will be best understood from what we know of Guy de Chauliac's visit to
the medical school here about the middle of the century. The great
French surgeon tells us that he came to Bologna to study anatomy under
the direction of Mondino's successor, Bertruccius. When he wrote his
preface to his great surgery he recalled this teaching of anatomy at
Bologna and said, "It is necessary and useful to every physician to
know, first of all, anatomy. For this purpose the study of books is
indeed useful, but it is not sufficient to explain those things which
can only be appreciated by the senses and which need to be seen in the
dead body itself." He advises his students to consult Mundinus' treatise
but to demonstrate its details for themselves on the dead body. He
relates that he himself had often, _multitoties_, done this, especially
under the direction of Bertruccius at Bologna. Curiously enough, as
pointed out by Professor Pilcher, Mondino had used this same word
_multitotiens_ (the variant spelling makes no difference in the meaning)
in speaking about his own work. In describing the hypogastric lesion he
mentions that he had demonstrated certain veins in it many times,
_multitotiens_.
Mondino was just past fifty when he finished his little book and
permitted copies of it to be made. Though the book occurs so early in
the history of modern book-making the author offers his excuses to the
public for writing it, and quotes the authority of Galen, to whom he
turns in other difficult situations, for justification. As prefaces go,
Mondino's is so like that of many an author of more recent date that his
words have a bibliographic, as well as a personal, interest. He said:
"A work upon any science or art--as saith Galen--is issued for
three reasons: first, that one may satisfy his friends.
Second, that he may exercise his best mental powers. Third,
that he may be saved from the oblivion incident to old age.
Therefore, moved by these three causes, I have proposed to my
pupils to compose a certain work on medicine.
"And because a knowledge of the parts to be subjected to
medicine (which is the human body, and the names of its
various divisions) is a part of medical science, as saith
Averrhoes in his first chapter, in the section on the
definition of medicine, for this reason among others, I have
set out to lay before you the knowledge of the parts of the
human body which is derived from anatomy, not attempting to
use a lofty style, but the rather that which is suitable to a
manual of procedure."
Some of the early editions of Mondinus' book are said, according to old
writers, to have contained illustrations. None of these copies have come
down to us, but the assertion is made so definitely that it seems likely
to have been the case. The editions that we have contain wood engravings
of the method of making a dissection as frontispiece, so that it would
not be difficult to think of further such illustrations having been
employed in the book itself. As we note in the chapter on "Great
Surgeons of the Medieval Universities," Mondeville, according to Guy de
Chauliac, had pictures of anatomical preparations which he used for
teaching purposes. It is easy to understand that the value of such aids
would be recognized at a time when the difficulty of preserving bodies
made it necessary to do dissections hurriedly so as to get the rapidly
decomposing material out of the way.
Beyond his book and certain circumstances connected with it we know very
little about Mondino. What we know, however, enables us to conclude
that, like many another great teacher, he must have had the special
faculty of inspiring his students with an ardent enthusiasm for the work
that they were taking under him. Hence the body-snatching and other
stories. Mondino continued to be held in high estimation by the
Bolognese for centuries after his death. Dr. Pilcher calls attention to
the fact that his sepulchral tablet, which is in the portico of the
Church of San Vitari in Bologna, and a replica of which he was allowed
to have made in order to bring it to America, is the only one of the
sepulchral tablets in the great churches of Florence, San Domenico, San
Martino, the Cathedral and the Cloister of San Giacomo degli Ermitani,
which has not been removed from its original location and placed in the
halls of the Civic Museum. Their removal he considers "a kind of
desecration which does violence to one's sense of sanctity and
propriety." "Fortunately, thus far, the Mondino Tablet has escaped the
spoiler." Very probably Dr. Pilcher's replica of the tablet which he
was required to deposit in the Civic Museum at the time when the copy
was made to be brought to America may save the tablet to be seen in its
original position for many generations.
Mondino's career is of special interest because it foreshadows the life
and accomplishment of many another maker of medicine of the after time.
He did a great new thing in medicine in organizing regular public
dissections, and then in making a manual that would facilitate the work.
He waited patiently for years before completing his book in order that
it might be the fruit of long experience, and so be more helpful to
others. He was so modest as to require urging to secure the publication.
He had the reward of his patience in the popularity of his little work
for centuries after his time. The glimpse that we get of his relations
to his young assistants, Agenius and Alessandra, seems to show us a
teacher of distinct personal magnetism. Undoubtedly the reputation of
his book did much for not only the medical school of the University of
Bologna, but also for the medical schools of other north Italian
universities, and helped to bring to them the crowds of students that
flocked there during the fourteenth and fifteenth centuries.
