ORAL SURGERY AND THE MINOR SURGICAL SPECIALITIES
The surgical specialities, as they are called--that is, the surgery of the
mouth, throat, and nose, and of the eye and ear, as well of course as of
certain other portions of the body--have developed to a striking extent in
our time. As a consequence of this recent development, there is an
impression prevalent that this is the first time that serious attention
has been paid by surgeons to these phases of their work. The feeling is
probably that the minor operations usually required in the surgical
specialities were either thought so trivial, or involved such delicate
technique, that they never received due attention, rather than that they
were deliberately neglected.
Because of this very general persuasion, even among physicians, it is all
the more interesting to trace the phases of attention during the Middle
Ages to these special subjects in surgery, which was far from lacking at
any time, and which led at various periods to some rather important
developments. While specialism is considered new by most people, it must
not be forgotten that at every time in the world's history, when men have
had much chance to think about themselves rather than the actual
necessities of the situation in which they were placed, and the things
they were compelled to do for actual self-preservation, specialism has
enjoyed a period of more or less intense evolution. It is rather easy to
trace this in the Ebers Papyrus near the beginning of the second
millennium B.C.; and Herodotus called attention to the fact that the old
Egyptians had divided the practice of medicine into many specialities. His
passage on the subject is well known.[11]
If the surgical specialities had been neglected in the Middle Ages, then
that fact would have constituted the surest evidence of that backwardness
of medical and surgical progress which is usually supposed to have existed
at that time. But the real story is exactly to the contrary, and has many
surprises in it because of the anticipations of very recent advances which
it represents.[12]
It would be surprising, then, if we were to find no attention paid to
dentistry during the Middle Ages. As a matter of fact, a number of the old
surgeons include in their textbooks of surgery the discussion of oral
surgery. Aëtius evidently knew much about the hygiene of the teeth, and
discusses extraction and the cure of fistulæ of the gums as well as the
surgical treatment of many other lesions of the mouth. Paul of Ægina in
the century after Aëtius has even more details; and while they both
quote mainly from older authors, there seems no doubt that they
themselves must have had considerable practical experience in the
treatment of the teeth and had made not a few observations. The Arabians
took up the subject, and discussed dental diseases and their treatment
rationally and in considerable detail. Abulcassis particularly has much
that is of significance and interest. We have pictures of two score of
dental instruments that were used by him. The Arabs not only treated and
filled carious teeth, and even replaced those that were lost, but they
also corrected deformities of the mouth and the dental arches. Orthodontia
is usually thought of as of much later origin, yet no one who knows
Abulcassis's work can speak of efforts at straightening the teeth as
_invented_ after his time.
[Illustration: SURGICAL INSTRUMENTS OF THE ARABS, ACCORDING TO ABULCASIM
_After plates in Gurlt's "Geschichte der Chirurgie"_
1. A pincher for extracting foreign bodies from the ear
2. An ear syringe for injections
3. A tongue depressor
4. Concave scissors for the removal of tonsils
5. Curved pinchers for foreign bodies in the throat
6 to 29. Instruments for the treatment of the teeth
19 and 20. Forceps
21 to 25. Levers and hooks for the removal of roots
26. Strong pinchers for the same
27. A tooth saw 28 and 29. Files for the teeth]
The great surgeons of the later Middle Ages in their textbooks of surgery
usually include remarks on oral surgery, and suggest treatment for the
various diseases of the teeth. Guy de Chauliac in "La Grande Chirurgie"
lays down certain rules for the preservation of the teeth, and shows that
the ordinary causes of dental decay were well recognized in his time.
Emphasis was laid by him on not taking foods too hot or too cold, and
above all on the advisability of not having either hot or cold food
followed by something very different from it in temperature. The breaking
of hard things with the teeth was warned against as responsible for such
fissures in the enamel as gave opportunity for the development of decay.
The eating of sweets, and especially the sticky sweets, preserves, and the
like, were recognized as an important source of caries. The teeth were
supposed to be cleaned frequently, and not to be cleaned too roughly, for
this would do more harm than good.
Chauliac is particularly emphatic in his insistence on not permitting
alimentary materials to remain in the cavities, and suggests that if
cavities between the teeth tend to retain food material they should even
be filled in such a way as to prevent these accumulations. His directions
for cleansing the teeth were rather detailed. His favourite treatment for
wounds was wine, and he knew that he succeeded by means of it in securing
union by first intention. It is not surprising, then, to find that he
recommends rinsing of the mouth with wine as a precaution against dental
decay. A vinous decoction of wild mint and of pepper he considered
particularly beneficial, though he thought that dentifrices, either powder
or liquid, should also be used. He seems to recommend the powder
dentifrices as more efficacious. His favourite prescription for a
tooth-powder, while more elaborate, resembles to such an extent at least,
some, if not indeed most, of those that are used at the present time,
that it seems worth while giving his directions for it. He took equal
parts of cuttle-bones, small white seashells, pumice-stone, burnt stag's
horn, nitre, alum, rock salt, burnt roots of iris, aristolochia, and
reeds. All of these substances should be carefully reduced to powder and
then mixed.
