Part 10 (1/2)

Modern surgery may be said to owe its origin to a school of surgeons, the leaders of whom were educated at Salerno in the early part of the thirteenth century, and who, teaching at various north Italian universities, wrote out their surgical principles and experiences in a series of important contributions to that department of medical science.

The fact that the origin of the school was at Salerno, where, as is well known, Arabian influence counted for much and for which Constantine's translations of Arabian works proved such a stimulus a century before, makes most students conclude that this later medieval surgical development is simply a continuation of the Arabian surgery that, as we have seen, developed very interestingly during the earlier Middle Ages.

Any such idea, however, is not founded on the realities of the situation, but on an a.s.sumption with regard to the extent of Arabian influence. Gurlt in his ”History of Surgery” (Vol. I, page 701) completely contradicts this idea, and says with regard to the first of the great Italian writers on surgery, Rogero, that ”though Arabian works on surgery had been brought over to Italy by Constantine Africa.n.u.s 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.”

It is in the history of medicine particularly that it is possible to trace the true influence of the Arabs on European thought in the later Middle Ages. We have already seen in the chapter on Salerno that Arabian influence did harm to Salernitan medical teaching. The school of Salerno itself had developed simple, dietetic, hygienic, and general remedial measures that included the use of only a comparatively small amount of drugs. Its teachers emphasized nature's curative powers. With Arabian influence came polypharmacy, distrust of nature, and attempts to cure disease rather than help nature. In surgery, which developed very wonderfully in the thirteenth and fourteenth centuries, Salerno must be credited with the incentive that led up to the marvellous development that came. With this, however, Arabian influence has nothing to do.

Gurlt, besides calling attention to the fact that the author of the first great text-book on the subject not only did not draw his inspiration from Arab sources, insisted that ”instead of any Arabisms being found in his [Roger's] writings many Graecisms occur.” The Salernitan school of surgery drank at the fountain-head of Greek surgery. Apart from Greek sources Roger's book rests entirely upon his own experiences, those of his teachers and his colleagues, and the tradition in surgery that had developed at Salerno. This tradition was entirely from the Greek. Roger himself says in one place, ”We have resolved to write out deliberately our methods of operation such as they have been derived from our own experience and that of our colleagues and ill.u.s.trious men.”

ROGER, ROLAND, AND THE FOUR MASTERS

Ruggero, or Rogero, who is also known as Rogerio and Rogerus with the adjective Parmensis, or Salernita.n.u.s, of Parma or of Salerno, and often in German and English history simply as Roger, lived at the end of the twelfth or the beginning of the thirteenth century and probably wrote his text-book about 1180. This text-book was, according to tradition, originally drafted for his lessons in surgery at Salerno. It attracted much attention and after being commented on by his pupil Rolando, the work of both of them being subsequently annotated by the Four Masters, this combined work became the basis of modern surgery. Roger was probably born either in Palermo or Parma. There are traditions of his having taught for a while at Paris and at the University of Montpellier, though these are not substantiated. His book was printed at Venice in 1546, and has been lately reprinted by De Renzi in his ”Collectio Salernitana.”

Roland was a pupil of Roger's, and the two names that often occur in medieval romance became a.s.sociated in a great historic reality as a consequence of Roland's commentary on his master's work, which was a favorite text-book in surgery for a good while in the thirteenth century at Salerno. Some s.p.a.ce will be given to the consideration of their surgical teaching after a few words with regard to some disciples who made a second commentary, adding to the value of the original work.

This is the well-known commentary of the Four Masters, a text-book of surgery written somewhat in the way that we now make text-books in various departments of medicine, that is, by asking men who have made specialties of certain subjects to write on that subject and then bind them all together in a single volume. It represents but another striking reminder that most of our methods are old, not new as we are likely to imagine them. The Four Masters took the works of Roger and Rolando, acknowledged their indebtedness much more completely than do our modern writers on all occasions, I fear, and added their commentaries.

