From Salerno come many of the traditions of the conferring of degrees which are still used in a large number of modern medical schools. Before receiving his degree, the candidate had to take an oath, of which the following were the principal tenets: “Not to contradict the teaching of his college, not to teach what was false or lying, and not to receive fees from the poor even though they were offered; to commend the sacrament of penance to his patients, to make no dishonest agreement with the druggists, to administer no abortifacient drug to the pregnant, and to prescribe no medicament that was poisonous to human bodies.”
It has sometimes been said that youths of tender age were admitted to the study of medicine at Salerno, and that many of them were given their degrees at the age of twenty-one. De Renzi’s discussion would seem to show that the usual age of receiving the degree was twenty-five to twenty-seven. As medical students had to have threeyears of preparatory studies in literature and philosophy, it would seem that they must have been rather mature on their admission to the medical schools.
De Renzi tells us that the medical school of Salerno was of great importance not only for medical education, but it acquired sufficient means to extend its benefits over the entire city. Gifts were made of statues to the churches, and especially to the shrine of St. Matthew the Apostle, situated here; monuments were set up, inscriptions placed and ample donations made to the various institutions of the city. The formal name of the medical school wasAlmum et Hippocraticum Medicorum Collegium. This is the first use that I know of the wordalmumin connection with a college, and may very well be the distant source of our termalma mater. The medical school was situated in the midst of an elevated valley which opened up on the mountain that dominates Salerno, and while enjoying very pure air must have been scarcely disturbed at all by the winds which can be blustery enough from the gulf. De Renzi says that in his time some of the remains could still be seen, though visitors to Salerno now come away very much disappointed because nothing of interest is left.
The most famous of the teachers at Salerno was Constantine Africanus, so called because he wasborn near Carthage. His life runs from the early part of the eleventh century to near its close, and he lived probably well beyond eighty years of age. Having studied medicine in his native town, he wandered through the East, became familiar with a number of Oriental languages, and studied the Arabian literature of science, and above all of medicine, very diligently. The Arabs, owing to their intimate contact with the Greeks in Asia Minor, had the Greek authors constantly before them, and Hippocrates and Galen have always roused men to do good work in medicine. Constantine seems not to have learned Greek, finding enough to satisfy him in the Arabic commentaries on the Greek authors, and probably confident, as all young men have ever been, that what his own time was doing must represent an advance over the Greek. He brought back with him Arabian books and a thorough knowledge of Arabian medicine. When he settled down in Carthage he was accused of magical practices, his medical colleagues being apparently jealous of his success—at least, there is a tradition to that effect to account for his removal to Salerno, though the immediate reason seems to have been that his reputation attracted the attention of Duke Robert of Salerno, who invited him to become his physician.
After Constantine’s time the principal textbooksof the school became, according to De Renzi, Hippocrates, Galen, and Avicenna. To these were added theAntidotariumof Mesue, and there were various compendiums of medical knowledge, quite as in our own time—one well known under the name ofArticella. In surgery the principal textbook was the surgical works of the Four Masters of Salerno, which interestingly enough was the sort of combination work gathered from a series of masters that we are accustomed to see so frequently at the present day. De Renzi insists that there was much less Arabic influence at Salerno than is usually thought; and Gurlt more recently has emphasized, as we have said, the fact that the great textbooks of surgery which we have from Salerno contain not Arabisms, as might be expected from the traditions of Arabic influence that we hear so much of, but Græcisms, which show that here at Salerno there was a very early Renaissance, and the influence of Greek writers was felt even in the twelfth century.
Probably the best way to convey in brief form a good idea of the teaching in medicine at Salerno is to quote theRegimen Sanitatis Salernitanum, the Code of Health of the School of Salernum, which for many centuries was popular in Europe, and was issued in many editions even after the invention of printing. Professor Ordronaux,Professor of Medical Jurisprudence in the law school of Columbia College (now Columbia University, New York), issued a translation of it in verse,[3]which gives a very good notion of the contents and the spirit and the mode of expression of the little volume.
