Part 10 (2/2)

The first of this important group of north Italian surgeons who taught at these universities was Bruno of Longoburgo. While he was born in Calabria, and probably studied in Salerno, his work was done at Vicenza, Padua, and Verona. His text-book, the ”Chirurgia Magna,” dedicated to his friend Andrew of Piacenza, was completed at Padua in January, 1252.

Gurlt notes that he is the first of the Italian surgeons who quotes, besides the Greeks, 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. Gurlt tells us that Bruno owed much of what he wrote to his own experience and observation. He 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 gla.s.s 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.”

In his second chapter on healing he talks about healing by first and second intention. Wounds must be more carefully looked to in summer than in winter, because _putrefactio est major in aestate quam in hyeme_, putrefaction is greater in summer than in winter. For 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 st.i.tching indispensable, and recommends for this a fine, square needle. The preferable suture material in his experience was silk or linen.

The end of the wound was to remain open in order that lint might be placed therein in order to draw off any objectionable material. He is particularly insistent on the necessity for drainage. In deep wounds special provision must be made, and in wounds of extremities the limb must be so placed as to encourage drainage. If drainage does not take place, then either the wound must be thoroughly opened, or if necessary a counter opening must be made to provide drainage. All his treatment of wounds is dry, however. Water, he considered, always did harm. We can readily understand that the water generally available and especially as surgeons saw it in camps and on the battlefield, was likely to do much more harm than good. In penetrating wounds of the belly cavity, 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 developments 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 fistulae 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 fistulae, for this would leave the patient in a worse state than before.

HUGH OF LUCCA

Bruno brought up with him the methods and principles of surgery from the south of Italy, but there seems to have been already in the north at least one distinguished surgeon who had made his mark. This was Ugo da Lucca or Ugo Lucca.n.u.s, sometimes known in the modern times in German histories of medicine as Hugo da Lucca and in English, Hugh of Lucca. He flourished early in the thirteenth century. In 1214 he was called to Bologna to become the city physician, and joined the Bolognese volunteers in the crusade in 1218, being present at the siege of Damietta. He returned to Bologna in 1221 and was given the post of legal physician to the city. The civic statutes of Bologna are, according to Gurlt, the oldest monument of legal medicine in the Middle Ages. Ugo died not long after the middle of the century, and is said to have been nearly one hundred years old. Of his five sons, three became physicians.

The most celebrated of these was Theodoric, who wrote a text-book of surgery in which are set down the traditions of surgery that had been practised in his father's life. Theodoric is especially enthusiastic in praise of his father, because he succeeded in bringing about such perfect healing of wounds with only wine and water and the ligature and without the employment of any ointments.

Ugo seems to have occupied himself much with chemistry. To him we owe a series of discoveries with regard to anodyne and anaesthetizing drugs. He is said to have been the first who taught the sublimation of a.r.s.enic.

Unfortunately he left no writings after him, and all that we know of him we owe to the filial devotion of his son Theodoric.

THEODORIC

This son, after having completed his medical studies at the age of about twenty-three, entered the Dominican Order, then only recently established, but continued his practice of medicine undisturbed. His ecclesiastical preferment was rapid. He attracted the attention of the Bishop of Valencia, and became his chaplain in Rome. At the age of about fifty he was made a bishop in South Italy and later transferred to the Bishopric of Cervia, not far from Ravenna. Most of his life seems to have been pa.s.sed in Bologna however, and he continued to practise medicine, devoting his fees, however, entirely to charity. His text-book of surgery was written about 1266 and is signed with his full name and t.i.tle as Bishop of Cervia. Even at this time however, he still retained the custom of designating himself as a member of the Dominican Order.

The most interesting thing in the first book of his surgery is undoubtedly his declaration that all wounds should be treated only with wine and bandaging. Wine he insists on as the best possible dressing for wounds. It was the most readily available antiseptic that they had at that time, and undoubtedly both his father's recommendation of it and his own favorable experience with it were due to this quality. It must have acted as an excellent inhibitive agent of many of the simple forms of pus formation. At the conclusion of this first book he emphasizes that it is extremely important for the healing of wounds that the patient should have good blood, and this can only be obtained from suitable nutrition. It is essential therefore for the physician to be familiar with the foods which produce good blood in order that his wounded patients may be fed appropriately. He suggests, then, a number of articles of diet which are particularly useful in producing such a favorable state of the tissues as will bring about the rebirth of flesh and the adhesion of wound surfaces. Shortly before he emphasizes the necessity for not injuring nerves, though if nerves have been cut they should be brought together as carefully as possible, the wound edges being then approximated.

Probably the most interesting feature for our generation of the great text-books of the surgeons of the medieval universities is the occurrence in them of definite directions for securing union in surgical wounds, at least by first intention and their insistence on keeping wounds clear. The expression union by first intention comes to us from the olden time. They even boasted that the scars left after their incisions were often so small as to be scarcely noticeable. Such expressions of course could only have come from men who had succeeded in solving some of the problems of antisepsis that were solved once more in the generation preceding our own. With regard to their treatment of wounds, Professor Clifford Allb.u.t.t says:[19]

”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, Pare, and Wurtz. In older wounds they did their best to obtain union by cleansing, desiccation, and refres.h.i.+ng of the edges. Upon the outer surface they laid only lint steeped in wine. Powders they regarded as too desiccating, for powder shuts in decomposing matters wine after was.h.i.+ng, purifying, and drying the raw surfaces evaporates.”

