knowing anything about the wonderful powers of observation of the men
from whom it comes, it would be very easy to think that it is merely a
set of general directions which they had made on some general principle,
perhaps quite foolish in itself. We know, however, that these men had by
observation detected nearly every feature of importance in fractures of
the skull, their indications and contra-indications for operation and
their prognosis. They had anticipated nearly everything of importance
that has come to be insisted on even in our own time in the handling of
these difficult cases. It is not unlikely, therefore, that they had also
arrived at the recognition by observations on many patients that the
satisfactory after-course of these cases which were operated on by the
surgeon after due regard to such meticulous cleanliness as is suggested
in the paragraph I have quoted, made it very clear that these aseptic
precautions, as we would call them, were extremely important for the
outcome of the case and, therefore, were well worth the surgeon's
attention, though they must have required very careful precautions and
considerable self-denial. Indeed this whole subject, the virtual
anticipation of our nineteenth-century principles of aseptic surgery in
the thirteenth century, is not a dream nor a far-fetched explanation
when one knows enough about the directions that were laid down in the
surgical text-books of that time.
THE NORTH ITALIAN SURGEONS
After Roger and Rolando and the Four Masters, who owe the inspiration
for their work to Salerno and the south of Italy, comes a group of north
Italian surgeons: Bruno da Longoburgo, usually called simply Bruno;
Theodoric and his father, Hugo of Lucca, and William of Salicet.
Immediately following them come two names that belong, one almost feels,
to a more modern period: Mondino, the author of the first text-book on
dissection, and Lanfranc (the disciple of William of Salicet), who
taught at Paris and "gave that primacy to French surgery which it
maintained all the centuries down to the nineteenth" (Pagel). It might
very well be thought that this group of Italian surgeons had very little
in their writings that would be of any more than antiquarian interest
for the modern time. It needs but a little knowledge of their writings
as they have come down to us to show how utterly false any such opinion
is. To Hugo da Lucca and his son Theodoric we owe the introduction and
the gradual bringing into practical use of various methods of
anaesthesia. They used opium and mandragora for this purpose and later
employed an inhalant mixture, the composition of which is not absolutely
known. They seem, however, to have been very successful in producing
insensibility to pain for even rather serious and complicated and
somewhat lengthy operations. Indeed it is to this that must be
attributed most of their surprising success as surgeons at this early
date.
We are so accustomed to think that anaesthesia was discovered about the
middle of the nineteenth century in America that we forget that
literature is full of references in Tom Middleton's (seventeenth
century) phrase to "the mercies of old surgeons who put their patients
to sleep before they cut them." Anaesthetics were experimented with
almost as zealously, during the latter half of the thirteenth century at
least, as during the latter half of the nineteenth century. They were
probably not as successful as we are, but they did succeed in producing
insensibility to pain, otherwise they could never have operated to the
extent they did. Moreover the traditions show that the Da Luccas
particularly had invented a method that left very little to be desired
in this matter of anaesthesia. A reference to the sketch of Guy de
Chauliac in this volume will show how practical the method was in his
time.
Nearly the same story as with regard to anaesthetics has to be repeated
for what are deemed so surely modern developments,--asepsis and
antisepsis. I have already suggested that Roger seems to have known how
extremely important it was to approach operations upon the skull with
the most absolute cleanliness. There are many hints of the same kind in
other writers which show that this was no mere accidental remark, but
was a definite conclusion derived from experience and careful
observation of results. We find much more with regard to this same
subject in the writings of the group of northern Italian surgeons and
especially in the group of those associated with William of Salicet.
Professor Clifford Allbutt, Regius Professor of Medicine at the
University of Cambridge, England, in his address before the St. Louis
World's Fair Congress of Arts and Science in 1904, did not hesitate to
declare that William discussed the causes for union by first intention
and the modes by which it might be obtained. He, too, insisted on
cleanliness as the most important factor in having good surgical
results, and all of this group of men, in operating upon septic cases,
used stronger wine as a dressing. This exerted, as will be readily
understood, a very definite antiseptic quality.
