MEDIEVAL SURGEONS: ITALY
Strange as it may seem, and quite contrary to the usual impressions in the
matter, the most interesting department of the history of the medical
science during the Middle Ages is that of surgery. Because of this fact we
have to divide the subject into two chapters, one for the surgery of
Italy, the other for the surgery of the rest of Europe.
We have two series of medieval textbooks which treat largely of surgical
subjects in a thoroughly scientific and professional way. The first of
these comes to us from the earlier centuries of the Middle Ages, when
Greek classic influence on medicine and the medical sciences was on the
wane; and the other set comes to us from the later Middle Ages, when the
earlier Renaissance of Greek influence was just making itself felt in
Europe. Both sets of books serve to show very well that the men of these
times were not only deeply interested in the affections for which surgery
can provide the only relief possible, but that they had reached very
definite, indeed sometimes ultimate, solutions of a large number of the
constantly recurring problems of surgery.
The greatest surprise of the whole range of medical history is that these
medieval surgeons of both periods anticipated not a few of the surgical
advances that we have been accustomed to think of as having been reserved
for our time to make. Our knowledge of these details of the work of the
medieval surgeons not only of the sixth and seventh centuries, but also of
the thirteenth and fourteenth, is not founded on tradition, nor on a few
scattered expressions which a modern medievalist might exaggerate, but on
actual textbooks, which fortunately for us were reprinted as a rule during
the Renaissance period, and have been preserved for us usually in a number
of rather readily available copies. Most of them have been reprinted
during the past generation, and have revolutionized our knowledge of the
history of surgery; for these textbooks exhibit in detail a deep knowledge
of surgical affections, a well-developed differential diagnosis, a
thoroughly conservative treatment, and yet a distinct effort to give the
patient every possible surgical opportunity for his life, compatible with
reasonable assurance of successful surgical intervention. As I have
pointed out, the surgical history of the old Crusades was as interesting
and almost as valuable for civil surgery as that of our own Great War.[8]
Three writers whom we have already mentioned (Early Medieval
Medicine)--Aëtius, Alexander of Tralles, and Paul of Ægina--were, as we
have seen, all of them interested in surgery, and wrote very interestingly
on that subject. It is, however, from the end of the Middle Ages--that is,
from the writers of the twelfth century down to the end of the
fifteenth--that surprising contributions were made to surgical knowledge.
This surgery of the end of the Middle Ages began its development at
Salerno. The first great textbook was that of Roger--known also as Rogero
and Ruggiero, with the adjective Parmensis or Salernitanus, of Parma or
Salerno--who wrote his work about 1180. It is of this that Gurlt, in his
"History of Surgery," vol. i., p. 701, says: "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." He insisted,
further, that Arabisms are not found in Roger's writings, while many
Græcisms occur. The Salernitan School of Surgery drank, then, at the
fountain-head of Greek surgery.
After Roger comes Rolando, his pupil, who wrote a commentary on his
master's work, and then the combined work of both of them was subsequently
annotated by the Four Masters. It is this textbook, the work of many hands
and the combined experience of many great teachers, that is the foundation
stone of modern surgery. Some of the expressions in this volume will serve
to give the best idea of how thoroughly these surgeons of the later
medieval period studied their cases, how careful they were in observation,
and how well they solved many problems that we are inclined to think of as
having come up for serious consideration only much later than this time.
After studying their chapter on Injuries of the Head, it is easy to
understand why Gurlt should declare that, though there is some doubt about
the names of the authors, this volume makes it very clear that these
writers drew their opinions from a rich experience.
They warn about the possibility of fracture of the skull even when there
is no penetrating wound of the scalp, and they even suggest the
advisability of exploratory incision when there is some good reason for
suspicion of, though no evident sign of, fracture. In "Old-Time Makers of
Medicine," I quoted some of the details of this teaching as to head
surgery that may serve to illustrate what these surgeons taught on this
important subject.
There are many warnings 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 observation 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." 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 pia. 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."