Theodoric comes nearest to us of all these old surgeons. The surgeon who in 1266 wrote: ”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” was more than half a millennium ahead of his time. The italics in the word modern are mine, but 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 he obtained without the use of any ointment, _pulcherrimas cicatrices sine unguento aliquo inducebat_, then further that he impugned the use of poultices and of oils on wounds, while powders were too drying and besides had a tendency to prevent drainage, the literal meaning of the Latin words _saniem incarcerare_ is to ”incarcerate sanious material,” it is easy to understand that the claim that antiseptic surgery was antic.i.p.ated 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.

Theodoric's treatment of many practical problems is interesting for the modern time. For instance, in his discussion of cancer he says that there are two forms of the affection. One of them is due to a melancholy humor, a const.i.tutional tendency as it were, and occurs especially in the b.r.e.a.s.t.s of women or latent in the womb. This is difficult of treatment and usually fatal. The other cla.s.s consists of a deep ulcer with undermined edges, occurring particularly on the legs, difficult to cure and ready of relapse, but for which the outlook is not so bad. His description of _noli me tangere_ and of lupus is rather practical. Lupus is ”eating herpes,” occurs mainly on the nose, or around the mouth, slowly increases, and either follows a preceding erysipelas or comes from some internal cause. _Noli me tangere_ is a corroding ulcer, so called perhaps because irritation of it causes it to spread more rapidly. He thinks that deep cauterization of it is the best treatment. Since these are in the department of skin diseases this seems the place to mention that Theodoric describes salivation as occurring after the use of mercury for certain skin diseases. He has already shown that he knows of certain genital ulcers and sores on the genital regions and of distinctions between them.

WILLIAM OF SALICET

The third of the great surgeons in northern Italy was William of Salicet. He was a pupil of Bruno's and the master of Lanfranc. The first part of his life was pa.s.sed at Bologna and the latter part as the munic.i.p.al and hospital physician of Verona. He probably died about 1280.

He was a physician as well as a surgeon and was one of those who insisted that the two modes of practising medicine should not be separated, or if they were both medicine and surgery would suffer. He thought that the physician learned much by seeing the interior of the body during life, while the surgeon was more conservative if he were a physician. It is curiously interesting to find that the Regius Professors at both Oxford and Cambridge in our time have expressed themselves somewhat similarly. Professor Clifford Allb.u.t.t is quite emphatic in this matter and Professor Osler is on record to the same effect. Following Theodoric, William of Salicet did much to get away from the Arabic abuse of the cautery and brought the knife back to its proper place again as the ideal surgical instrument. Unlike those who had written before him, William quoted very little from preceding writers. Whenever he quotes his contemporaries it is in order to criticise them. He depended on his own experience and considered that it was only what he had actually learned from experience that he should publish for the benefit of others.

A very good idea of the sort of surgery that William of Salicet practised may be obtained even from the beginning of the first chapter of his first book. This is all with regard to surgery of the head. 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 an incision because of the danger of it. In a number of cases, however, he had had success by puncturing the scalp and membranes with a cautery, though but a very small opening was made and the fluid was allowed to escape only drop by drop. He then takes up eye diseases, a department of surgery rather well developed at that time, as can be seen from our account of the work of Pope John XXI as an ophthalmologist during the thirteenth century. See _Ophthalmology_ (January, 1909), reprinted in ”Catholic Churchmen in Science,”

Philadelphia, The Dolphin Press, 1909.

William devotes six chapters to the diseases of the eyes and the eyelids. Then there are two chapters on affections of the ears. Foreign bodies and an acc.u.mulation of ear wax are removed by means of instruments. A polyp is either cut off or its pedicle bound with a ligature, and it is allowed to shrivel. The next chapter is on the nose.

Nasal polyps were to be grasped with a sharp tenaculum, _c.u.m tenacillis acutis_, and either wholly or partially extracted. Ranula was treated by being lifted well forward by means of a sharp iron hook and then split with a razor. It is evident that the tendency of these to fill up again was recognized, and accordingly it was recommended that vitriol powder, or alum with salt, be placed in the cavity for a time after evacuation in order to produce adhesive inflammation.

In the same chapter on the mouth one finds that William did not hesitate to perform what cannot but be considered rather extensive operations within the oral cavity. For instance, he tells of removing a large epulis and gives an account in detail of the case. To quote his own words: ”I cured a certain woman from Piacenza who was suffering from fleshy tumor on the gums of the upper jaw, the tumor having grown to such a size above the teeth and the gums that it was as large or perhaps larger than a hen's egg. I removed it at four operations by means of heated iron instruments. At the last operation I removed the teeth that were loose with certain parts of the jawbone.”

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