consolidari, vel conjungi nec sui. Nos autem dicimus quod potest
consolidari et iterum ad motum reddi habillis, cum hac cautela:
Cauterizetur utrumque caput nervi incisi peroptime cum ferro candenti,
sed cave vulneris lobia cum ferro calido tangantur. Deinde apponantur
vermes contusi et pulveres consolidativi, etc._
It will be observed that Gilbert, in spite of the rejection by Roland
of the egg-albumen dressing of Roger, still recommends its use in
wounds of the neck, and although he professes to have seen many nerves
regenerated (_consolidari_) under the simple angle-worm treatment
of his master, he still makes no mention of the painful treatment of
divided nerves by the actual cautery, so highly praised by Roland. It
would seem, therefore, that Gilbert was not familiar with the writings
of Roland when his Compendium was written, or he would, doubtless,
not have omitted so peculiar a plan of treatment in an injury of such
gravity. As Roland's edition of Roger's "Chirurgia" is said to have
been written in 1264, the comparison of these passages would seem to
indicate that Gilbert must have written the Compendium after 1230 and
prior to the year 1264.
Gilbert's surgical chapters discuss the general treatment of wounds
and their complications, and more specifically that of wounds of the
head, neck, throat, wounds of nerves, of the oesophagus, scapula,
clavicle, of the arm, the stomach, intestines and the spleen;
fractures of the clavicle, arm, forearm and ribs; compound fractures;
dislocations of the atlas, jaw, shoulder and elbows; fistulae in
various localities, and the operations on the tonsils and uvula, on
goitre, hernia and stone in the bladder, etc.--certainly a surgical
compendium of no despicable comprehensiveness for a physician of his
age and country.
In the general treatment of wounds (f. 86 c) Gilbert tells us
the surgeon must consider the time, the age of the patient, his
temperament (_complexio_) and the locality, and be prepared to
temper the hot with the cold and the dry with the moist. Measures
for healing, cleansing and consolidation are required in all wounds,
and these objects may, not infrequently, be accomplished by a single
agent. The general dressing of most wounds is a piece of linen
moistened with the white of egg (_pecia panni in albumine ovi
infusa_), and, as a rule, the primary dressing should not be changed
for two days in summer, and for three days in the winter. In moist
wounds _vitreolum_ reduces the flesh; in dry wounds it repairs and
consolidates. _Flos aeris_, in dry wounds, reduces but does not
consolidate, but rather corrodes the tissues. Excessive suppuration
is sometimes the result of too stimulating applications, sometimes
of those which are too weak. In the former case the wound enlarges,
assumes a concave form, is red, hot, hard and painful, and the pus is
thin and watery (_subtilis_). If the application is too weak, the pus
is thick and viscous, and the other signs mentioned are wanting. In
either case the dressings are to be reversed. If any dyscrasia, such
as excessive heat, coldness, dryness or moisture appears in the wound
and delays its healing, it is to be met by its contrary. If fistula or
cancer develops, this complication is to be first cured and then the
primary wound. The signs of a hot dyscrasia are heat, burning and pain
in the wound; of a cold dyscrasia, lividity of the wound; the moist
dyscrasia occasions flabbiness (_mollicies_) and profuse suppuration,
and the dry produces dryness and induration.
Wounds of the head (f. 84 c) occur with or without fracture of the
cranium, but always require careful examination and exact diagnosis.
The wound is to be carefully explored with the finger, and, if
necessary, should be enlarged for this purpose. Large, but simple,
wounds of the scalp should be stitched with silk in three or four
places, leaving the most dependent angle open for escape of the
discharges, and in this opening should be inserted a tent (_tuellus_),
to facilitate drainage. The wound is then sprinkled with the _pulvis
rubeus_ and covered with a plantain or other leaf. On the ninth to the
eleventh day, if the wound seems practically healed, the stitches are
to be removed and the cure completed with simple dressings.
The signs and symptoms of fracture of the cranium are: Loss
of appetite and failure of digestion, insomnia, difficulty in
micturition, constipation, a febrile dyscrasia, difficulty in cracking
nuts or crusts of bread with the jaws, or severe pain when a string is
attached to the teeth and pulled sharply. If the meninges are injured
we have further: headache, a slow and irregular but increasing fever,
alternating with chills, distortion of the angles of the eyes, redness
of the cheeks, mental disturbances, dimness of vision, a weak voice
and bleeding from the ears or the nose. In the presence of such
symptoms the death of the patient may be expected within at most a
hundred days.