Evidently some details of the teaching of this group of great surgeons
in northern Italy in the second half of the thirteenth century will make
clearer to us how much the rising universities of the time were
accomplishing in medicine and surgery as well as in their other
departments. The dates of the origin of some of these universities
should perhaps be recalled so as to remind readers how closely related
they are to this great group of surgical teachers. Salerno was founded
very early, probably in the tenth century, Bologna, Reggio, and Modena
came into existence toward the end of the twelfth century; Vicenza,
Padua, Naples, Vercelli, and Piacenza, as well as Arezzo, during the
first half of the thirteenth century; Rome, Perugia, Trevizo, Pisa,
Florence, Sienna, Lucca, Pavia, and Ferrara during the next century. The
thirteenth century was the special flourishing period of the
universities, and the medical departments, far from being behind, were
leaders in accomplishment. (See my "The Thirteenth Greatest of
Centuries," N.Y., 1908.)
BRUNO DA LONGOBURGO
The first of this important group of north Italian surgeons who taught
at these universities was Bruno of Longoburgo. While he was born in
Calabria, and probably studied in Salerno, his work was done at Vicenza,
Padua, and Verona. His text-book, the "Chirurgia Magna," dedicated to
his friend Andrew of Piacenza, was completed at Padua in January, 1252.
Gurlt notes that he is the first of the Italian surgeons who quotes,
besides the Greeks, the Arabian writers on surgery. Eclecticism had
definitely come into vogue to replace exclusive devotion to the Greek
authors, and men were taking what was good wherever they found it. Gurlt
tells us that Bruno owed much of what he wrote to his own experience and
observation. He begins his work by a definition of surgery, _chirurgia_,
tracing it to the Greek and emphasizing that it means handwork. He then
declares that it is the last instrument of medicine to be used only when
the other two instruments, diet and potions, have failed. He insists
that surgeons must learn by seeing surgical operations and watching them
long and diligently. They must be neither rash nor over bold and should
be extremely cautious about operating. While he says that he does not
object to a surgeon taking a glass of wine, the followers of this
specialty must not drink to such an extent as to disturb their command
over themselves, and they must not be habitual drinkers. While all that
is necessary for their art cannot be learned out of books, they must not
despise books however, for many things can be learned readily from
books, even about the most difficult parts of surgery. Three things the
surgeon has to do:--"to bring together separated parts, to separate
those that have become abnormally united, and to extirpate what is
superfluous."
In his second chapter on healing he talks about healing by first and
second intention. Wounds must be more carefully looked to in summer than
in winter, because _putrefactio est major in aestate quam in hyeme_,
putrefaction is greater in summer than in winter. For proper union care
must be exercised to bring the wound edges accurately together and not
allow hair, or oil, or dressings to come between them. In large wounds
he considers stitching indispensable, and recommends for this a fine,
square needle. The preferable suture material in his experience was silk
or linen.
The end of the wound was to remain open in order that lint might be
placed therein in order to draw off any objectionable material. He is
particularly insistent on the necessity for drainage. In deep wounds
special provision must be made, and in wounds of extremities the limb
must be so placed as to encourage drainage. If drainage does not take
place, then either the wound must be thoroughly opened, or if necessary
a counter opening must be made to provide drainage. All his treatment of
wounds is dry, however. Water, he considered, always did harm. We can
readily understand that the water generally available and especially as
surgeons saw it in camps and on the battlefield, was likely to do much
more harm than good. In penetrating wounds of the belly cavity, if there
was difficulty in bringing about the reposition of the intestines, they
were first to be pressed back with a sponge soaked in warm wine. Other
manipulations are suggested, and if necessary the wound must be
enlarged. If the omentum finds its way out of the wound, all of it that
is black or green must be cut off. In cases where the intestines are
wounded they are to be sewed with a small needle and a silk thread and
care is to be exercised in bringing about complete closure of the wound.
