to diminish them as far as we can. We do not think the right way to do this is by ignoring their existence, though doubtless many ailments partake of the nature of hypochondria, and can be lessened or cured by the mental attitude towards them.

6

We believe that it is our duty to learn the working of the laws which the Creator has made, and in obedience to them to work towards the healing or salvation of the spirits, souls, and bodies of mankind. When we are told, as we are by our Lord, that mountains can be removed through faith, it surely implies that every means He has provided must be employed in order to attain our end. Medicine, doctors, physicians, surgeons and healers of every description have their place in the Divine Economy. Such a terrible visitation as the Plague of London in the seventeenth century we believe to be impossible in modern days; and this is not because we ignore the reality of disease and infection, but because increasing knowledge (in this case medical science) has taught us that such epidemics are the result of bad sanitation and crowded dwellings. We are intended to make use of every source of knowledge and of every appliance. It has been discovered that the infection in the case of the Great Plague was carried by fleas which are found upon rats and mice. It was ignorance of this fact which caused the widespread character of the visitation in this country.

This, while showing what advance had been made in early days, may explain an obscure passage in the Old Testament (1 Sam. vi. 5). When the Ark had been captured by the Philistines it brought trouble wherever it was taken. Tumours broke out upon the inhabitants of the cities. It was therefore decided to send it back to the Israelites, from whom it had been captured, and with it a guilt offering in the shape of five golden tumours, and five golden mice, 'images of your mice that mar the land.'

It is also a notorious fact that in the Great War the number of deaths through sickness was an almost negligible percentage compared with that in preceding wars on a much smaller scale. In the Boer War, at the beginning of this century, the death roll through disease formed a great part of the total list of casualties. In the last war inoculation and other sanitary precautions had a wonderful effect and saved innumerable lives.

This is surely what is intended by the removal of mountains and is the sphere of faith, or trust, working through love in the care of the bodies of men. This is of much greater practical use in the world, as we know it, than the ignoring of the mountains as mere figments of a diseased imagination.

• Spiritual Healing, by Harold Anson. University of London Press.

C. H. PRICHARD.

1925

ASEPTIC SURGERY IN THE FOURTEENTH CENTURY

ARTS and crafts once definitely lost to mankind have not usually been recovered. The beautiful art of making stained glass, such as may be seen in mediæval windows, is not now known to us. We do not know exactly the dyers' secrets from which came the lovely Persian carpets which have survived from the Middle Ages. Tyrian purple cannot now be produced. No modern contractor can make mortar such as the Romans used.

Some lost arts have however been recovered. A pleasing reproduction of the Roman ware called 'Samian' has recently been made, for instance, and the material used is none other than that terra sigillata from which our old conquerors fashioned their domestic vessels.

But when it is suggested that aseptic surgery is really one of these old lost arts now recovered, something more than the mere assertion of so very unlikely a thesis seems to be required. For Listerism has been hailed by the civilised world as one of the greatest discoveries of an ingenious age; and the originality of this discovery can hardly be impugned.

Let it therefore be stated, with all the solemnity that so remarkable a fact demands, that in the early fourteenth century there were men who not only knew that wounds could be healed without suppuration, but who practised continually, and with marked success, that cleanly letting alone of the wounds which is the basis of aseptic surgery to-day. They used as a mild antiseptic application warm wine alone.

The story of the evolution of antiseptic methods by Lister in the nineteenth century has been often told. His ingenious and determined interpretation of Pasteur's work on microbes in connection with fermentation and putrefaction has been the theme of innumerable orations, lectures, essays, and writings during the fifty odd years that have passed since his early publications. But the wonderful story of Henry de Mondeville's work, developed from what was really very little more than a hint by his teacher and predecessor, Theodoric, has yet to be told in its entirety. As we shall see, de Mondeville developed a definite

theory of wound-healing, and practised a method, which in essentials were indistinguishable from those of to-day.

It is our present task to show how this wonderful invention came to be neglected and soon forgotten, so that surgery was flung back into the six hundred years of ignorance that have intervened, in which suppuration, produced often by messy applications and uncleanly dressings, has reigned supreme and slain its millions.

Historically, this must be reckoned as perhaps one of the greatest of all the misfortunes that have befallen the world. For it is hardly possible to imagine the heights to which surgery might have risen in the course of six hundred years of the practice of these aseptic methods.

It is therefore of interest to see how this priceless boon, after being actually given to the world, was thus carelessly dropped into the limbo of oblivion. For it may safely be affirmed that at no point in the social history of the world has so great a prize been won and lost again to the human race.

Theodoricus, Theodoric or Thederic, as his name is variously found, was born in Italy in A.D. 1208, almost certainly of Italian parentage. He lived to the advanced age of ninety. He learned his medicine and surgery from Hugh of Lucca, of whom he affectionately speaks as his 'father.' Like most learned men of his age, he entered the Church, and was consecrated Bishop of Cervia. His surgery was that of the Bolognese school, and he recorded his experience and set forth his teaching in his great text-book Chirurgia Magna.