While these old-time surgeons insisted on the necessity for treating all
depressed fractures, and even suggested that many fissure fractures
required trephining, they deprecated meddlesome surgery of the cranium,
unless there was evident necessity, quite as much as we do now. Surgeons
who in every serious wound of the head have recourse to the trephine must,
they said, be looked upon as fools and idiots (_idioti et stolidi_). When
operations were done on the head, cold particularly was to be avoided. The
operations were not to be done in cold weather, and above all not in cold
places. The air of the operating-room 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. They had many
experiences with fractures at the base of the skull. Hæmorrhages from the
mouth and nose and from the ears were considered a bad sign. They even
suggested, for diagnostic purposes, what seems to us the rather dangerous
procedure that the patient should hold his mouth and nostrils tight shut
and blow strongly. 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, as well
he might, _sed hoc aliquando fallit_--"but this sign sometimes fails."
Split or crack fractures were also diagnosticated by the methods suggested
by Hippocrates of pouring some coloured fluid over the skull after the
bone was exposed, when a linear fracture would show by coloration. The
Four Masters suggest a sort of red ink for this purpose.
One might well expect that, with trephining as frequent as this textbook
of the Four Masters more than hints, the death-rate of these medieval
surgeons must have been very high in head cases. We can scarcely
understand such intervention in the conditions of operation assumed to
exist in the Middle Ages without almost inevitable infection and
consequent death. They seem to have come to an empiric recognition of the
advantage of absolute cleanliness in such operations. Indeed, in the light
of our modern asepsis and its development during our own generation, it is
rather startling to note the anticipation of what is most recent in the
directions that are given to a surgeon to be observed on the day when he
is to do a trephining. I give it in the original Latin as it may be found
in Gurlt (vol. i., p. 707): "_Et nota quod die illa cavendum est medico a
coitu et malis cibis æra corrumpentibus, ut sunt allia, cepe, et
hujusmodi, et colloquio mulieris menstruosæ, et manus ejus debent esse
mundæ_, etc." The directions are most interesting. The surgeon's hands
must be clean; he must avoid coitus and the taking of food that may
corrupt the air, such as onions, leeks, and the like; must avoid
menstruating women; and in general must keep himself in a state of
absolute cleanliness.
After the South Italian surgeons, some of whom taught at Bologna, a group
of North Italian surgeons, most of whom probably were either direct or
indirect pupils of the Salernitan School, must be considered. This
includes such distinguished names in the history of surgery as Bruno da
Longoburgo, usually called simply Bruno; Theodoric and his father Hugh of
Lucca; William of Salicet; Lanfranc, the disciple of William who taught at
Paris, and gave that primacy to French surgery which was maintained all
the centuries down to the nineteenth (p. 1); and Mondino, the author of
the first manual on dissection, which continued for two centuries to be
used by practically everyone who anywhere did dissection throughout
Europe. Practically all of these men did their best work between 1250 and
1300. Bruno of Longoburgo taught at Padua and Vicenza, and his textbook,
the "Chirurgia Magna," was completed in Padua in January, 1252. Gurlt
notes that "He is the first of the Italian surgeons who besides the Greeks
quotes also 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.
Bruno 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."
While the old textbooks had emphasized the necessity for not allowing the
circulation in the head to be disturbed by the cold, and insisted on the
taking of special precautions in this matter, Bruno insists that wounds
must be more carefully looked to in summer than in winter, because
"putrefaction is greater in warm than in cold weather"--_putrefactio est
major in æstate quam in hyeme_. He is particularly insistent on the
necessity of drainage. In wounds of the extremities the limb must always
be so placed as to encourage drainage. To secure it the wound may be
enlarged; if necessary, even a counter-opening must be made to provide
drainage. In order to secure 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 the preferable suture material in his experience is
silk or linen. He discusses healing by first and second intention, and
declares that with proper care the healing of a great many wounds by first
intention can be secured. All his treatment of wounds is dry. Water he
considered always did harm, and it is quite easy to understand that his
experience taught him this, for the water generally available for surgeons
in camps and battlefields and in emergency surgery was likely to do much
more harm than good.