His favourite liquid dentifrice contained the following ingredients: Half
a pound each of sal ammoniac and rock salt, and a quarter of a pound of
saccharin alum. All these were to be reduced to powder and placed in a
glass alembic and dissolved. The teeth should be rubbed with it, using a
little scarlet cloth for the purpose. Just why this particular colour of
cleansing cloth was recommended is not quite clear.
He recognized, however, that cleansing of the teeth properly often became
impossible by any scrubbing method, no matter what the dentifrice used,
because of the presence of what he called hardened limosity or limyness
(_limosité endurcie_). When that condition is present he suggests the use
of rasps and spatumina and other instrumental means very similar to those
we make use of for removing tartar.
Guy de Chauliac was also interested in mechanical dentistry and the
artificial replacement of lost teeth; and, indeed, dental prosthesis
represents, as treated by him, a distinct anticipation of dental
procedures usually thought quite modern.
When teeth become loose he advises that they be fastened to the healthy
ones with a gold chain. Guerini, in his "History of Dentistry"
(Philadelphia, 1907), suggests that he evidently means a gold wire. If the
teeth fall out Chauliac recommends that they be replaced by the teeth of
another person, or with artificial teeth made from ox-bone, 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
Abulcassis 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.
Guerini called particular attention to the fact that Chauliac recognized
the dentists as specialists. He observes that operations on the teeth are
in a class by themselves, and belong to the _dentatores_ to whom they had
been entrusted. He remarks, however, that the operations on the mouth
should be performed under the direction of a surgeon. It is in order to
give surgeons the general principles by means of which they may be able
to judge of the advisability or necessity for dental operations, that his
brief presentation of the subject is made. If their advice is to be of
value, physicians should know the various methods of treatment suitable
for dental diseases, including "mouth washes, gargles, masticatories and
ointments, rubbings, fumigations, cauterizations, fillings, filings," as
well as the various dental operations. He says that the _dentator_ must be
provided with appropriate instruments, among which he named scrapers,
rasps, straight and curved, spatumina, elevators, simple and with two
branches, toothed tenacula, and many different forms of probes and
cannulas. He should have also small scalpels, tooth trephines, and files.
After Guy de Chauliac, the most important contributor to dentistry is
Giovanni of Arcoli--or simply Arcolano, but sometimes better known by his
Latin name Johannes Arculanus--who was Professor of Medicine and Surgery
at Bologna just before and after the middle of the fifteenth century. He
is sometimes treated in history as belonging rather to the Renaissance,
but he owed his training to the Middle Ages and was teaching before they
closed, so he has a place in Medieval Medicine. Guerini, in his "History
of Dentistry," says that Arculanus treats the subject of dentistry rather
fully and with great accuracy. The Italian historian makes a summary of
Arculanus's rules for dental hygiene which shows how thoroughly he
appreciated the care of the teeth. The medieval surgeon arranged his rules
in ten distinct canons, 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, 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, or 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, 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 dentifrices 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.
Shortly after Arculanus, when the Middle Ages are over--if they end with
the middle of the fifteenth century, though perhaps not if the later date
of the discovery of America is to be taken as the medieval terminal--John
de Vigo has in a few lines a very complete description of the method of
filling teeth with gold-leaf which deserves to be quoted. Only that it was
a common practice he would surely have described it more in detail,
though he could have added nothing to the significance of what he has to
say: "By means of a drill or file the putrefied or corroded part of the
teeth should be completely removed. The cavity left should then be filled
with gold-leaf."
Much more is known about the medieval anticipation of other
specialities--those of the throat and nose, and eye and ear--and the
surprise is with regard to dentistry, which is usually quite unknown. The
fact, however, that dentistry developed so much more than is usually
thought prepares the mind for the anticipations in other departments.
Following that of dentistry should come naturally the mouth and throat,
and it happens that the men whose writings in dentistry are known also
touched on these subjects.
The medical writers of the early Middle Ages, particularly Aëtius,
Alexander of Tralles, and Paul of Ægina, have not a little to say with
regard to affections of the throat and nose, and the eye and ear.
Alexander's chapter on the Treatment of Affections of the Ear, Gurlt
considers ample evidence of large practical experience and power of
observation. Alexander describes the ordinary mode of getting water out of
the external auditory canal by standing on the leg corresponding to the
side in which the water is, and kicking out with the opposite leg.