TheRegimenwas written in the rhymed verses which were so familiar at this time. Many writers on the history of medicine have marvelled at this use of verse, but anyone who knows how many verse-makers there were in the twelfth and thirteenth centuries all over Europe will not be surprised. It used to be the custom to make little of these rhymed Latin verses of the Middle Ages, but it may be well to recall that in recent years a great change has come over the appreciation of the world of literature in their regard. The rhymed Latin hymns of the Church, especially theDies Iræ, theStabat Mater, and others, are now looked upon as representing some of the greatest poetry that ever was written. Professor Saintsbury of the University of Edinburgh has declared them the most wondrous wedding of sense and sound that the world has ever known. TheRegimen Sanitatisof Salerno is of course no such poetry, mainly because its subject was commonplace and it could not rise to poetic heights. A good deal of thedeprecation of its Latinity might well be spared, for most of the mistakes are undoubtedly due to copyists and interpolation. The verses not only rhyme at the end, but often there are internal sub-rhymes. This too was a very common custom among the hymn-writers, as the great sequence of Bernard of Morlaix, so well known through its translations in our time, as “Jerusalem the Golden” attests.
TheRegimenwas not written for physicians, but for popular information. It seems to have been a compilation of maxims of health from various professors of the Salernitan School. Nothing that I know shows more clearly the genuine knowledge of medicine, and the careful following of the first rule of medical practicenon nocereto which Salerno had reached at this time, than the fact that this popular volume contained no recommendation of specific remedies, but only health rules for diet, air, exercise, and the like, many of which are as valuable in our time as they were in that, and very few of which have been entirely superseded—together with some general information as to simples, and a few details of medical knowledge that would give a convincing air to the compilation.
The book was dedicated to the King of the English,Anglorum regi scribit schola tota Salerni,and in the translation made by Professor Ordonaux begins as follows:
If thou to health and vigour wouldst attain,Shun weighty cares—all anger deem profane,From heavy suppers and much wine abstain.Nor trivial count it, after pompous fare,To rise from table and to take the air.Shun idle, noonday slumber, nor delayThe urgent calls of Nature to obey.These rules if thou wilt follow to the end,Thy life to greater length thou mayst extend.[4]
Evidently it was rather easy to commit such rhymes to memory, and this accounts for the fact that we have many different versions of theRegimenand disputed readings of all kinds. These medieval hygienists believed very much in early rising, cold water, thorough cleansing, exercise in the open air, yet without sudden cooling afterwards. The lines on morning hygiene seem worth while giving in Ordonaux’s translation.
At early dawn, when first from bed you rise,Wash, in cold water, both your hands and eyes.With brush and comb then cleanse your teeth and hair,And thus refreshed, your limbs outstretch with care.Such things restore the weary, o’ertasked brain;And to all parts ensure a wholesome gain.Fresh from the bath, get warm. Rest after food,Or walk, as seems most suited to your mood.But in whate’er engaged, or sport, or feat,Cool not too soon the body when in heat.
The Salernitan writers were not believers in noonday sleep, though one might have expected that the tradition of thesiestain Italy had been already established. They insist that it makes one feel worse rather than better to break the day by a sleep at noonday.
Let noontide sleep be brief, or none at all;Else stupor, headache, fever, rheums, will fallOn him who yields to noontide’s drowsy call.
They believed in light suppers—
Great suppers will the stomach’s peace impair;Wouldst lightly rest, curtail thine evening fare.
With regard to the interval between meals, the Salernitan rule was, wait until your stomach is surely empty:
Eat not again till thou dost certain feelThy stomach freed of all its previous meal.This mayst thou know from hunger’s teasing call,Or mouth that waters—surest sign of all.
Pure air and sunlight were favourite tonics at Salerno—
Let air you breathe be sunny, clear, and light,Free from disease or cess-pool’s fetted blight.
Taking “a hair of the dog that bit you” was, however, a maxim with Salernitans for the cure of potation headaches.
Art sick from vinous surfeiting at night?Repeat the dose at morn, ’twill set thee right.