This much will give a good idea of Bruno's thoroughness. Altogether,
Gurlt, in his "History of Surgery," gives about fifteen large octavo
pages of rather small type to a _brief_ compendium of Bruno's teachings.
One or two other remarks of Bruno are rather interesting in the light of
modern developments in medicine. For instance, he suggests the
possibility of being able to feel a stone in the bladder by means of
bimanual palpation. He teaches that mothers may often be able to cure
hernias, both umbilical and inguinal, in children by promptly taking up
the treatment of them as soon as noticed, bringing the edges of the
hernial opening together by bandages and then preventing the reopening
of the hernia by prohibiting wrestling and loud crying and violent
motion. He has seen overgrowth of the mamma in men, and declares that it
is due to nothing else but fat, as a rule. He suggests if it should hang
down and be in the way on account of its size it should be extirpated.
He seems to have known considerable about the lipomas and advises that
they need only be removed in case they become bothersomely large. The
removal is easy, and any bleeding that takes place may be stopped by
means of the cautery. He divides rectal fistulae into penetrating and
non-penetrating, and suggests salves for the non-penetrating and the
actual cautery for those that penetrate. He warns against the
possibility of producing incontinence by the incision of deep fistulae,
for this would leave the patient in a worse state than before.
HUGH OF LUCCA
Bruno brought up with him the methods and principles of surgery from the
south of Italy, but there seems to have been already in the north at
least one distinguished surgeon who had made his mark. This was Ugo da
Lucca or Ugo Luccanus, sometimes known in the modern times in German
histories of medicine as Hugo da Lucca and in English, Hugh of Lucca. He
flourished early in the thirteenth century. In 1214 he was called to
Bologna to become the city physician, and joined the Bolognese
volunteers in the crusade in 1218, being present at the siege of
Damietta. He returned to Bologna in 1221 and was given the post of legal
physician to the city. The civic statutes of Bologna are, according to
Gurlt, the oldest monument of legal medicine in the Middle Ages. Ugo
died not long after the middle of the century, and is said to have been
nearly one hundred years old. Of his five sons, three became physicians.
The most celebrated of these was Theodoric, who wrote a text-book of
surgery in which are set down the traditions of surgery that had been
practised in his father's life. Theodoric is especially enthusiastic in
praise of his father, because he succeeded in bringing about such
perfect healing of wounds with only wine and water and the ligature and
without the employment of any ointments.
Ugo seems to have occupied himself much with chemistry. To him we owe a
series of discoveries with regard to anodyne and anaesthetizing drugs. He
is said to have been the first who taught the sublimation of arsenic.
Unfortunately he left no writings after him, and all that we know of him
we owe to the filial devotion of his son Theodoric.
THEODORIC
This son, after having completed his medical studies at the age of about
twenty-three, entered the Dominican Order, then only recently
established, but continued his practice of medicine undisturbed. His
ecclesiastical preferment was rapid. He attracted the attention of the
Bishop of Valencia, and became his chaplain in Rome. At the age of about
fifty he was made a bishop in South Italy and later transferred to the
Bishopric of Cervia, not far from Ravenna. Most of his life seems to
have been passed in Bologna however, and he continued to practise
medicine, devoting his fees, however, entirely to charity. His text-book
of surgery was written about 1266 and is signed with his full name and
title as Bishop of Cervia. Even at this time however, he still retained
the custom of designating himself as a member of the Dominican Order.
The most interesting thing in the first book of his surgery is
undoubtedly his declaration that all wounds should be treated only with
wine and bandaging. Wine he insists on as the best possible dressing for
wounds. It was the most readily available antiseptic that they had at
that time, and undoubtedly both his father's recommendation of it and
his own favorable experience with it were due to this quality. It must
have acted as an excellent inhibitive agent of many of the simple forms
of pus formation. At the conclusion of this first book he emphasizes
that it is extremely important for the healing of wounds that the
patient should have good blood, and this can only be obtained from
suitable nutrition. It is essential therefore for the physician to be
familiar with the foods which produce good blood in order that his
wounded patients may be fed appropriately. He suggests, then, a number
of articles of diet which are particularly useful in producing such a
favorable state of the tissues as will bring about the rebirth of flesh
and the adhesion of wound surfaces. Shortly before he emphasizes the
necessity for not injuring nerves, though if nerves have been cut they
should be brought together as carefully as possible, the wound edges
being then approximated.