Some of the details of his technique of abdominal wounds will be
particularly interesting to modern surgeons.
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 development 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 fistulæ 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 fistulæ, for this would leave the patient in a worse
state than before.
The most interesting feature of the work of the North Italian surgeons of
the later Middle Ages is their discovery and development of the two
special advances of our modern surgery in which we are inclined to take
most pride. These are, union by first intention, and anæsthesia. It is of
course very startling to think that surgeons of seven centuries ago should
have made advances in these important phases of surgery--which were
afterwards to be forgotten; but human history is not a story of constant
progress, but of ups and downs, and the mystery of human history is the
decadence that almost inevitably follows any period of supremely great
accomplishment by mankind. The later Middle Age enjoyed a particularly
great period of efflorescence and achievement in surgery, and this, quite
as with literature and other phases of human accomplishment, was followed
by distinct descent of interest in surgical theory, and decadence in
surgical practice, until the Renaissance came to provide another climax
of surgical development. It would be perilous to say, however, that the
acme of the curve of Renaissance surgical progress was higher than its
predecessor, though once more there is the surprise to find that this high
point was followed by another descent, until the curve ascended again in
our time.
What we have said already with regard to the requirement of cleanliness in
operating upon the skull, insisted upon by the Salernitan School, will
suggest that some of the practical value of asepsis had come home to these
old-time surgeons. The North Italian surgeons went, however, much farther
in their anticipations of asepsis. They insisted that if a surgeon made a
wound through an unbroken surface and did not secure union by first
intention, it was usually his own fault.
It is to them we owe the expression "union by first intention"--_unio per
primam intentionem_--which means nothing to us except through its Latin
equivalent. They boasted of getting linear cicatrices which could scarcely
be seen, and evidently their practice fostered the best of surgical
technique and was founded on excellent principles. The North Italian
surgeons replaced the use of ointments by wine, and evidently realized its
cleansing--that is, antiseptic--quality. What is often not realized is,
that the very old traditional treatment of wounds by the pouring of wine
and oil into them represented a mild antiseptic and a soothing protective
dressing. The wine inhibited the growth of ordinary germs, the oil
protected the wound from dust and dirt. They were not ideal materials for
the purpose, but they were much better when discreetly used than many
surgical dressings of much more modern times founded on elaborate
theories.
Professor Clifford Allbutt, reviewing the practice of these North Italian
surgeons of the thirteenth century, says:[9]
"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,
Paré, 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. Powder they regarded as
too desiccating, for powder shuts in decomposing matters; wine, after
washing, purifying, and drying the raw surfaces, evaporates."
Theodoric wrote in 1266 on that question that so much disturbed the
surgeons of the generations before ours, as to whether pus was a natural
development in the healing of wounds or not. While laudable pus was for
centuries after his time supposedly a scientific doctrine, Theodoric did
not think so, and emphatically insisted that such teaching represented a
great error. He said: "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." The italics in the word modern are mine, but the whole expression
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 his father had obtained without the use of any
ointment--_pulcherrimas cicatrices sine unguento inducebat_--then,
further, that he impugned the use of poultices and of oils in wounds,
while powders were too drying, and besides had a tendency to prevent
drainage (the literal meaning of the Latin words he employs, _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.
After Bruno, who brought with him the methods and principles of surgery
from the South of Italy, his contemporary of the North, Hugh of Lucca--Ugo
da Lucca, or Luccanus, as he is also called--deserves to be mentioned. He
was called to Bologna in 1214 as City Physician, and was with the regiment
of crusaders from Bologna at Damietta in 1220. He returned to Bologna in
1221 and occupied the post of legal physician. The Civic Statutes of
Bologna are, according to Gurlt, the oldest monument of legal medicine in
the Middle Ages. Hugh seems to have been deeply intent on chemical
experiments, and especially anodyne and anæsthetic drugs. He is said to
have been the first to have taught the sublimation of arsenic. Like many
another distinguished practitioner of medicine and surgery, he left no
writings. All that we know of him and his work, and above all his
technique, we owe to the filial devotion of his son Theodoric.