Foreign bodies should be removed by an ear spoon, or a small instrument
wrapped in wool and dipped in sticky material. He suggests sneezing with
the head leaning toward the side on which the foreign body is present.
Insects or worms that find their way into the ear may be killed by
injections of dilute acid and oil or other substances.
Paul of Ægina has a very practical technique for the removal of fish-bones
or other objects caught in the throat. He also gives the detailed
technique of opening the larynx or trachea, with the indications for this
operation. He also describes how wounds of the neck should be sewed after
attempts at suicide. In a word, the more one knows of these old-time
medieval writers of the sixth and seventh centuries the clearer it becomes
that they had learned their lessons well from the ancients, and passed on
an excellent tradition to their colleagues of succeeding generations. If
these lessons were not properly taken, it was because the disturbance of
civilization caused by the coming down of the Teutonic invaders into Italy
took away interest in the things of the mind and of the body, until the
coming of another upward turn in progress.
Arculanus has some very interesting paragraphs with regard to the
treatment of conditions in the nose. 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 fine scissors; or with a
narrow file just small enough to permit 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 hæmorrhage, or if there is fear of it, the instruments with
which the section 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 of the 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 Ægina (Æginetas),
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.
Among the affections of the upper air passages mentioned by Arculanus are
various forms of sore throat, which he calls Synanche or Cynanche, or
angina. A milder form of the affection was called Parasynanche. The
medieval teaching with regard to an angina that was causing severe
difficulty of breathing was to perform tracheotomy. Arculanus goes into
some detail with regard to affections of the uvula, which was made much
more responsible for throat affections than at the present time. The
popular tradition in our time of the uvula and its fall is evidently a
remnant of the medieval teaching with regard to it. Arculanus's
description of the removal of the uvula, or at least of the tip of it,
gives a very good idea of how thorough the teaching of surgical technique
was in his time. His directions are: "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, he insists that the application must
be firmly made and must be frequently repeated.
With regard to ophthalmology the older history has always been thoroughly
appreciated. Even as early as the time of Hammurabi (2200 B.C.) some
rather extensive and interesting surgery of the eye was practised, for the
fees for these operations are mentioned in the code. All of the early
medieval writers on medicine and surgery--Aëtius, Alexander of Tralles,
and Paul of Ægina--have paragraphs at least, and sometimes more, with
regard to eye operations and the care of the eyes.
Operations above all for cataract have been practised from very early
times, and are mentioned also by many medieval writers on medicine and
surgery. It is not surprising, then, to find that the medieval surgeons
particularly discussed a number of eye diseases and the operations for
them. Pope John XXI., who before he became Pope was known as _Petrus
Hispanus_ (the Spaniard), and who had been a professor of surgery and a
papal physician, wrote a book on eye diseases in the latter half of the
thirteenth century, which has come down to us. He had much to say of
cataract, dividing it into traumatic and spontaneous, and suggesting
operation by needling, a gold needle being used for that purpose. Pope
John describes a form of hardness of the eye which would seem to be what
we now call glaucoma, and has a number of external applications for eye
diseases. Most of his collyria had some bile in them, the bile of various
kinds of animals and birds being supposed to be progressively more
efficient for the cure of external affections of the eye. This very
general use of bile, or of an extract of the livers of animals or fishes,
seems to be a heritage from biblical times, when old Toby was cured of his
blindness by the gall of the fish.[13] The Pope ophthalmologist (see
_Opthalmology_, Milwaukee, January, 1909) recommended the urine of infants
as an eye-wash, experience having evidently shown that this fluid, which
is usually bland and unirritating, a solution of salts of a specific
gravity such that it would not set up osmotic processes in the eye, was
empirically of value. In the Middle Ages the idea of using it would be
much less deterrent, because it was quite a common practice for physicians
to taste urine in order to test it for pathological conditions.
Spectacles were rather commonly used in the Middle Ages, probably having
been invented in the second half of the thirteenth century by Salvino de
Armato of Florence. Bernard de Gordon mentions them under the name _oculus
berellinus_ early in the fourteenth century. They were originally made
from a kind of smoky crystal, _berillus_, whence the German name _Brillen_
and the French _besicles_ (Garrison). Guy de Chauliac suggests that when
collyria failed to improve the sight spectacles should be employed. Almost
needless to say, this use of spectacles meant very much for the comfort
and convenience of old people. Up to that time most of those who reached
the age of three-score would be utterly unable to read, and would have to
depend either on others or on their memory for teaching and many other
purposes. External eye troubles, as those due to trichiasis and to various
disturbances of the lachrymal apparatus, were treated by direct mechanical
means. Some very ingenious suggestions and manipulations were made with
regard to them.