Taddeo and Mondino turned the attention of the medical students of their
generations Bolognawards. Before that time they had mainly gone to
Salerno. After their time most of the ardent students of medicine felt
that they must study for a time at least at Bologna. Other important
medical schools of Italian universities at Padua, at Vicenza, at
Piacenza, arose and prospered. During the time when the political
troubles of Italy reached a climax about the middle of the fourteenth
century, while the Popes were at Avignon, there was a remission in the
attendance at all the Italian universities, but with the Popes' return
to Rome and the coming of even comparative peace to Italy, Bologna once
more became the term of medical pilgrimages for students from all over
the world. In the meantime Mondino's book went forth to be the most used
text-book of its kind until Vesalius' great work came to replace it. To
have ruled in the world of anatomy for two centuries as the best known
of teachers is of itself a distinction that shows us at once the
teaching power and the scientific ability of this professor of anatomy
of Bologna in the early fourteenth century.
X
GREAT SURGEONS OF THE MEDIEVAL UNIVERSITIES
Strange as it may appear to those who have not watched the development
of our knowledge of the Middle Ages in recent years the most interesting
feature in the medical departments and, indeed, of the post-graduate
work generally of the medieval universities, is that in surgery. There
is a very general impression that this department of medicine did not
develop until quite recent years, and that particularly it failed to
develop to any extent in the Middle Ages. A good many of the historians
of this period, indeed, though never the special historians of medicine,
have even gone far afield in order to find some reason why surgery did
not develop at this time. They have insisted that the Church by its
prohibition of the shedding of blood, first to monks and friars, and
then to the secular clergy, prevented the normal development of surgery.
Besides they add that Church opposition to anatomy completely precluded
all possibility of any genuine natural evolution of surgery as a
science.
There is probably no more amusing feature of quite a number of
supposedly respectable and presumably authoritative historical works
written in English than this assumption with regard to the absence of
surgery during the later Middle Ages. Only the most complete ignorance
of the actual history of medicine and surgery can account for it. The
writers who make such assertions must never have opened an authoritative
medical history. Nothing illustrates so well the expression of the
editors of the "Cambridge Modern History" referred to more than once in
these pages that "in view of changes and of gains such as these [the
jointing of original documents] it has become impossible for historical
writers of the present day to trust without reserve even to the most
respected secondary authority. The honest student finds himself
continually deserted, retarded, misled by the classics of historical
literature." Fortunately for us this sweeping condemnation does not hold
to any great extent for the medical historical classics. All of the
classic historians of medicine tell us much of the surgery of the
thirteenth and fourteenth centuries, and in recent years the
republication of old texts and the further study of manuscript documents
of various kinds have made it very clear that there is almost no period
in the history of the world when surgery was so thoroughly and
successfully cultivated as during the rise and development of the
universities and their medical schools in the thirteenth and fourteenth
centuries.
It is interesting to trace the succession of great contributors to
surgery during these two centuries. We know their teaching not from
tradition, but from their text-books so faithfully preserved for us by
their devoted students, who must have begrudged no time and spared no
labor in copying, for many of the books are large, yet exist in many
manuscript copies.
Modern surgery may be said to owe its origin to a school of surgeons,
the leaders of whom were educated at Salerno in the early part of the
thirteenth century, and who, teaching at various north Italian
universities, wrote out their surgical principles and experiences in a
series of important contributions to that department of medical science.
The fact that the origin of the school was at Salerno, where, as is well
known, Arabian influence counted for much and for which Constantine's
translations of Arabian works proved such a stimulus a century before,
makes most students conclude that this later medieval surgical
development is simply a continuation of the Arabian surgery that, as we
have seen, developed very interestingly during the earlier Middle Ages.
Any such idea, however, is not founded on the realities of the
situation, but on an assumption with regard to the extent of Arabian
influence. Gurlt in his "History of Surgery" (Vol. I, page 701)
completely contradicts this idea, and says with regard to the first of
the great Italian writers on surgery, Rogero, that "though Arabian works
on surgery had been brought over to Italy by Constantine Africanus a
hundred years before Roger's time, these exercised no influence over
Italian surgery in the next century, and there is scarcely a trace of
the surgical knowledge of the Arabs to be found in Roger's works."
It is in the history of medicine particularly that it is possible to
trace the true influence of the Arabs on European thought in the later
Middle Ages. We have already seen in the chapter on Salerno that Arabian
influence did harm to Salernitan medical teaching. The school of Salerno
itself had developed simple, dietetic, hygienic, and general remedial
measures that included the use of only a comparatively small amount of
drugs. Its teachers emphasized nature's curative powers. With Arabian
influence came polypharmacy, distrust of nature, and attempts to cure
disease rather than help nature. In surgery, which developed very
wonderfully in the thirteenth and fourteenth centuries, Salerno must be
credited with the incentive that led up to the marvellous development
that came. With this, however, Arabian influence has nothing to do.