Anæsthesia is perhaps an even greater surprise in the Middle Ages than
practical antisepsis. A great many of these surgeons of the time seem to
have experimented with substances that might produce anæsthesia.
Mandragora was the base of most of these anæsthetics, though a combination
with opium seems to have been a favourite. They succeeded apparently, even
with such crude means, in producing insensibility to pain without very
serious dangers. One of these methods of Da Lucca was by inhalation, and
seems to have been in use for a full century. Guy de Chauliac describes
the method as it was used in his day, and a paragraph with regard to it
will be found in the chapter on Surgeons of the West of Europe. It is
quite clear that the extensive operations which are described in their
textbooks of surgery at this time could not possibly have been performed,
only that the surgeons were able to secure rather a deep and prolonged
insensibility to pain. With anæsthesia combined with antisepsis, it is
easy to understand how well equipped the surgeons of this time were for
the development of their speciality.
The fourth of these great surgeons at the North of Italy was William of
Salicet. He was a pupil of Bruno of Longoburgo. Some idea of his practice
as a surgeon may be obtained from even the first chapter of his first
book. 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 incision because of the danger of it. He had successfully
treated some of these difficult cases, however, by puncturing the scalp
and membrane by a cautery, a very small opening being made and fluid being
allowed to escape only drop by drop. William did not quote his
predecessors much, but depended to a great extent on his own experience.
He has many interesting details of technique with regard to the special
subject of surgery of the nose, the ear, the mouth; and he did not even
hesitate to treat goitre when it grows large, and says that if the sac is
allowed to remain it should be thoroughly rubbed over on the inside with
"green ointment." He warned "that in this affection many large
bloodvessels make their appearance, and they find their way everywhere
through the fleshy mass."
A very interesting development of surgery along a line where it would
probably be least expected was in plastic surgery. In the first half of
the fifteenth century the two Brancas, father and son, performed a series
of successful operations for the restoration of the nose particularly, and
the son invented a series of similar procedures for the restoration of
mutilated lips and ears. The father seems to have built up the nose from
other portions of the face, possibly using, as Gurlt suggests, the skin of
the forehead, as the Indian surgeons had done, though without any known
hint of their work. Fazio, the historian of King Alphonso I. of Naples,
who died in 1457, describes the favourite operation of Antonio Branca, the
son, who in order not to disfigure any further the face in these cases,
made the new nose from the skin of the upper arm; and in anticipation of
Tagliacozzi, who attracted much attention by a similar operation in the
latter half of the sixteenth century, separated the new nose from the arm
sometime during the third week. There is abundance of other evidence as to
the Brancas' work from contemporary writers--for instance, Bishop Peter
Ranzano the annalist, the poet Calenzio, and Alexander Benedetti, the
physician and anatomist--so that there can be no doubt of the fact that
this wonderful invention in surgical technique was actually made before
the close of the Middle Ages.
It is interesting to realize that, while we hear much about the work of
the Brancas, and from ecclesiastical authorities, there is no word of
condemnation of the practice of restoring the nose or other facial
features until much later in history. Tagliacozzi, who revived the
operation of rhinoplasty just about the beginning of the seventeenth
century, did not share so kind a fate. The latter Italian surgeon was
roundly abused by some of his colleagues, even, it is said, by Fallopius
and Paré, and bitterly satirized in Butler's "Hudibras." As late as 1788
(!) the Paris faculty interdicted face-repairing altogether. It is this
sort of intolerance, on some superstitious ground or other, that is
usually attributed to the Middle Ages. For such events the adjective
medieval seems particularly adapted. As a matter of fact, we find
comparatively little trace of such intolerance in medieval times; but it
is comparatively easy to find the bitterest treatment of fellow-mortals
for all sorts of foolish reasons in the seventeenth and eighteenth
centuries.