If the fracture of the cranium is accompanied by a large scalp wound,
any fragments of bone or other foreign body are to be extracted at
once, unless haemorrhage or the weakness of the patient are feared,
and then a piece of linen is to be cautiously worked in with a feather
between the cranium and the dura mater. In the fracture itself a piece
of linen, or better of silk, is inserted, the apparent purpose of this
double dressing being to protect the dura mater from the discharges
and to solicit their flow to the exterior. A piece of sponge,
carefully washed, dried and placed in the wound, Gilbert tells us,
absorbs the discharges satisfactorily and prevents their penetration
internally. Over the wound is placed a bit of linen moistened with
egg-albumen, then a dressing of lint, and the whole is maintained in
place by a suitable bandage. Finally the patient is to be laid in bed
and maintained in such a position that the wound will be dependent, so
as to favor the ready escape of the discharges. This dressing is to be
renewed three times a day in summer, and twice in winter. Proud flesh
upon the dura mater is to be repressed by the application of a sponge,
well-washed and dried, and if it appears upon the surface of the wound
after the healing of the fracture, it is to be destroyed by the use of
the hermodactyl. When the external wound is healed, the cicatrix is
to be dressed with the _apostolicon cyrurgicum_, an ointment very
valuable for the consolidation of bones, the leveling (_adaequatio?_)
of wounds, etc.
When the wound of the scalp is small, so as to render difficult the
determination of the extent of the fracture by exploration with the
finger, it should be enlarged by crucial incisions, the flaps loosened
from the cranium by a suitable scraper (_rugine_) and folded back
out of the way, and any fragments of bone removed by the forceps
(_pinceolis_). If, however, haemorrhage prevents the immediate removal
of the fragments, this interference may be deferred for a day or
two, until the bleeding has stopped or has been checked by suitable
remedies. Then, after their removal, the piece of linen described
above is to be inserted between the cranium and dura mater. Upon the
cranium and over the flaps of the scalp, as well as in their angles,
the ordinary dressing of albumen is to be applied, covered by a
pledget of lint and a suitable bandage. No ointment, nor anything
greasy, should be applied until after the healing of the wound, lest
some of it may accidentally run down into the fracture and irritate
the dura matter. Some surgeons, Gilbert tells us, insert in the place
of the fragments of the cranium removed a piece of a cup (_ciphi_) or
bowl (_mazer_), or a plate of gold, but this plan, he says, has been
generally abandoned (_dimittitur_.)
Sometimes the cranium is simply cracked without any depression of the
bone, and such fractures are not easily detected. Gilbert tells us,
however, that if the patient will close firmly his mouth and nose and
blow hard, the escape of air through the fissured bone will reveal the
presence of the fracture (f. 88a). In the treatment of such fissures
he directs that the scalp wound be enlarged, the cranium perforated
very cautiously with a trepan (_trepano_) at each extremity of the
fissure and the two openings then connected by a chisel (_spata_?),
in order to enable the surgeon to remove the discharges by a delicate
bit of silk or linen introduced with a feather. If a portion of the
cranium is depressed so that it cannot be easily raised into position,
suitable openings are to be made through the depressed bone in order
to facilitate the free escape of the discharges.
Gunshot wounds were, of course, unknown in Gilbert's day. In a chapter
entitled "_De craneo perforato_" he gives us, however, the treatment
of wounds of the head produced by the transfixion of that member by an
arrow. If the arrow passes entirely through the head, and the results
are not immediately fatal, he directs the surgeon to enlarge the wound
of exit with a trephine, remove the arrowhead through this opening,
and withdraw the shaft of the arrow through the wound of entrance. The
wounds of the cranium are then to be treated like ordinary fractures
of that organ (f. 88c).
In wounds of the neck involving the jugular vein (_vena organica_),
Gilbert directs ligation of both extremities of the wounded vessel,
after which the wound is to be dressed (but not packed) with the
ordinary dressing of egg-albumen.
Wounds of nerves are treated with a novel dressing of earthworms
lightly beaten in a mortar and mixed with warm oil, and he professes
to have seen nerves not only healed (_conglutinari_), but even the
divided nerve fibres regenerated (_consolidari_) under this treatment.