The tradition with regard to the difficulty of the digestion of pork, which we are trying to combat in the modern time, had already been established at Salerno. The digestibility of pork could, however, be improved by good wine.
Inferior far to lamb is flesh of swine,Unqualified by gen’rous draughts of wine;But add the wine, and lo! you’ll quickly findIn them both food and medicine combined.
Milk for consumptives was a favourite recommendation. The tradition had come down from very old times, and Galen insisted that fresh air and milk and eggs was the best possible treatment for consumption. The Salernitan physicians recommended various kinds of milk, goat’s, camel’s, ass’s, and sheep’s milk as well as cow’s. It is probable, as I pointed out in my “Psychotherapy,” that the mental influence of taking some one of the unusual forms of milk did a good deal to produce a favourable reaction in consumptives, who are so prone to be affected favourably by unusual remedies. TheRegimenwarned, however, that milk will not be good if it produces headacheor if there is fever. Apparently some patients had been seen with the idiosyncrasy for milk, and the tendency to constipation and disturbance after it which have been noted also in the modern time.
Goat’s milk and camel’s, as by all is known,Relieve poor mortals in consumption thrown;While ass’s milk is deemed far more nutritious,And e’en beyond all cow’s or sheep’s, officious.But should a fever in the system riot,Or headache, let the patient shun this diet.
Salerno’s common sense with regard to diet is very well illustrated by a number of maxims. Diet tinkering was not much in favour.
We hold that men on no account should varyTheir daily diet until necessary:For, as Hippocrates doth truly show,Diseases sad from all such changes flow.A stated diet, as it is well known,Of physic is the strongest cornerstone—By means of which, if you can nought impart,Relief or cure, vain is your Healing Art.
They believed firmly that many of the conditions of eating were quite as important as the diet itself, and said:
Doctors should thus their patients’ food revise—Whatis it?Whenthe meal? And what itssize?Howoften?Where?lest, by some sad mistake,Ill-sorted things should meet and trouble make.
They recommended the various simples, mallow, mint, sage, rue, the violet for headache and catarrh,the nettle, mustard, hyssop, elecampane, pennyroyal, cresses, celandine, saffron, leeks—a sovereign remedy for sterility—pepper, fennel, vervaine, henbane, and others. There were certain special affections, as hoarseness, catarrh, headaches, fistula, for which specific directions for cure were given. Here for instance are the directions to be given a patient suffering from rheum or catarrh. The verses conveyed interesting information with nice long names for the various affections, as well as the directions for its management.
Fast well and watch. Eat hot your daily fare,Work some, and breathe a warm and humid air;Of drink be spare; your breath at time suspend;These things observe if you your cold would end.A cold whose ill-effects extend as farAs in the chest, is known as a catarrh;Bronchitis, if into the throat it flows;Coryza, if it reach alone the nose.
TheRegimenconveyed a deal of information in compact form. It gives the number of bones in the body as 219 with 32 teeth, and the number of veins as 365, this number being chosen doubtless because of some supposed relation to the number of days in the year. It contains also a good brief account of the four humours in the human body—black bile, blood, phlegm, and yellow bile; and of the four temperaments—the sanguine, the bilious, the phlegmatic, and the melancholy. These fourtemperaments were discussed at considerable length by all the psychologists and most of the writers on religious life for centuries afterwards, largely on the basis of the information conveyed by the Salernitan handbook. There are descriptions of the symptoms of plethora or excess of blood, of excess of bile, of excess of phlegm, and excess of black bile. The little volume finally contains discussions as to bleeding, its indications, contraindications, as in youth—“Ere seventeen years we scarce need drawing blood”—and in old age; and then of the mode of practising it, and the place whence the blood should be drawn to relieve different symptoms.[5]
Salerno impressed itself much more deeply on surgery than on medicine, for the magnificent development of medieval surgery, the knowledge of which has proved so surprising in our day, began down at Salerno. Some of the details of this phase of Salernitan accomplishment are given in the chapter on Medieval Surgeons of Italy. Roger and Roland and the Four Masters were great original founders in a phase of medical science that proved extremely important for the next three or four centuries. Undoubtedly the presence of a hospital at Salerno, where there were gathered a number of the chronic cases from all over Europe, most of them of the better-to-do classes looking for ease from their ills, gave the incentive to this development. When the natural means of cure, tried for a considerable time, failed, recourse was had to surgery for relief, and often with excellent results. This chapter on Salerno’s history shows how thoroughgoing was the effort of the members of the faculty of the medical school to develop every possible means of aid for their patients, even when that required pioneer work.
