absolutely necessary and no other method of treatment would avail to
save the patient from continuous distress. He summarizes the authorities
with regard to the extraction of teeth and the removal of dental
fragments and roots. He evidently knew of the many methods suggested
before his time of removing teeth without recourse to instrumental
extraction. There were a number of applications to the gums that were
claimed by older authors to remove the teeth without the need of metal
instruments. We might expect that Chauliac would detect the fallacy with
regard to these and expose it. He says that while much is claimed for
these methods he has never seen them work in practice and he distrusts
them entirely.
The most interesting phase of what Guy de Chauliac has to say with
regard to dentistry is of course to be found in his paragraphs on the
artificial replacement of lost teeth and the subject of dental
prosthesis generally. When teeth become loose he advises that they be
fastened to the healthy ones with a gold chain. Guerini suggests that he
evidently means a gold wire. If the teeth fall out they may be replaced
by the teeth of another person or with artificial teeth made from
oxbone, which may be fixed in place by a fine metal ligature. He says
that such teeth may be serviceable for a long while. This is a rather
curt way of treating so large a subject as dental prosthesis, but it
contains a lot of suggestive material. He was quoting mainly the Arabian
authors, and especially Abulcasis and Ali Abbas and Rhazes, and these of
course, as we have said, mentioned many methods of artificially
replacing teeth as also of transplantation and of treatment of the
deformities of the dental arches.
On the whole, however, it must be confessed that we have here in the
middle of the fourteenth century a rather surprising anticipation of the
knowledge of a special department of medicine which is usually
considered to be distinctly modern, and indeed as having only attracted
attention seriously in comparatively recent times.
After Guy de Chauliac the next important contributor to dentistry is
Giovanni of Arcoli, often better known by his Latin name, Johannes
Arculanus, who was a professor of medicine and surgery at Bologna and
afterwards at Padua, just before and after the middle of the fifteenth
century, and who died in 1484. He is famous principally for being the
first we know who mentions the filling of teeth with gold.
It might possibly be suggested that coming at this time Arculanus should
rather be reckoned as a Maker of Medicine in the Renaissance than as
belonging to the Middle Ages and its influences. His education, however,
was entirely completed before the earliest date at which the Renaissance
movement is usually said to begin, that is with the fall of
Constantinople in 1452, and he was dead before the other date, that of
the discovery of America in 1492, which the Germans have in recent years
come to set down as the end of the Middle Ages. Besides, what he has to
say about dentistry occurs in typical medieval form. It is found in a
commentary on Rhazes, written just about the middle of the fifteenth
century. In the later true Renaissance such a commentary would have been
on a Greek author. In his commentary Arculanus touches on most of the
features of medicine and surgery from the standpoint of his own
experience as well as from what he knows of the writings of his
predecessors and contemporaries. With the rest he has a series of
chapters on diseases of the teeth. Guerini in his "History of Dentistry"
says that "this subject [dentistry] is treated rather fully, and with
great accuracy." Even some short references to it will, I think,
demonstrate this rather readily.[29]
Arculanus is particularly full in his directions for the preservation of
the teeth. We are rather prone to think that prophylaxis is
comparatively a modern idea, and that most of the principles of
conservation of human tissues and the prevention of deterioration and
disease are distinctly modern. It needs only a little consideration of
Arculanus' instruction in the matter of the teeth, however, to undo any
such false impression. For obvious reasons I prefer to quote Guerini's
summation of this medieval student of dentistry's rules for dental
hygiene:
"For the preservation of teeth--considered by him, quite
rightly, a matter of great importance--Giovanni of Arcoli
repeats the various counsels given on the subject by preceding
writers, but he gives them as ten distinct canons or rules,
creating in this way a kind of decalogue of dental hygiene.