In puncture of a nerve Gilbert surprises us (f. 179d) by the advice
to divide completely the wounded nerve, in order to relieve pain and
prevent tetanus (_spasmus_).
Goitre, not too vascular in character, is removed by a longitudinal
incision over the tumor, after which the gland is to be dragged out,
with its entire capsule, by means of a blunt hook. A large goitre in
a feeble patient, however, is better left alone, as it is difficult
to remove all the intricate roots of the tumor, and if any portion is
left it is prone to return. In such cases Gilbert says we shrink
from the application of the actual cautery, for fear of injury to
the surrounding vessels and nerves. Whatever method of operation is
selected, the patient is to be tied to a table and firmly held in
position.
Wounds of the trachea and oesophagus, according to Gilbert, are
invariably mortal.
In wounds of the thorax the ordinary dressing of albumen is to be
applied, but if blood or pus enters the cavity of the thorax, the
patient is directed to bend his body over a dish, twisting himself
from one side to another (_supra discum[10] flectat se modo hac modo
ilac vergendo_) until he expels the sanies through the wound, and to
always lie with the wound dependent until it is completely healed (f.
182d).
[Footnote 10: It is interesting to observe how the Latin discus
developed dichotomously into the English "dish" and the German
"Tisch." The former is doubtless the meaning of the word in this
place.]
In case an arrow is lodged within the cavity of the thorax, the
surgeon is directed to trepan the sternum (_os pectoris_), remove the
head of the arrow gently from the shaft, and withdraw the shaft itself
through the original wound of entrance. If the head is lodged beneath
or between the ribs, an opening is to be made into the nearest
intercostal space, the ribs forced apart by a suitable wedge and
the head thus extracted. The wound through the soft parts is to be
kept open by a tent greased with lard and provided with a suitable
prolongation (_cauda aliqua_) to facilitate its extraction and prevent
its falling into the cavity of the chest.
Wounds of the heart, lungs, liver, stomach and diaphragm are regarded
as hopelessly mortal (f. 233d), and the physician is advised to have
nothing to do with them. Wounds of the heart are recognized by the
profuse haemorrhage and the black color of the blood; those of the
lung by the foamy character of the blood and the dyspnoea; wounds of
the diaphragm occasion similar dyspnoea and are speedily fatal; those
of the liver are known by the disturbance of the hepatic functions,
and wounds of the stomach by the escape of its contents. Wounds of
the intestine are either incurable, or at least are cured only with
the utmost difficulty. Longitudinal wounds of the spine which do not
penetrate the cord may be repaired, but transverse wounds involving
the cord, so that the latter escapes from the wound, are rarely, if
ever, cured by surgery. Wounds of the kidneys are also beyond the art
of the surgeon. Wounds of the penis are curable, and if the wound is
transverse and divides the nerve, they are likewise painless.
_Si vene titillares in coxis abscidantur homo moritur ridendo._ A
passage which I can refer only to the erudition and risibility of our
modern surgeons and anatomists. The ticklish _vene titillares_ are to
me entirely unknown.
Modern abdominal surgeons will probably be interested in reading
Gilbert's chapter on the treatment of wounds of the intestines in the
thirteenth century. He says (f. 234c):
If some portion of the intestine has escaped from a wound of the
abdomen and is cut either longitudinally or transversely, while the
major portion remains uninjured; if the wound has existed for some
time and the exposed intestine is cold, some living animal, like a
puppy (_catulus_), is to be killed, split longitudinally and placed
over the intestine, until the latter is warmed, vivified by the
natural heat and softened. Then a small tube of alder is prepared, an
inch longer than the wound of the intestine, carefully thinned down
(_subtilietur_) and introduced into the gut through the wound and
stitched in position with a very fine square-pointed needle, threaded
with silk. This tube or canula should be so placed as to readily
transmit the contents of the intestine, and yet form no impediment to
the stitches of the wound. When this has been done, a sponge moistened
in warm water and well washed should be employed to gently cleanse the
intestines from all foreign matters, and the gut, thus cleansed, is to
be returned to the abdominal cavity through the wound of the abdominal
wall. The patient is then to be laid upon a table and gently shaken,
in order that the intestines may resume their normal position in the
abdomen. If necessary the primary wound should be enlarged for this
purpose. When the intestines have been thus replaced, the wound in
the abdominal wall is to be kept open until the wound of the intestine
seems healed. Over the intestinal suture a little _pulvis ruber_
should be sprinkled every day, and when the wound of the intestine is
entirely healed (_consolidatur_), the wound of the abdominal wall is
to be sewed up and treated in the manner of ordinary flesh wounds.