Probably the most interesting feature for our generation of the great
text-books of the surgeons of the medieval universities is the
occurrence in them of definite directions for securing union in surgical
wounds, at least by first intention and their insistence on keeping
wounds clear. The expression union by first intention comes to us from
the olden time. They even boasted that the scars left after their
incisions were often so small as to be scarcely noticeable. Such
expressions of course could only have come from men who had succeeded in
solving some of the problems of antisepsis that were solved once more in
the generation preceding our own. With regard to their treatment of
wounds, Professor Clifford Allbutt says:[19]
"They washed the wound with wine, scrupulously removing every
foreign particle; then they brought the edges together, not
allowing wine nor anything else to remain within--dry adhesive
surfaces were their desire. Nature, they said, produces the
means of union in a viscous exudation, or natural balm, as it
was afterwards called by Paracelsus, Pare, and Wurtz. In older
wounds they did their best to obtain union by cleansing,
desiccation, and refreshing of the edges. Upon the outer
surface they laid only lint steeped in wine. Powders they
regarded as too desiccating, for powder shuts in decomposing
matters wine after washing, purifying, and drying the raw
surfaces evaporates."
Theodoric comes nearest to us of all these old surgeons. The surgeon
who in 1266 wrote: "For it is not necessary, as Roger and Roland have
written, as many of their disciples teach, and as all _modern_ surgeons
profess, that pus should be generated in wounds. No error can be greater
than this. Such a practice is indeed to hinder nature, to prolong the
disease, and to prevent the conglutination and consolidation of the
wound" was more than half a millennium ahead of his time. The italics in
the word modern are mine, but might well have been used by some early
advocate of antisepsis or even by Lord Lister himself. Just six
centuries almost to the year would separate the two declarations, yet
they would be just as true at one time as at another. When we learn that
Theodoric was proud of the beautiful cicatrices which he obtained
without the use of any ointment, _pulcherrimas cicatrices sine unguento
aliquo inducebat_, then further that he impugned the use of poultices
and of oils on wounds, while powders were too drying and besides had a
tendency to prevent drainage, the literal meaning of the Latin words
_saniem incarcerare_ is to "incarcerate sanious material," it is easy to
understand that the claim that antiseptic surgery was anticipated six
centuries ago is no exaggeration and no far-fetched explanation with
modern ideas in mind of certain clever modes of dressing hit upon
accidentally by medieval surgeons.
Theodoric's treatment of many practical problems is interesting for the
modern time. For instance, in his discussion of cancer he says that
there are two forms of the affection. One of them is due to a
melancholy humor, a constitutional tendency as it were, and occurs
especially in the breasts of women or latent in the womb. This is
difficult of treatment and usually fatal. The other class consists of a
deep ulcer with undermined edges, occurring particularly on the legs,
difficult to cure and ready of relapse, but for which the outlook is not
so bad. His description of _noli me tangere_ and of lupus is rather
practical. Lupus is "eating herpes," occurs mainly on the nose, or
around the mouth, slowly increases, and either follows a preceding
erysipelas or comes from some internal cause. _Noli me tangere_ is a
corroding ulcer, so called perhaps because irritation of it causes it to
spread more rapidly. He thinks that deep cauterization of it is the best
treatment. Since these are in the department of skin diseases this seems
the place to mention that Theodoric describes salivation as occurring
after the use of mercury for certain skin diseases. He has already shown
that he knows of certain genital ulcers and sores on the genital regions
and of distinctions between them.