These rules are: (1) It is necessary to guard against the
corruption of food and drink within the stomach; therefore,
easily corruptible food--milk, salt fish, etc.--must not be
partaken of, and after meals all excessive movement, running
exercises, bathing, coitus, and other causes that impair the
digestion, must also be avoided. (2) Everything must be
avoided that may provoke vomiting. (3) Sweet and viscous
food--such as dried figs, preserves made with honey,
etc.--must not be partaken of. (4) Hard things must not be
broken with the teeth. (5) All food, drink, and other
substances that set the teeth on edge must be avoided. (6)
Food that is too hot or too cold must be avoided, and
especially the rapid succession of hot and cold, and vice
versa. (7) Leeks must not be eaten, as such a food, by its own
nature, is injurious to the teeth. (8) The teeth must be
cleaned at once, after every meal, from the particles of food
left in them; and for this purpose thin pieces of wood should
be used, somewhat broad at the ends, but not sharp-pointed or
edged; and preference should be given to small cypress twigs,
to the wood of aloes, or pine, rosemary, or juniper and
similar sorts of wood which are rather bitter and styptic;
care must, however, be taken not to search too long in the
dental interstices and not to injure the gums or shake the
teeth. (9) After this it is necessary to rinse the mouth by
using by preference a vinous decoction of sage, or one of
cinnamon, mastich, gallia, moschata, cubeb, juniper seeds,
root of cyperus, and rosemary leaves. (10) The teeth must be
rubbed with suitable dentrifices before going to bed, or else
in the morning before breakfast. Although Avicenna recommended
various oils for this purpose, Giovanni of Arcoli appears
very hostile to oleaginous frictions, because he considers
them very injurious to the stomach. He observes, besides, that
whilst moderate frictions of brief duration are helpful to the
teeth, strengthen the gums, prevent the formation of tartar,
and sweeten the breath, too rough or too prolonged rubbing is,
on the contrary, harmful to the teeth, and makes them liable
to many diseases."
All this is so modern in many ways that we might expect a detailed exact
knowledge of the anatomy of the teeth and even something of their
embryology from Arculanus. It must not be forgotten, however, that
coming as he does before the Renaissance, the medical sciences in the
true sense of the word are as yet unborn. Men are accumulating
information for practical purposes but not for the classification and
co-ordination that was to make possible the scientific development of
their knowledge.
Giovanni of Arcoli's acquaintance with the anatomy of the teeth was
rather sadly lacking. He does not know even with certainty the number of
roots that the teeth have. This has been attributed to the fact that he
obtained most of his information from books, and had not the time to
verify descriptions that he had found. It has been argued from this that
he was himself probably not a practical dentist, and turned to that
specialty only as a portion of his work as a general surgeon, and that
consequently he was not sufficiently interested to verify his
statements. His chapters on dentistry would seem to bear out this
conclusion to some extent, though the very fact that one who was himself
not specially interested in dental surgery should have succeeded in
gathering together so much that anticipates modern ideas in dentistry,
is of itself a proof of how much knowledge of the subject there was
available for a serious student of that time. The anatomy of the teeth
continued to be rather vague until about the middle of the next century
when Eustachius, whose investigations of the anatomy of the head have
deservedly brought him fame and the attachment of his name to the
Eustachian canal, wrote his "Libellus de Dentibus--Manual of the Teeth,"
which is quite full, accurate, and detailed. Very little has been added
to the microscopic anatomy of the teeth since Eustachius' time. He had
the advantage, of course, of being intimately in contact with the great
group of Renaissance anatomists,--Vesalius, Columbus, Varolius,
Fallopius, and the others, the great fathers of anatomy. Besides, his
position as Papal Physician and Professor of Anatomy at the Papal
Medical School at Rome gave him opportunities for original
investigation, such as were not easily obtained elsewhere.