Gurlt says (”Geschichte der Chirurgie,” Vol. I, p. 703) that ”in spite of the fact that there is some doubt about the names of the authors, this volume const.i.tutes one of the most important sources for the history of surgery of the later Middle Ages and makes it very clear that these writers drew their opinions from a rich experience.” It is rather easy to ill.u.s.trate from the quotations given in Gurlt or from the accounts of their teaching in Daremberg or De Renzi some features of this experience that can scarcely fail to be surprising to modern surgeons. For instance, what is to be found in this old text-book of surgery with regard to fractures of the skull is likely to be very interesting to surgeons at all times. One might be tempted to say that fewer men would die every year in prison cells who ought to be in hospitals, if the old-time teaching was taken to heart. For there are rather emphatic directions not to conclude because the scalp is unwounded that there can be no fracture of the skull. Where nothing can be felt care must be exercised in getting the history of the case. For instance, if a man is. .h.i.t by a metal instrument shaped like the clapper of a bell or by a heavy key, or by a rounded instrument made of lead--this would remind one very much of the lead pipe of the modern time, so fruitful of mistakes of diagnosis in head injuries--special care must be taken to look for symptoms in spite of the lack of an external penetrating wound. Where there is good reason to suspect a fracture because of the severity of the injury, the scalp should be incised and a fracture of the cranium looked for carefully. That is carrying the exploratory incision pretty far. If a fracture is found the surgeon should trephine so as to relieve the brain of any pressure of blood that might be affecting it.

There are many warnings, however, 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 observations 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.”[18] 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 pin. 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.”

For wounds of the scalp sutures of silk are recommended because this resists putrefaction and holds the wound edges together. Interrupted sutures about a finger-breadth apart are recommended. ”The lower part of the wound should be left open so that the cure may proceed properly.”

Red powder was strewed over the wound and the leaf of a plant set above it. In the lower angle of the wound a pledget of lint for drainage purposes was inlaid. Hemorrhage was prevented by pressure, by the binding on of _burnt_ wool firmly, and by the ligature of veins and by the cautery.

There are rather interesting discussions of the prognosis of wounds of the head, especially such as may be determined from general symptoms in this commentary of the Four Masters on Roger's and Rolando's treatises.

If an acute febrile condition develops, the wound is mortal. If the patient loses the use of the hands and feet or if he loses his power of direction, or his sensation, the wound is mortal. If a universal paralysis comes on, the wound is mortal. For the treatment of all these wounds careful precautions are suggested. Cold was supposed to be particularly noxious to them. Operations on the head were not to be done in cold weather and, above all, not in cold places. The air where such operations were done 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. These precautions are interesting as foreshadowing many ideas of much more modern time and especially indicating how old is the idea that cold may be taken in wounds. In popular medicine this still has its place. Whenever a wound does badly in the winter time patients are sure that they have taken cold. Such popular medical ideas are always derived from supposedly scientific medicine, and until we learned about microbes physicians used the same expressions. We have not got entirely away from them yet.

These old surgeons must have had many experiences with fractures at the base of the skull. Hemorrhages from the mouth and nose, for instance, and from the ears were considered bad signs. They were inclined to suggest that openings into the skull should be discovered by efforts to demonstrate a connection between the mouth and nares and the brain cavity. For instance, in their commentary the Four Masters said: ”Let the patient hold his mouth and nostrils tight shut and blow strongly.”

If there was any lessening of the pressure or any appearance of air in the wound in the scalp, then a connection between the mouth and nose was diagnosticated. This is ingenious but eminently dangerous because of the infectious material contained in the nasal and oral cavities, so likely to be forced by such pressure into the skull. They were particularly anxious to detect linear fractures. 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 ”_sed hoc aliquando fallit_--but this sign sometimes fails.” Split or crack fractures were also diagnosticated by the method suggested by Hippocrates of pouring some colored fluid over the skull after the bone was exposed, when the linear fracture would show by coloration. The Four Masters suggest a sort of red ink for this purpose.

While they have so much to say about fractures of the skull and insist, over and over again, that though all depressed fractures need treatment and many fissure fractures require trepanation, still great care must be exercised in the selection of cases. They say, for instance, that surgeons who in every serious wound of the head have recourse to the trephine must be looked upon as ”fools and idiots” (_idioti et stolidi_). In the light of what we now know about the necessity for absolute cleanliness,--asepsis as we have come to call it,--it is rather startling to note the directions that are given to a surgeon to be observed on the day when he is to do a trepanation. For obvious reasons I prefer to quote it in the Latin: ”_Et nota quod die ilia cavendum est medico a coitu et malis cibis aera corrumpentibus, ut sunt allia, cepe, et hujusmodi, et colloquio mulieris menstruosae, et ma.n.u.s ejus debent esse mundae, etc._” My quotation is from Gurlt, Vol. I, p. 707. The directions are most interesting. The surgeon's hands must be clean, he must avoid the taking of food that may corrupt the air, such as onions, leeks, and the like; must avoid menstruating and other women, and in general must keep himself in a state of absolute cleanliness.