Gurlt, besides calling attention to the fact that the author of the
first great text-book on the subject not only did not draw his
inspiration from Arab sources, insisted that "instead of any Arabisms
being found in his [Roger's] writings many Graecisms occur." The
Salernitan school of surgery drank at the fountain-head of Greek
surgery. Apart from Greek sources Roger's book rests entirely upon his
own experiences, those of his teachers and his colleagues, and the
tradition in surgery that had developed at Salerno. This tradition was
entirely from the Greek. Roger himself says in one place, "We have
resolved to write out deliberately our methods of operation such as they
have been derived from our own experience and that of our colleagues and
illustrious men."
ROGER, ROLAND, AND THE FOUR MASTERS
Ruggero, or Rogero, who is also known as Rogerio and Rogerus with the
adjective Parmensis, or Salernitanus, of Parma or of Salerno, and often
in German and English history simply as Roger, lived at the end of the
twelfth or the beginning of the thirteenth century and probably wrote
his text-book about 1180. This text-book was, according to tradition,
originally drafted for his lessons in surgery at Salerno. It attracted
much attention and after being commented on by his pupil Rolando, the
work of both of them being subsequently annotated by the Four Masters,
this combined work became the basis of modern surgery. Roger was
probably born either in Palermo or Parma. There are traditions of his
having taught for a while at Paris and at the University of Montpellier,
though these are not substantiated. His book was printed at Venice in
1546, and has been lately reprinted by De Renzi in his "Collectio
Salernitana."
Roland was a pupil of Roger's, and the two names that often occur in
medieval romance became associated in a great historic reality as a
consequence of Roland's commentary on his master's work, which was a
favorite text-book in surgery for a good while in the thirteenth century
at Salerno. Some space will be given to the consideration of their
surgical teaching after a few words with regard to some disciples who
made a second commentary, adding to the value of the original work.
This is the well-known commentary of the Four Masters, a text-book of
surgery written somewhat in the way that we now make text-books in
various departments of medicine, that is, by asking men who have made
specialties of certain subjects to write on that subject and then bind
them all together in a single volume. It represents but another striking
reminder that most of our methods are old, not new as we are likely to
imagine them. The Four Masters took the works of Roger and Rolando,
acknowledged their indebtedness much more completely than do our modern
writers on all occasions, I fear, and added their commentaries.
Gurlt says ("Geschichte der Chirurgie," Vol. I, p. 703) that "in spite
of the fact that there is some doubt about the names of the authors,
this volume constitutes one of the most important sources for the
history of surgery of the later Middle Ages and makes it very clear that
these writers drew their opinions from a rich experience." It is rather
easy to illustrate from the quotations given in Gurlt or from the
accounts of their teaching in Daremberg or De Renzi some features of
this experience that can scarcely fail to be surprising to modern
surgeons. For instance, what is to be found in this old text-book of
surgery with regard to fractures of the skull is likely to be very
interesting to surgeons at all times. One might be tempted to say that
fewer men would die every year in prison cells who ought to be in
hospitals, if the old-time teaching was taken to heart. For there are
rather emphatic directions not to conclude because the scalp is
unwounded that there can be no fracture of the skull. Where nothing can
be felt care must be exercised in getting the history of the case. For
instance, if a man is hit by a metal instrument shaped like the clapper
of a bell or by a heavy key, or by a rounded instrument made of
lead--this would remind one very much of the lead pipe of the modern
time, so fruitful of mistakes of diagnosis in head injuries--special
care must be taken to look for symptoms in spite of the lack of an
external penetrating wound. Where there is good reason to suspect a
fracture because of the severity of the injury, the scalp should be
incised and a fracture of the cranium looked for carefully. That is
carrying the exploratory incision pretty far. If a fracture is found the
surgeon should trephine so as to relieve the brain of any pressure of
blood that might be affecting it.
There are many warnings, however, of the danger of opening the skull and
of the necessity for definitely deciding beforehand that there is good
reason for so doing. How carefully their observations had been made and
how well they had taken advantage of their opportunities, which were, of
course, very frequent in those warlike times when firearms were unknown,
hand-to-hand conflict common, and blunt weapons were often used, can be
appreciated very well from some of the directions. For instance, they
knew of the possibility of fracture by _contrecoup_. They say that
"quite frequently though the percussion comes in the anterior part of
the cranium, the cranium is fractured on the opposite part."[18] They
even seem to have known of accidents such as we now discuss in
connection with the laceration of the middle meningeal artery. They warn
surgeons of the possibilities of these cases. They tell the story of "a
youth who had a very small wound made by a thrown stone and there seemed
no serious results or bad signs. He died the next day, however. His
cranium was opened and a large amount of black blood was found
coagulated about his dura mater."