Arculanus can scarcely be blamed, therefore, for not having anticipated
the Renaissance, and we must take him as merely the culmination of
medieval knowledge with regard to anatomy and surgery. Medieval medical
men did not have the time nor apparently the incentive to make formal
medical science, though it must not be forgotten, as has been said, that
they did use the knowledge they obtained by their own and others'
observation to excellent advantage for the practical benefit of ailing
humanity. The sciences related to medicine are conscious developments
that follow the evolution of practical medicine, nor must it be
forgotten that far from always serving as an auxiliary to applied
medical science, often indeed in the history of medicine scientific
pursuits have led men away into side issues from which they had to be
brought back by some genius medical observer. As might be expected,
then, it is with regard to the practical treatment and general
consideration of ailments of the teeth that Giovanni of Arcoli is most
interesting. In this some of his chapters contain a marvellous series of
surprises.
Arculanus was probably born towards the end of the fourteenth century.
The date of his death is variously placed as either 1460 or 1484, with
the probability in favor of the former. From 1412 to 1427 he was
professor at Bologna, where in accordance with the non-specializing
tendencies of the time he did not occupy a single chair but several in
succession. He seems first to have taught Logic, then Moral Philosophy,
and finally Medicine. His reputation in medicine drew many students to
the university, and his fame spread all over Italy. The rival University
of Padua then secured him, and he seems to have been for some twenty
years there. Later apparently he accepted a professor's chair at
Ferrara, where the D'Estes were trying to bring their university into
prominence. It was at Ferrara that he died. He was a man of wide
reading, of extensive experience, both of men and medicine, and one of
the scholars of his time. His works are, as we have said, mainly
excerpts from earlier writers and particularly the Arabians, but they
contain enough of hints drawn from his own observation and experience
to make his work of great value.
While, as Gurlt remarks in his "History of Surgery," Arculanus' name is
one of those scarcely known--he is usually considered just one of many
obscure writers of the end of the Middle Ages--his writings deserve a
better fate. They contain much that is interesting and a great deal that
must have been of the highest practical value to his contemporaries.
They attracted wide attention in his own and immediately succeeding
generations. The proof of this is that they exist in a large number of
manuscript copies. Just as soon as printing was introduced his books
appeared in edition after edition. His "Practica" was printed in no less
than seven editions in Venice. Three of them appeared before the end of
the fifteenth century, which places them among the _incunabula_ of
printing.
Probably nothing in the history of human intellectual interest is more
striking than the excellent judgment displayed by the editors who
selected the works to be printed at this time. Very few of them were
trivial or insignificant. Fewer still were idle speculations, and most
of them were almost of classical import for literature and science. Four
editions of this work were printed in Venice in the sixteenth century,
one of them as late as 1560, when the work done by such men as Vesalius,
Columbus, Eustachius, and Fallopius would seem to have made Arculanus
out of date. The dates of the various editions are Venice, 1483, 1493,
1497, 1504, 1542, 1557, and 1560. Besides there was an edition printed
at Basel in 1540.
Arculanus is said to have re-introduced the use of the seton, that is
the method of producing intense counter-irritation by the introduction
of some foreign body into an incision in the skin. We owe to him, too,
according to Pagel in the chapters on medieval medicine in Puschmann's
"Handbook of the History of Medicine," an excellent description of
alcoholic insanity.
His directions for the treatment of conditions in the mouth and nose
apart from the teeth are quite as explicit and practical, and in many
ways quite as great an anticipation of some of our modern notions as
what he has to say with regard to the teeth. For instance, in the
treatment of polyps he says that they should be incised and cauterized.
Soft polyps should be drawn out with a toothed tenaculum as far as can
be without risk of breaking them off. The incision should be made at the
root so that nothing or just as little as possible of the pathological
structure be allowed to remain. It should be cut off with a fine
scissors, or with a narrow file just small enough to permit its ingress
into the nostrils, or with a scalpel without cutting edges on the sides,
but only at its extremity, and this cutting edge should be broad and
well sharpened. If there is danger of hemorrhage, or if there is fear of
it, the instruments with which dissection is made should be fired
(_igniantur_), that is, heated at least to a dull redness. Afterwards
the stump, if any remains, should be touched with a hot iron or else
with cauterizing agents so that as far as possible it should be
obliterated.