Pagel’s appreciation of Salerno’s place in the history of medicine, in his chapter on Medicine in the Middle Ages in Puschmann’s “Handbuch Der Geschichte der Medicin,” Berlin, 1902, gives in very brief space a summary of what wasaccomplished at Salerno that emphasizes what has been said here, and his authority will confirm those who might possibly continue to doubt of any institution of the Middle Ages having achieved so much. He said:
“If we take up now the accomplishments of the School of Salerno in the different departments, there is one thing that is very remarkable. It is the rich, independent productivity with which Salerno advanced the banners of medical science for hundreds of years, almost as the only autochthonous centre of medical influence in the whole West. One might almost say that it was like aversprengten Keim—a displaced embryonic element—which, as it unfolded, rescued from destruction the ruined remains of Greek and Roman medicine. This productivity of Salerno, which may well be compared in quality and quantity with that of the best periods of our science, and in which no department of medicine was left without some advance, is one of the striking phenomena of the history of medicine. While positive progress was not made, there are many noteworthy original observations to be chronicled. It must be acknowledged that pupils and scholars set themselves faithfully to their tasks to further, as far as their strength allowed, the science and art of healing. In the medical writers of the older period ofSalerno, who had not yet been disturbed by Arabian culture or scholasticism, we cannot but admire the clear, charmingly smooth, easy-flowing diction, the delicate and honest setting forth of cases, the simplicity of their method of treatment, which was to a great extent dietetic and expectant; and while we admire the carefulness and yet the copiousness of their therapy, we cannot but envy them a certain austerity in their pharmaceutic formulas, and an avoidance of medicamental polypragmasia. The work in internal medicine was especially developed. The contributions to it from a theoretic and literary standpoint, as well as from practical applications, came from ardent devotees.”
One very interesting contribution to medical literature that comes to us from Salerno bears the title “The Coming of a Physician to His Patient, or an Instruction for the Physician Himself.” It illustrates very well the practical nature of the teaching of Salerno, and gives a rather vivid picture of the medical customs of the time. The instruction as to the conduct of the physician when he first comes into the house and is brought to the patient runs as follows:
“When the doctor enters the dwelling of his patient, he should not appear haughty, nor covetous, but should greet with kindly, modest demeanour those who are present, and then seatinghimself near the sick man accept the drink which is offered him [sic], and praise in a few words the beauty of the neighbourhood, the situation of the house, and the well-known generosity of the family—if it should seem to him suitable to do so. The patient should be put at his ease before the examination begins, and the pulse should be felt deliberately and carefully. The fingers should be kept on the pulse at least until the hundredth beat in order to judge of its kind and character; the friends standing round will be all the more impressed because of the delay, and the physician’s words will be received with just that much more attention.”
The rest of the advice smacks rather more of sophistication than we care to think of in a professional man, but its display of a profound knowledge of human nature makes it interesting.
“On the way to see the sick person he (the physician) should question the messenger who has summoned him upon the circumstances and the conditions of the illness of the patient; then, if not able to make any positive diagnosis after examining the pulse and the urine, he will at least excite the patient’s astonishment by his accurate knowledge of the symptoms of the disease, and thus win his confidence.”
Salerno taught as well as it could the science of medicine, and initiated great advances in surgery; but it also emphasized the art of medicine, andrecognized very clearly that the personality of the physician counted for a great deal, and that his influence upon his patients must be fostered quite as sedulously as his knowledge of the resources of medicine for their ills.