There are many interesting things said with regard to depressed
fractures and the necessity for elevating the bone. If the depressed
portion is wedged then an opening should be made with the trephine and
an elevating instrument called a spatumen used to relieve the pressure.
Great care should be taken, however, in carrying out this procedure lest
the bone of the cranium itself, in being lifted, should injure the soft
structures within. The dura mater should be carefully protected from
injury as well as the pin. Care should especially be exercised at the
brow and the rear of the head and at the commissures (_proram et pupim
et commissuras_), since at these points the dura mater is likely to be
adherent. Perhaps the most striking expression, the word _infect_ being
italicized by Gurlt, is: "In elevating the cranium be solicitous lest
you should infect or injure the dura mater."
For wounds of the scalp sutures of silk are recommended because this
resists putrefaction and holds the wound edges together. Interrupted
sutures about a finger-breadth apart are recommended. "The lower part of
the wound should be left open so that the cure may proceed properly."
Red powder was strewed over the wound and the leaf of a plant set above
it. In the lower angle of the wound a pledget of lint for drainage
purposes was inlaid. Hemorrhage was prevented by pressure, by the
binding on of _burnt_ wool firmly, and by the ligature of veins and by
the cautery.
There are rather interesting discussions of the prognosis of wounds of
the head, especially such as may be determined from general symptoms in
this commentary of the Four Masters on Roger's and Rolando's treatises.
If an acute febrile condition develops, the wound is mortal. If the
patient loses the use of the hands and feet or if he loses his power of
direction, or his sensation, the wound is mortal. If a universal
paralysis comes on, the wound is mortal. For the treatment of all these
wounds careful precautions are suggested. Cold was supposed to be
particularly noxious to them. Operations on the head were not to be done
in cold weather and, above all, not in cold places. The air where such
operations were done must be warmed artificially. Hot plates should
surround the patient's head while the operation was being performed. If
this were not possible they were to be done by candlelight, the candle
being held as close as possible in a warm room. These precautions are
interesting as foreshadowing many ideas of much more modern time and
especially indicating how old is the idea that cold may be taken in
wounds. In popular medicine this still has its place. Whenever a wound
does badly in the winter time patients are sure that they have taken
cold. Such popular medical ideas are always derived from supposedly
scientific medicine, and until we learned about microbes physicians used
the same expressions. We have not got entirely away from them yet.
These old surgeons must have had many experiences with fractures at the
base of the skull. Hemorrhages from the mouth and nose, for instance,
and from the ears were considered bad signs. They were inclined to
suggest that openings into the skull should be discovered by efforts to
demonstrate a connection between the mouth and nares and the brain
cavity. For instance, in their commentary the Four Masters said: "Let
the patient hold his mouth and nostrils tight shut and blow strongly."
If there was any lessening of the pressure or any appearance of air in
the wound in the scalp, then a connection between the mouth and nose was
diagnosticated. This is ingenious but eminently dangerous because of the
infectious material contained in the nasal and oral cavities, so likely
to be forced by such pressure into the skull. They were particularly
anxious to detect linear fractures. One of their methods of negative
diagnosis for fractures of the skull was that if the patient were able
to bring his teeth together strongly, or to crack a nut without pain,
then there was no fracture present. One of the commentators, however,
adds to this "_sed hoc aliquando fallit_--but this sign sometimes
fails." Split or crack fractures were also diagnosticated by the method
suggested by Hippocrates of pouring some colored fluid over the skull
after the bone was exposed, when the linear fracture would show by
coloration. The Four Masters suggest a sort of red ink for this purpose.
While they have so much to say about fractures of the skull and insist,
over and over again, that though all depressed fractures need treatment
and many fissure fractures require trepanation, still great care must be
exercised in the selection of cases. They say, for instance, that
surgeons who in every serious wound of the head have recourse to the
trephine must be looked upon as "fools and idiots" (_idioti et
stolidi_). In the light of what we now know about the necessity for
absolute cleanliness,--asepsis as we have come to call it,--it is rather
startling to note the directions that are given to a surgeon to be
observed on the day when he is to do a trepanation. For obvious reasons
I prefer to quote it in the Latin: "_Et nota quod die ilia cavendum est
medico a coitu et malis cibis aera corrumpentibus, ut sunt allia, cepe,
et hujusmodi, et colloquio mulieris menstruosae, et manus ejus debent
esse mundae, etc._" My quotation is from Gurlt, Vol. I, p. 707. The
directions are most interesting. The surgeon's hands must be clean, he
must avoid the taking of food that may corrupt the air, such as onions,
leeks, and the like; must avoid menstruating and other women, and in
general must keep himself in a state of absolute cleanliness.