After the operation a pledget of cotton dipped in the green ointment
described by Rhazes should be placed in the nose. This pledget should
have a string fastened to it, hanging from the nose in order that it may
be easily removed. At times it may be necessary to touch the root of the
polyp with a stylet on which cotton has been placed that has been dipped
in _aqua fortis_ (nitric acid). It is important that this cauterizing
fluid should be rather strong so that after a certain number of touches
a rather firm eschar is produced. In all these manipulations in the nose
Arculanus recommends that the nose should be held well open by means of
a nasal speculum. Pictures of all these instruments occur in his extant
works, and indeed this constitutes one of their most interesting and
valuable features. They are to be seen in Gurlt's "History of Surgery."
In some cases he had seen the polyp was so difficult to get at or was
situated so far back in the nose that it could not be reached by means
of a tenaculum or scissors, or even the special knife devised for that
purpose. For these patients Arculanus describes an operation that is to
be found in the older writers on surgery, Paul of AEgina (AEginetus),
Avicenna, and some of the other Arabian surgeons. For this three
horse-tail hairs are twisted together and knotted in three or four
places, and one end is passed through the nostrils and out through the
mouth. The ends of this are then pulled on backward and forward after
the fashion of a saw. Arculanus remarks evidently with the air of a man
who has tried it and not been satisfied that this operation is quite
uncertain, and seems to depend a great deal on chance, and much reliance
must not be placed on it. Arculanus suggests a substitute method by
which latent polyps or occult polyps as he calls them may be removed.
There is scarcely an important disease for which Arculanus has not some
interesting suggestions, and the more one reads of him the more is one
surprised to find how many things that we might think of as coming into
the purview of medicine long after his time or at least as having been
neglected from the time of the Greeks almost down to our own time are
here treated explicitly, definitely, and with excellent practical
suggestions. He has a good deal to say with regard to the treatment of
angina, which he calls synanche, or synanchia, or cynanche, or angina.
Parasynanche is a synonymous term, but refers to a milder synanche. He
distinguished four forms of it. In one called canine angina, because the
patient's tongue hangs out of his mouth, somewhat the same as from an
overheated dog in the summer time, while at the same time the mouth is
held open and he draws his breath pantingly, Arculanus suggests an
unfavorable prognosis, and would seem to refer to those cases of
Ludwig's angina in which there is involvement of the tongue and in which
our prognosis continues to be of the very worst even to our own day. At
times the angina causes such swelling in the throat that the breathing
is interfered with completely. For this Arculanus' master, Rhazes,
advised tracheotomy. Arculanus himself, however, apparently hesitated
about that.
It is not surprising, then, to find that Arculanus is very explicit in
his treatment of affections of the uvula. He divides its affections into
_apostema, ulcus, putredo sive corrosio, et casus_. _Apostema_ was
abscess, _ulcus_ any rather deep erosion, _putredo_ a gangrenous
condition, and _casus_ the fall of the uvula. This is the notorious
falling of the soft palate which has always been in popular medical
literature at least. Arculanus describes it as a preternatural
elongation of the uvula which sometimes goes to such an extent as to
make it resemble the tail of a mouse. For shorter elongations he
suggests the cautery; for longer, excision followed by the cautery so
that the greater portion of the extending part may be cut off. If people
fear the knife he suggests following Rhazes, the application of an
astringent powder directly to the part by blowing through a tube. His
directions for the removal of the uvula are very definite. Seat the
patient upon a stool in a bright light while an assistant holds the
head; after the tongue has been firmly depressed by means of a speculum
let the assistant hold this speculum in place. With the left hand then
insert an instrument, a stilus, by which the uvula is pulled forward,
and then remove the end of it by means of a heated knife or some other
process of cauterization. The mouth should afterwards be washed out with
fresh milk.