MONTPELLIER AND MEDICAL EDUCATION IN THE WEST
After Salerno the next great medical school was that of Montpellier in the South of France. The conditions which brought about its original establishment are very like those which occasioned the foundation of Salerno. Montpellier, situated not far from the Mediterranean, came to be a health resort. Patients flocked to it from many countries of the West of Europe; physicians settled there because patients were numerous, and medical instruction came to be offered to students. Fame came to the school. The fundamental reason for this striking development of the intellectual life seems to have been that Montpellier was not far from Marseilles, which had been a Greek colony originally and continued to be under Greek influence for many centuries. As a consequence of this the artistic and intellectual life of the southern part of France was higher during the earlier Middle Ages than that of any other part of Europe, except certain portions of South Italy. The remains of the magnificent architecture of theRoman period are well known, and Provence has always been famous for its intellectual and literary life. Among a people who were in this environment, we might well look for an early renaissance of education.
It is not surprising, then, that one of the earliest of the medical schools of modern history around which there gradually developed a university should have come into existence in this part of the world. What is even more interesting perhaps for us, is that this medical school has persisted down to our own day, and has always been, for nearly ten centuries now, a centre of excellent medical education.
There gathered around the story of its origin such legends as were noted with regard to the history of Salerno, and there is no doubt that Jewish and Moorish physicians who became professors there contributed not a little to the prestige of the school and the reputation that it acquired throughout Europe. The attempt to attribute all of the stimulus for the intellectual life at Montpellier to these foreign elements is, however, simply due to that paradoxical state of mind which has so often tried to minimize the value of Christian contributions to science and the intellectual life, even by the exaggeration of the significance of what came from foreign and un-Christian sources.Proper recognition must be accorded to both Jewish and Moorish factors at Montpellier, but the one important element is that these foreign professors brought with them, even though always in rather far-fetched translations, the ideas of the great Greek masters of medicine to which the region and the people around Montpellier were particularly sensitive, because of the Greek elements in the population, and hence the development of a significant centre of education here.
The date of the rise of the medical school at Montpellier is, as suggested by Puschmann, veiled in the obscurity of tradition. There seems to be no doubt that it goes back to as early as the tenth century, it was already famous in the eleventh, and it attracted students from all over Europe during the twelfth century. When Bishop Adalbert of Mainz came thither in 1137, the school possessed buildings of its own, as we learn from the words of a contemporary, Bishop Anselm of Havelberg. St. Bernard in a letter written in 1153 tells that the Archbishop of Lyons, being ill, repaired to Montpellier to be under the treatment of the physicians there. Perhaps the most interesting feature of this letter is the fact that the good Archbishop not only spent what money he had with him on physicians, but ran into debt.
The two schools, Salerno and Montpellier, cameto be mentioned by writers of the period as representing the twins of medical learning of the time. John of Salisbury, a writer of the early thirteenth century, declares that those who wished to devote themselves to medicine at this time went either to Salerno or Montpellier. Ægidius or Gilles de Corbeil, the well-known physician, and Hartmann von der Aue, the Meistersinger, both mention Salerno and Montpellier, usually in association, in their writings, and make it very clear that in the West at least the two names had come to be almost invariably connected as representing rival medical schools of about equal prominence.
The reputation of Montpellier spread in Italy also, however, and we have the best evidence for this from an incident that took place in Rome at the beginning of the thirteenth century, which is more fully dwelt on in the chapter on Medieval Hospitals. Pope Innocent III. wanted to create a model hospital at Rome, and made inquiries as to who would be best fitted to organize such an institution. He was told of the work of Guy or Guido of Montpellier, who was a member of the Order of the Holy Ghost and had made a great hospital at Montpellier. Accordingly Guy was summoned to Rome, and the establishment of the Santo Spirito Hospital was entrusted to him. It was on the model of this that a great many hospitalswere founded throughout the world, for Pope Innocent insisted that every diocese in Christianity should have a hospital, and Bishops who came on formal visits to the Holy See were asked to inspect the Santo Spirito for guidance in their own diocesan hospital establishments. Many of the hospitals throughout the world came as a result to be hospitals of the Holy Ghost and this contribution alone of Montpellier to the medical world of the time was of great significance and must have added much to her prestige.
