Henri de Mondeville (c. 1260 – 1316) was the surgeon to two French kings – Philip IV and Louis X. In 1312 he wrote Cyrurgia (Surgery), one of the first works of its kind from the Middle Ages. Based on his years of training, in both France and Italy, this work offers a wide scope of medical treatments, ranging from removing arrows to how to amputate. Here are a few sections from the Cyrurgia.
As to the removal of barbed arrowheads, of prime importance is knowing just what kind of arrow you are dealing with. There are different techniques for each, and various instruments accordingly. If the surgeon lacks that information he frequently be misled … as once happened to me … in a case when an arrow had entered the forearm near the wrist and had passed beneath the soft tissues along the surface of the bone, directed toward the elbow. It went under the outer cord which moves the hand. As I tried to pull it out through the wound of entry I failed to recognize that it had small barbs – it was an English arrow – which had caught the muscle and I could neither unhook it nor extract the arrow. I had to make an incision over the point to remove the metal piece, having to enlarge the wound in the process, much to the great distress of the victim as well as of me.
Removing an iron garrott from a knee
I saw case when none of the equipment for an extraction was suitable, and a new device had to be invented. A man had an iron garrott impaling his knee-joint, with ends protruding equally on both sides. The middle portion was slender while both ends were bulbous. The knee was distorted at the wound of the entry, and the leg was held stiffly bent.
This is how we got it out: We set a fat log securely fixed in the ground, its end was hollowed to a width and depth large enough to encompass the entire knee region … we cut slots on both edges that would accept the protruding garrott. We padded the inside of the hollow with cloths to protect the knee from further injury. We placed a metal plate alongside the leg with a hole that fitted over the one protruding end of the garrott set against the slot in the log. Then a strong man with a heavy hammer struck a powerful blow against the end of the garrott and it flew out the opposite side of the log.
The Jugular Vein in the Neck
In my experience there has been only one kind of wound in which the hemorrhage could not be controlled: a penetrating (ie. arrow) wound in the neck involving the jugular vein and the nearby carotid artery and trachea. The weapon must be removed promptly lest the patient suffocates, and the surgeon who acts does not know that the weapon has penetrated any of those channels, and he may not be overly concerned because the patient can still speak, albeit with a hoarse voice.
After he removes the arrow he may be able to do something about the external bleeding but he can do nothing about the unanticipated internal bleeding which will cause death immediately after the arrow is withdrawn…If the blood spurts forcefully, stopper the wound with a coin or another similar object…do not extract the weapon before the patient has received last rites from a priest when there is a real concern for an ensuing hemorrhage. When the spurting blood forebodes death unless the treatment is undertaken, the surgeon and the priest should stand ready to do their jobs.
Patients Who Can See Their Own Blood
Now a word about the wounded patient who can see his own lost blood. Whether or not the bleeding has stopped, tell him it was for his own good. And, later on, if he sees that he is bleeding again and he is fearful that it will continue, tell him the same.
Remember, imagination dominates the other faculties. His image of himself bleeding may be as misleading as that of the hen who imagines she is a rooster … It will serve him well to give the patient some bread soaked in spiced wine. That will calm his nerves and restore his vitality, and the comforted patient will retain the blood that is Nature’s friend, and he will collect his scattered and forsaken wits and with them his blood and his natural heat.
Dealing with Onlookers
Dismiss the household staff from the scene of the hemorrhage, all who are not the surgeon’s own staff or the close friends of the patient. Vegetius wrote that a crowd of onlookers hear nothing but the bad news and embarrass those who are at work.
Another good reason is you will find in that crowd some who have had no experience with the frightful doings of surgery. They will faint and thereby frighten the patient and exacerbate his own shock. When he sees, amid the crowd of attendants, someone swoon and fall, his own fears will become more vivid. Send them away if you can. However, if they remain, you will derive some benefit. In serving the needs of the attendant who faints and dashes his head against a block of wood etc, you may have more success treating him than in treating the primary patient.
The Diet for Wounded Patients
The Bread: Use good wheaten flour; allowed to stand a while to ferment and then bake it half-way – neither too stale nor too fresh – about three days is proper. Other Foods: They should be light, tender, and easily digested; good, generous sources of blood, dry but not charred. Even small amounts are useful. These include hens, capons, chicks, gelded kids, pheasants, partridges, meadow birds with narrow beaks, hens eggs boiled in their shells. The meats should be roasted if possible and the charred crust removed. The wine: The best you can obtain – red or white, light, aromatic, tasty and of medium strength.
It may seem to you that wounds of the brain will be more lethal than all others. Yet Theodoric (one of Henri’s teachers) cured a man who had lost about a third of the posterior part of his brain, where the faculty of memory is seated. The man was a saddle-maker and he recovered his skills.
For my part, I often have removed bits of brain which adhered to arrows which I have extracted from wounded heads; brain tissue resembles soft white cheese. I treated the wounds strictly in accord with Theodoric, avoiding painful measures which disturb patients. However, if you treat these wounds the wrong way, they will be more lethal than the wounds described in this catalogue.
Where to Amputate
When a surgeon encounters gangrene that has resisted all other treatments, he must amputate the limb to save the patient’s life as well as to arrest the advance of the gangrene. Thus, if the end of a digit is gangrenous, amputate through the next joint; that is the rule to follow elsewhere.
For example, if the gangrene reaches the palm, amputate at the wrist. If it involves the forearm amputation at the elbow. But if it extends into the upper arm the patient cannot survive. What I have said about the arm applies as well to the toes, the foot and lower leg; if the gangrene reaches the thigh the patient will die.
How to Amputate
Encircle the limb with two tightly wrapped cords or towels. Place one just below the join and the other on the healthy side of the site amputation. Two aides must grasp the limb securely, above and below, to enable the surgeon to do his work in a stable field. The tight bindings will reduce the patient’s sensibility. The limb should be elevated to lessen the loss of blood.
The operation should avoid causing unnecessary suffering. Disarticulation is not so difficult and requires less skill for an experienced surgeon who knows his anatomy. If you must saw a bone, do as follows: Make a circular incision between the two bindings. Cut right down to the bone with a hot iron or gold cautery, as broad and as slim as a knife blade. Then cover both surfaces of the soft tissues with damp cloths to spare them injury by the saw. Use the correct tool and saw through the bone with deft, light and smooth strokes.
In Normandy the most esteemed treatment for rabid dog-bites is known to everybody, no matter how uneducated they may be, known for its easy use. It consists of nine immersions in the sea by every person or animal that has been bitten by a dog, whether or not it is known to be rabid and the victim need not be certain about the danger. All the surgeon has to do is treat a simple wound. Theriac is of no use. I have often seen people and animals taken to the seashore who already exhibit the bad signs, at peace and docile as they are led. In such cases I venture to give some tormentilla as a suitable intervention.
You can read a complete translation of Cyrurgia by Leonard D. Rosenman in The Surgery Of Henri De Mondeville. You can read more about medieval medicine, including:
Medieval management of spinal injuries: parallels between Theodoric of Bologna and contemporary spine surgeons
Top Image: British Library MS Sloane 1977 fol. 2