The application of a cauterizing solution by means of a cotton swab
wrapped round the end of a sound may be of service in patients who
refuse the actual cautery. To be successful the application must be
firmly made and must be frequently repeated.
After this it is not surprising to find that Arculanus has very
practical chapters on all the other ordinary surgical affections.
Empyema is treated very thoroughly, liver abscess, ascites, which he
warns must be emptied slowly, ileus especially when it reaches
stercoraceous vomiting, and the various difficulties of urination, he
divides them into dysuria, ischuria, and stranguria, are all discussed
in quite modern fashion. He gives seven causes for difficulty of
urination. One, some injury of the bladder; two, some lesion of the
urethra; three, some pathological condition in the power to make the
bladder contract; four, some injury of the muscle of the neck of the
bladder; five, some pathological condition of the urine; six, some
kidney trouble, and seven, some pathological condition of the general
system. He takes up each one of these and discusses the various phases,
causes, disposition, and predispositions that bring them about. One
thing these men of the Middle Ages could do, they reasoned logically,
they ordered what they had to say well, and they wrote it out
straightforwardly.
That Arculanus' work with regard to dentistry was no mere chance and not
solely theoretic can be understood very well from his predecessors, and
that it formed a link in a continuous tradition which was well preserved
we may judge from what is to be found in the writings of his great
successor, Giovanni or John de Vigo, who is considered one of the great
surgeons of the early Renaissance, and to whom we owe what is probably
the earliest treatise on "Gun-shot Wounds." John of Vigo was a Papal
physician and surgeon, generally considered one of the most
distinguished members of the medical profession of his time. Two
features of his writing on dental diseases deserve mention. He insists
that abscesses of the gums shall be treated as other abscesses by being
encouraged to come to maturity and then being opened. If they do not
close promptly, an irritant Egyptian ointment containing verdigris and
alum among other things should be applied to them. In the cure of old
fistulous tracts near the teeth he employs not only this Egyptian
ointment but also arsenic and corrosive sublimate. What he has to say
with regard to the filling of the teeth is, however, most important. He
says it with extreme brevity, but with the manner of a man thoroughly
accustomed to doing it. "By means of a drill or file the putrefied or
corroded part of the tooth should be completely removed. The cavity left
should then be filled with gold leaf." It is evident that the members of
the Papal court, the Cardinals and the Pope himself, had the advantage
of rather good dentistry at John de Vigo's hands even as early as the
beginning of the sixteenth century.
John de Vigo, however, is not medieval. He lived on into the sixteenth
century and was influenced deeply by the Renaissance. He counts among
the makers of modern medicine and surgery, as his authorship of the
treatise on gun-shot wounds makes clear. He comes in a period that will
be treated of in a later volume of this series on "Our Forefathers in
Medicine."
XIII
CUSANUS AND THE FIRST SUGGESTION OF LABORATORY METHODS IN MEDICINE
As illustrating how, as we know more about the details of medical
history, the beginnings of medical science and medical practice are
pushed back farther and farther, a discussion in the _Berliner klinische
Wochenschrift_ a dozen years ago is of interest. Professor Ernest von
Leyden, in sketching the history of the taking of the pulse as an
important aid in diagnostics, said that John Floyer was usually referred
to as the man who introduced the practice of determining the pulse rate
by means of the watch. His work was done about the beginning of the
eighteenth century. Professor von Leyden suggested, however, that
William Harvey, the English physiologist, to whom is usually attributed
the discovery of the circulation of the blood, had emphasized the value
of the pulse in medical diagnosis, and also suggested the use of the
watch in counting the pulse. Professor Carl Binz, of the University of
Bonn, commenting on these remarks of Professor von Leyden, called
attention to the fact that more than a century before the birth of
either of these men, even the earlier, to whom the careful measurement
of the pulse rate is thus attributed as a discovery, a distinguished
German churchman, who died shortly after the middle of the fifteenth
century, had suggested a method of accurate estimation of the pulse
that deserves a place in medical history.