If, however, the wound is large, a pledget (_pecia_) of lint, long
enough to extend from one end to the other and project a little, is
placed in the wound, and over this the exterior portion of the wound
is to be carefully sewed, and sprinkled daily with the _pulvis ruber_.
Every day the pledget which remains in the wound is to be drawn
towards the most dependent part, so that the dressing in the wound may
be daily renewed. When the intestinal wound is found to be healed, the
entire pledget is to be removed and the unhealed openings dressed as
in other simple wounds. The diet of the patient should be also of the
most digestible sort.
Thus far Gilbert has followed Roger almost literally. But he now adds,
apparently upon his own responsibility, the following paragraph:
_Quod si placuerit, extrahe canellum: factis punctis in sutura
ubi debent fieri antequan stringantur, inter duo puncta canellus
extrahatur, et post puncta stringantur. Hoc dico si vulnus intestini
sic (sit) ex transverso._
Apparently Gilbert feels some compunctions of conscience relative to
the ultimate disposition of the canula of alder-wood, and permits,
if he does not advise, its removal from the intestine before the
tightening of the last stitches.
Roland adds nothing to the text of Roger. But The Four Masters
(_Quatuor Magistri_, about A.D. 1270) suggest that the canula be made
of the trachea of some animal, and add:
_Canellus autem per processum temporis putrefit et emittur per
egestionem, et iterum per concavitatem canelli transibit egestio._
In his further discussion of wounds of the intestine and their
treatment Gilbert also volunteers the information that:
"Mummy (shade of Lord Lister!) is very valuable in the healing of
wounds of the intestine, if applied with some astringent powder upon
the suture."
In amends for the mummy, however, we are also introduced to the
practice of mediaeval anaesthesia by means of what Gilbert calls the
_Confectio soporifera_ (f. 234d), composed as follows:
_R._
_Opii,
Succi Jusquiami (hyoscyami),
Succi papaveris nigri, vel ejus seminis,
Sacci mandragorae, vel ejus corticis, vel pomorunt ipsius si succo
carueris,
Foliorum hederae arborae (ivy),
Succi mororum rubi maturorum,
Seminis lactucae,
Succi cuseutae (dodder)_, aa. ounce I.
Mix together in a brazen vessel and place this in the sun during the
dog-days. Put in a sponge to absorb the mixture, and then place the
sponge in the sun until all the moisture has evaporated. When an
operation is necessary, let the patient hold the sponge over his nose
and mouth until he goes to sleep, when the operation may be begun.
To awaken the patient after the operation, fill another sponge with
vinegar and rub the teeth and nostrils with the sponge, and put some
vinegar in the nostrils. An anaesthetic drink may also be prepared as
follows:
_R._
_Seminis papaveris albi et nigri,
Seminis lactucae, aa. ounce I.
Opii,
Misconis ( , poppy juice?)_, aa. scruples I-II, as
required.
The patient is to be aroused as before.
On folio 180d we find a chapter entitled "_De cathena gulae incisa
vel fracta_," and copied almost literally from the chapter "_De catena
gulae_" of Roger. In neither writer do I find any precise definition
of what the _cathena gulae_ is, though Roger says, _Si es gulae,
quod est catena, fractum fuerit_, etc., nor do I find the terms used
explained in any dictionary at present available. The description of
the treatment of this fracture seems, however, to indicate that the
_catena gulae_ of Roger and Gilbert is what we call the clavicle,
though the more common Latin names of this bone are _claviculus_,
_furcula_, _juglum_ or _os juguli_. Gilbert says: "But if the bone
which is the _cathena gulae_ is broken or in any way displaced
(_recesserit_), let the physician with one hand raise the forearm
(_brachium_) or arm (_humerum_) of the patient, and with the other
hand press down upon the projecting portion of the bone. Then apply a
pledget moistened with albumen, a pad and a splint in form of a cross,
and over all a long bandage embracing both the arm and the neck and
suspending the arm. A pad (_cervical_) should also be placed in the
axilla to prevent the dropping of the arm, and should not be removed
until the fracture is repaired. If the fracture is compound, the wound
of the soft parts is to be left open and uncovered by the bandage, so
that a tent (_stuellus_) may be inserted, and the wound is then to be
dressed in the ordinary manner."