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HOLY GHOST HOSPITAL (LÜBECK)
From “The Thirteenth: Greatest of Centuries,” by J. J. Walsh
Montpellier, like Salerno, seems to have attracted students to its medical school from all over the world. There were undoubtedly many English there, and probably also Irish and Scotch, though the journey must have been much longer and more difficult to make than is that from America to Europe at the present time. Of course there came many from Spain and from North France and the Netherlands. The fact that a number of Italians went there before the close of the Middle Ages shows how deeply interested were the men of this time in knowledge for its own sake, and indicates that something of that internationality of culture which we are priding ourselves on at the present time, because our students from all countries go far afield for postgraduate work and there is an interchange of professors, existed at this period.In spite of the fact that books were only written by hand, the teaching of distinguished professors had a wide diffusion, and students were quite ready to go through the drudgery of making these handwritten copies of a favourite master’s work. They had plenty of common sense as well as powers of observation, and some of their writing is still of great practical value.
A number of men who are famous in the history of medicine made their medical studies at Montpellier in the twelfth and thirteenth centuries. Among them are Mondeville, who afterwards taught surgery at Paris; and Guy de Chauliac, who was a Papal Physician at Avignon and at the same time a professor at Montpellier, probably spending a certain number of weeks, or perhaps months, each year in the university town. Sketches of these men, and of other students and teachers at Montpellier who reached distinction in surgery, will be found in the chapter on Surgeons of the West of Europe. Some other distinguished Montpellierians deserve brief mention.
One of the distinguished professors at Montpellier was the well-known Arnold de Villanova, of whose name there are a number of variants, including even Rainaldus and Reginaldus. In 1285 he was already a famous physician, and was sent for to treat Peter III., King of Aragon, whowas severely ill. In 1299 he was summoned on a consultation to the bedside of King Philip the Handsome (le Bel) at Paris. After this we hear of him in many places, as at the Court of Pope Benedict XI. at Rome, and in 1308 as the physician and friend of Pope Clement V. at Avignon. His writings were printed in a number of editions in the Renaissance time, Venice 1505, Lyons 1509, 1520, 1532, Basel 1585, and his medical and astronomical and chemical works in separate volumes at Lyons in 1586.
His aphorisms are well known, and used to be frequently quoted during the Middle Ages and afterwards, and some of them deserve to be remembered even at the present time. For instance, he said: “Where the veins and arteries are notably large, incision and deep cauterization should be avoided.” “When cauterization is to be done the direct cautery should be used; caustic applications are only suitable for very timid patients.” “The lips of a wound will glue together of themselves if there is no foreign substance between them, and in this way the natural appearance of the part will be preserved.” “In large wounds sutures should be used, and silk thread tied at short distances makes the best sutures.” “The infection of the dura mater is followed in most cases by death.” “A collection of pus is best dissolvedby incision and cleaning out of the purulent material.” “To put off the opening of an abscess brings many dangers with it.” “In most cases of scrofula external applications are better than the use of the knife. Scrofulous patients always have other sources of infection within them, and so it does them no good to operate externally.” “Tranquil and pure air is the best friend for convalescents.”
Villanova advised that the bite of a mad dog should not be permitted to heal at once, but the wound should be enlarged and allowed to bleed freely, leeches and cups being used to encourage bleeding, and healing should not be permitted for forty days. He believed very thoroughly in drainage, and in the dilation of narrow fistulous openings. He describes anthrax or carbuncle, and has chapters on various painful conditions for which he employs the terms arthritis, sciatica, chiragra, podagra, and gonagra.
Villanova’s treatment of the subject of hernia shows how thoroughly conservative he was, and how careful were his observations. In young persons in recent hernias he advised immediate complete reposition of the contents of the sac, the bringing together of the hernial opening by means of adhesive plaster, above which a bandage was placed, and the patient should be put to bed with the feetand legs elevated and the head depressed for ten to fifteen days or more if necessary. He says that “there are some—especially surgeons—who claim that they can cure hernia by incision, and some others by means of a purse-string ligature, and still others by the cautery or by some cauterizing material [they manifestly had our complete catalogue of ‘fakes’ in the matter]; but I prefer not to mention these procedures, since I have seen many patients perish under them, and others brought into serious danger of death, and I do not think that the surgeon will acquire glory or an increase of his friends from such perilous procedures, and I do not approve their use.”