From the first century of our era the theory and practice of surgery as recorded by Galen, and founded on the Hippocratic teaching of the medical school of Cos, had been paramount. Its prestige was absolute, and can only be compared to that enjoyed in subsequent ages by Holy Writ.

By Galen suppuration in wounds was conceived to be a natural condition, and was thought to be the physiological process leading to cicatrisation. So necessary was it considered to be that applications called 'suppuratives' were constantly applied to the wound to hasten the establishment of the process, in which no doubt much success was obtained. Such applications often consisted of honey or oil of roses or white of egg.

The great step forward taken by Theodoric was the enunciation of the theory that suppuration, so far from being a natural process, is really a complication, and one which can nearly always be avoided by appropriate measures. This idea was warmly adopted, widely applied, and greatly perfected by Henri de Mondeville. The battlefield on which in later days Lister performed such immortal feats

was in fact fought over at the beginning of the fourteenth century. But in this great contest for cleanliness, simplicity, and sound surgery all was eventually lost; and a very few years after de Mondeville's death, in 1320, suppuration once more reigned supreme in the surgical world. And for nearly six hundred years it has done its deadly work, levying a toll of pain, misery, and death beyond all possibility of computation.

The treatment, then, which Theodoric inherited from the ancients depended upon the theory that suppuration is useful, so that if it does not occur naturally it must be promoted by the use of the medicaments called 'suppuratives.' Starting from this point, the ancient surgeons, when they were confronted by a wound, first allowed a certain amount of blood to flow, to prevent, as they thought, inflammatory complications. They then probed and enlarged the wound, filling it with tents and packings soaked in white of egg and other suppuratives, the whole being secured with a bandage. The patient was brought under a rigorous diet, meat and wine being withheld. A surgical potion called a 'vulnerary' was then administered, which was supposed to promote healing.

It will be sufficiently obvious that this treatment practically always brought about suppuration, often leading to severe and phlegmonous inflammation. The pain, fever and other complications of such treatment, to say nothing of the death-rate, must have been appalling. It is really not so very surprising, after all, that the surgeon, the barber, the torturer, and the executioner were all classed together in those days, and that some bloated pluralists combined all four offices.

And it would have been astonishing if the gentle and humane Bishop Theodoric had not sought a way of escape from procedures which doubtless often caused more and greater ills than those which they were supposed to alleviate. In this one is forcibly reminded of good Ambrose Paré, whom we find, two hundred years later, seeking earnestly some alternative for the common soldier to the dreadful cauterising iron and the still more horrible boiling oil recommended and constantly used for all wounds by John of Vigo and his successors.

Theodoric therefore begins with the assumption that suppuration is neither necessary, inevitable nor desirable, but that, on the contrary, it can be avoided and must be combated by every means in our power.

He therefore enters upon treatment at once by taking every possible step to check hæmorrhage. He very wisely does not probe the wound, does not enlarge it, puts in no packing nor tents, but, on the contrary, he bravely approximates the edges and sutures the wound forthwith.

This procedure, like much of the rest of Theodoric's work,

although it may appear, and is indeed claimed, to be rational, is really a piece of the purest empiricism. Thus he advocates the immediate closure of the wound because he believes that contact with the air is one of the greatest sources of suppuration. The reasoning is of course wrong, but the action is right, based as it really is on the practical consideration that he had tried it and found that it produced excellent results. And it may be remarked that to this day nearly all surgeons use dressings which effectually exclude air.

Of all Theodoric's recommendations not the least remarkable is that of warm wine as an application. And, after all, what better antiseptic could he have chosen? It cannot now be ascertained what was the alcoholic strength of the wines of Italy in the early fourteenth century, but it may be assumed beyond all doubt that they were of sufficient strength to have some antiseptic power. And as compared with the greasy and septic preparations recommended by Galen and all his successors for a thousand years, warm wine has such great advantages that it must be regarded as the predominating factor in the success of the wound treatment of Theodoric.

The teacher does not seem to have suspected that wounds could be contaminated by dirty hands or instruments. Indeed, in the absence of any inkling of the nature of what we now know to be microbic action, this could hardly have suggested itself, even to such ingenious and original minds as those of Theodoric or de Mondeville.

The essential features, then, of Theodoric's instructions on the treatment of wounds are, first, to clear the wound of foreign bodies; second, to suture the edges of the wound; third, with pads and pledgets soaked in wine to foment the sutured wound and the neighbouring parts. This fomentation is repeated many times, and the dressing is then proceeded with. The pledgets and compresses are spread out one over the other on each side of the wound, so as to compress the depth of it more than the line of union itself. Two or three pads soaked in warm wine are placed over the others to conserve the natural heat, and the part is then bandaged in accordance with the usual rules.

This was the method of Theodoric inherited, adopted and improved by Henri de Mondeville.

De Mondeville was one of the four body surgeons of Philip le Bel, King of France. He seems to have been the first French surgeon to have perceived the great value of Theodoric's idea, and he widely extended and developed its application to practical

surgery.

Born in A.D. 1260, he was a contemporary and loyal pupil of Lanfranc of Milan, and in 1304 he became Lecturer on Anatomy