WILLIAM OF SALICET
The third of the great surgeons in northern Italy was William of
Salicet. He was a pupil of Bruno's and the master of Lanfranc. The first
part of his life was passed at Bologna and the latter part as the
municipal and hospital physician of Verona. He probably died about 1280.
He was a physician as well as a surgeon and was one of those who
insisted that the two modes of practising medicine should not be
separated, or if they were both medicine and surgery would suffer. He
thought that the physician learned much by seeing the interior of the
body during life, while the surgeon was more conservative if he were a
physician. It is curiously interesting to find that the Regius
Professors at both Oxford and Cambridge in our time have expressed
themselves somewhat similarly. Professor Clifford Allbutt is quite
emphatic in this matter and Professor Osler is on record to the same
effect. Following Theodoric, William of Salicet did much to get away
from the Arabic abuse of the cautery and brought the knife back to its
proper place again as the ideal surgical instrument. Unlike those who
had written before him, William quoted very little from preceding
writers. Whenever he quotes his contemporaries it is in order to
criticise them. He depended on his own experience and considered that it
was only what he had actually learned from experience that he should
publish for the benefit of others.
A very good idea of the sort of surgery that William of Salicet
practised may be obtained even from the beginning of the first chapter
of his first book. This is all with regard to surgery of the head. He
begins with the treatment of hydrocephalus or, as he calls it, "water
collected in the heads of children newly born." He rejects opening of
the head by an incision because of the danger of it. In a number of
cases, however, he had had success by puncturing the scalp and membranes
with a cautery, though but a very small opening was made and the fluid
was allowed to escape only drop by drop. He then takes up eye diseases,
a department of surgery rather well developed at that time, as can be
seen from our account of the work of Pope John XXI as an
ophthalmologist during the thirteenth century. See _Ophthalmology_
(January, 1909), reprinted in "Catholic Churchmen in Science,"
Philadelphia, The Dolphin Press, 1909.
William devotes six chapters to the diseases of the eyes and the
eyelids. Then there are two chapters on affections of the ears. Foreign
bodies and an accumulation of ear wax are removed by means of
instruments. A polyp is either cut off or its pedicle bound with a
ligature, and it is allowed to shrivel. The next chapter is on the nose.
Nasal polyps were to be grasped with a sharp tenaculum, _cum tenacillis
acutis_, and either wholly or partially extracted. Ranula was treated by
being lifted well forward by means of a sharp iron hook and then split
with a razor. It is evident that the tendency of these to fill up again
was recognized, and accordingly it was recommended that vitriol powder,
or alum with salt, be placed in the cavity for a time after evacuation
in order to produce adhesive inflammation.
In the same chapter on the mouth one finds that William did not hesitate
to perform what cannot but be considered rather extensive operations
within the oral cavity. For instance, he tells of removing a large
epulis and gives an account in detail of the case. To quote his own
words: "I cured a certain woman from Piacenza who was suffering from
fleshy tumor on the gums of the upper jaw, the tumor having grown to
such a size above the teeth and the gums that it was as large or perhaps
larger than a hen's egg. I removed it at four operations by means of
heated iron instruments. At the last operation I removed the teeth that
were loose with certain parts of the jawbone."
In the next chapter there is an account of the treatment of a remarkable
case of abscess of the uvula. In the following chapter the swelling of
cervical glands is taken up. In his experience expectant treatment of
these was best. He advises internal medication with the building up of
the general health, or suggests allowing the inflamed glands to empty
themselves after pustulation. After much meddlesome surgery we are
almost back to his methods again. He did not hesitate to treat goitre
surgically, though he considered there were certain internal remedies
that would benefit it. In obstinate cases he suggests the complete
extirpation of cystic goitre, but if the sac is allowed to remain it
should be thoroughly rubbed over on the inside with green ointment. He
warns about the necessity for avoiding the veins and arteries in this
operation, and says that "in this affection many large veins make their
appearance and they find their way everywhere through the fleshy mass."