To read a pa.s.sage like this separated from its context and without knowing anything about the wonderful powers of observation of the men from whom it comes, it would be very easy to think that it is merely a set of general directions which they had made on some general principle, perhaps quite foolish in itself. We know, however, that these men had by observation detected nearly every feature of importance in fractures of the skull, their indications and contra-indications for operation and their prognosis. They had antic.i.p.ated nearly everything of importance that has come to be insisted on even in our own time in the handling of these difficult cases. It is not unlikely, therefore, that they had also arrived at the recognition by observations on many patients that the satisfactory after-course of these cases which were operated on by the surgeon after due regard to such meticulous cleanliness as is suggested in the paragraph I have quoted, made it very clear that these aseptic precautions, as we would call them, were extremely important for the outcome of the case and, therefore, were well worth the surgeon's attention, though they must have required very careful precautions and considerable self-denial. Indeed this whole subject, the virtual antic.i.p.ation of our nineteenth-century principles of aseptic surgery in the thirteenth century, is not a dream nor a far-fetched explanation when one knows enough about the directions that were laid down in the surgical text-books of that time.

THE NORTH ITALIAN SURGEONS

After Roger and Rolando and the Four Masters, who owe the inspiration for their work to Salerno and the south of Italy, comes a group of north Italian surgeons: Bruno da Longoburgo, usually called simply Bruno; Theodoric and his father, Hugo of Lucca, and William of Salicet.

Immediately following them come two names that belong, one almost feels, to a more modern period: Mondino, the author of the first text-book on dissection, and Lanfranc (the disciple of William of Salicet), who taught at Paris and ”gave that primacy to French surgery which it maintained all the centuries down to the nineteenth” (Pagel). It might very well be thought that this group of Italian surgeons had very little in their writings that would be of any more than antiquarian interest for the modern time. It needs but a little knowledge of their writings as they have come down to us to show how utterly false any such opinion is. To Hugo da Lucca and his son Theodoric we owe the introduction and the gradual bringing into practical use of various methods of anaesthesia. They used opium and mandragora for this purpose and later employed an inhalant mixture, the composition of which is not absolutely known. They seem, however, to have been very successful in producing insensibility to pain for even rather serious and complicated and somewhat lengthy operations. Indeed it is to this that must be attributed most of their surprising success as surgeons at this early date.

We are so accustomed to think that anaesthesia was discovered about the middle of the nineteenth century in America that we forget that literature is full of references in Tom Middleton's (seventeenth century) phrase to ”the mercies of old surgeons who put their patients to sleep before they cut them.” Anaesthetics were experimented with almost as zealously, during the latter half of the thirteenth century at least, as during the latter half of the nineteenth century. They were probably not as successful as we are, but they did succeed in producing insensibility to pain, otherwise they could never have operated to the extent they did. Moreover the traditions show that the Da Luccas particularly had invented a method that left very little to be desired in this matter of anaesthesia. A reference to the sketch of Guy de Chauliac in this volume will show how practical the method was in his time.

Nearly the same story as with regard to anaesthetics has to be repeated for what are deemed so surely modern developments,--asepsis and antisepsis. I have already suggested that Roger seems to have known how extremely important it was to approach operations upon the skull with the most absolute cleanliness. There are many hints of the same kind in other writers which show that this was no mere accidental remark, but was a definite conclusion derived from experience and careful observation of results. We find much more with regard to this same subject in the writings of the group of northern Italian surgeons and especially in the group of those a.s.sociated with William of Salicet.

Professor Clifford Allb.u.t.t, Regius Professor of Medicine at the University of Cambridge, England, in his address before the St. Louis World's Fair Congress of Arts and Science in 1904, did not hesitate to declare that William discussed the causes for union by first intention and the modes by which it might be obtained. He, too, insisted on cleanliness as the most important factor in having good surgical results, and all of this group of men, in operating upon septic cases, used stronger wine as a dressing. This exerted, as will be readily understood, a very definite antiseptic quality.

Evidently some details of the teaching of this group of great surgeons in northern Italy in the second half of the thirteenth century will make clearer to us how much the rising universities of the time were accomplis.h.i.+ng in medicine and surgery as well as in their other departments. The dates of the origin of some of these universities should perhaps be recalled so as to remind readers how closely related they are to this great group of surgical teachers. Salerno was founded very early, probably in the tenth century, Bologna, Reggio, and Modena came into existence toward the end of the twelfth century; Vicenza, Padua, Naples, Vercelli, and Piacenza, as well as Arezzo, during the first half of the thirteenth century; Rome, Perugia, Trevizo, Pisa, Florence, Sienna, Lucca, Pavia, and Ferrara during the next century. The thirteenth century was the special flouris.h.i.+ng period of the universities, and the medical departments, far from being behind, were leaders in accomplishment. (See my ”The Thirteenth Greatest of Centuries,” N.Y., 1908.)

BRUNO DA LONGOBURGO