Simple fracture of the humerus, Gilbert tells us, is to be reduced
(_ad proprium locum reducator_) at once by grasping the arm above and
below the seat of fracture and exercising gentle and gradual extension
and compression. Then four pieces of lint wet in egg-albumen are
to be placed around the arm on all sides, a bandage, four fingers
wide, also moistened in albumen is to be snugly applied, another dry
bandage placed above this, and finally splints fastened in position
by cords. This dressing is to remain undisturbed for three days, and
then renewed every third day for nine days. After the ninth day a
_strictura_ (cast, apparatus immobile?) is to be prepared and firmly
applied with splints and a bandage, and the patient is to be cautioned
not to bear any weight upon the injured arm (_ne infirmus se super
illud appodiet_?). The fracture is then left until it is believed that
consolidation has occurred. If, however, it is found that swelling
is occasioned by the cast (_ex strictorio_?), the latter should be
removed, and the arm well bathed in warm water containing mallowae and
other emollients and thoroughly cleansed. If the bone seems to be well
consolidated, it should be rubbed with an ointment of _dialthea_ or
the _unguentum marciation_, after which the splints and bandage are
to be reapplied. If, however, it is found that the bone is not well
consolidated, the cast should be replaced in the original manner,
until consolidation is accomplished. If erysipelas results from
the dressings, it is to be treated in the ordinary manner. During
the entire treatment potions of nasturtium seeds, _pes columbini_
(crowfoot) and other "consolidatives" are to be administered
diligently. If the fracture is compound, any loose fragments of
bone are to be removed, the fracture reduced as before, and similar
dressings applied, perforated, however, over the wound in the soft
parts.
In fracture of the ribs (_flexura costi_) Gilbert recommends a
somewhat novel plan for the replacement of the displaced bone. Having
put the patient in a bath, the physician rubs his hands well with
honey, turpentine, pitch or bird-lime (_visco_), applies his sticky
palms over the displaced ribs, and gradually raises them to their
normal position. He also says (f. 183a), the application of a dry cup
(_cuffa vero cum igne_?) over the displaced rib is a convenient method
for raising it into position.
Of fractures of the forearm Gilbert simply says that they are to be
recognized by the touch and a comparison of the injured with the sound
arm. They should be diligently fomented, extension made if necessary,
and then treated like other fractures.
Dislocation of the atlo-axoid articulation (_os juguli_) he tells us
threatens speedy death. The mouth of the patient is to be kept open
by a wooden gag, a bandage passed beneath the jaw and held by the
physician, who places his feet upon the shoulders of the patient and
pressing down upon them while he elevates the head by the bandage,
endeavors to restore the displaced bone to its normal position.
Inunctions of various mollitives are then useful.
Dislocations of the lower jaw are recognized by the failure of the
teeth to fit their fellows of the upper jaw, and by the detection of
the condyles of the jaw beneath the ears. The bone is to be grasped
by the rami and dragged down until the teeth resume and retain
their natural position, and the jaw is then to be kept in place by a
suitable bandage.
In dislocation of the humerus the patient is to be bound in the supine
position, a wedge-shaped stone wrapped with yarn placed in the axilla,
and the surgeon, pressing against the padded stone with his foot and
raising the humerus with his hands, reduces the head of the bone to
its natural position. If this method fails, a long crutch-like stick
is prepared to receive at one end the axillary pad, the patient is
placed standing upon a box or bench, the pad and crutch adjusted in
the axilla, and while the surgeon stands ready to guide the dislocated
bone to its place, his assistants remove the bench, leaving the
patient suspended by his shoulder upon the rude crutch. In boys,
Gilbert tells us, no special apparatus is required. The surgeon merely
places his doubled fist in the axilla, with the other hand grasps the
humerus and lifts the boy off the ground, and the head of the bone
slips readily back into place. After we are assured that the reduction
is complete, a strictorium is prepared, consisting of the _pulvis
ruber_, egg-albumen and a little wheat flour, with which the shoulder
is to be rubbed. Finally, when all seems to be going on well, warm
_spata drapum_ (sparadrap) is to be applied upon a bandage, and if
necessary the apostolicon ointment.