will dispute from jealousy or hatred; and the instant one of them suggests something reasonable and conformable to experience, the others, even though it was what each one of them himself would have recommended if he had been alone, rise one after the other and agree in declaring the contrary of what was proposed.
Mondeville thus describes consultations under two different aspects. The first picture presents the typical, orderly consultation; the second exhibits the daily strifes and rivalries, of which he collects several various types in a few lines. Viewed in this light, the men of the fourteenth century were much like those who followed them, except that they were more brutal and less careful of delicate forms.—Translated for the Popular Science Monthly from the Revue Scientifique.
- Chururgie de Maître Henri de Mondeville (Surgery, by Master Henri de Mondeville), Surgeon of Philippe le Bel of France, composed between 1306 and 1329; translated into French, with notes, an introduction, and a biography; published under the auspices of the Minister of Public Instruction, by E. Nicaise, assisted by Dr. Saint-Leger and F. Chavannes. Paris, 1893, F. Alcan.
- This was characteristic of the age. Even doctors well instructed and advanced in experience did not venture to rest on their personal opinion, but had always to invoke a predecessor, Galen or the Arabs, as the original authority. Mondeville, however, paid less attention to this custom than some of the others.
- Already at that time famous doctors and surgeons went to see their patients, notwithstanding the of communication; Lanfrance, Mondeville, and Guy de Chauliac give us proof of this fact. There were other doctors, clerks, and canons, as were most of the maitres régents of the Faculty of Paris, whose dignity forbade their visiting patients and who gave consultations by interrogating the messenger and analyzing the urine of the patient. This custom disappeared after the reform introduced in 1452 by Cardinal d'Estonteville, who obliged the new doctors regents who received no prebends from the Church, to busy themselves with their patients. The contest of the faculty and the surgeons originated at that time.
- "Most usually," says Mondeville, "the fever accompanying wounds is ephemeral; but sometimes it changes into a fever of suppuration, and this is to be feared when the fever is prolonged beyond four days." This is why our author makes the limit of four days intervene before determining it to be necessary to call in another surgeon.