One of the important writers of Montpellier was Gilbertus Anglicus (Gilbert the Englishman), who is called in one of the old translations of Mesue DoctorDesideratissimus, which I suppose might be Anglicized “loveliest of doctors.” After his studies in England he went for graduate work to some of the famous foreign universities, and is named as a chancellor of Montpellier. His best-known work is his “Compendium Medicinæ,” which bore as its full title “The Compendium of Medicine of Gilbert the Englishman; useful not only to physicians, but to clergymen for the treatment of all and every disease.” Gurlt says that it contains little that is original, being a copy ofRoger of Parma and Theodoric of Lucca, with a number of quotations from the Arabs, nearly all of whom Gilbert seems to have read with considerable attention. It is interesting to find that Gilbert was definitely of the opinion that cancer is incurable except by incision or cauterization. He declares that it yields to no medicine except surgery.
Another of the men whose names are connected with Montpellier was John of Gaddesden, often calledJoannes Anglicus. He was a student of Merton College, and received his degree of doctor of medicine at Oxford. He studied afterwards at Montpellier and also at Paris, and settled down to practise in London. He treated the son of King Edward II. for smallpox, and having wrapped him in red cloth and made all the hangings of his bed red, so that the patient was completely surrounded by this colour, he declared that he made “a good cure, and I cured him without any vestiges of the pocks.” The treatment is interesting, as an anticipation in a certain way of Finsen’s red light treatment for smallpox in our own time. Hanging the room, and especially the doors and the windows, with red when smallpox was to be treated was a favourite treatment down at Montpellier. Gaddesden’s book is called by the somewhat fanciful name “Rosa Anglica.” Bernard Gordon of Montpellier had written a “Lilium Medicinæ,”and we have a “Flos Medicinæ” from Salerno, so that flower names for medical textbooks were evidently the fashion of the time.
Gaddesden’s book is almost entirely a compilation, and except in the relation of his surgical experience, contains little that is new. Guy de Chauliac was quite impatient with it, and declared that “lately there had arisen a foolish Anglican rose which was sent to me and I looked it over. I expected to find the odour of sweetness in it, but I found only some old fables.” The criticism is, however, as Gurlt remarks, too severe and not quite justified, representing rather Guy’s high ideal of the originality that a new textbook should possess, than a legitimate critical opinion. If our own textbooks were to be judged by any such lofty standard, most of them would suffer rather severely.
Another of the well-known teachers at Montpellier was Valesco de Taranta. There are the usual variants of his name, his first name being written also Balesco, and his last name sometimes Tharanta. He was a Portuguese who studied in Lisbon, and later in Montpellier, where he taught afterwards and was considered one of the distinguished professors of his day, being for a time chancellor. He became so well known that he was summoned in consultation to the French King Charles VI., and there is some doubt as to whetherhe did not become his regular physician. One of his works, the “Philonium Pharmaceuticum et Chirurgicum de medendis omnibus, cum internis tum externis, humani corporis affectionibus,” had the honour of being printed at Lyons in two editions in 1490, and one at Venice the same year, at Lyons 1500, Venice 1502, Lyons 1516, 1521, 1532, 1535, Venice 1589, and Lyons 1599. It has also been reprinted subsequently in a number of editions, so that it must have been a much-read book. Valesco had two favourite authors, Galen and Guy de Chauliac. The fact that he should have appreciated two such great men so thoroughly is of itself the best evidence of his own ability and critical judgment. His book, from the number of printed editions, must have been in the hands of practically all the progressive physicians of the southern part of France, at least during the fifteenth, sixteenth, and part of the seventeenth centuries.
A very well-known teacher of Montpellier, who has had a reputation in English-speaking countries because his name was supposed to indicate that he was a Scotchman, was Bernard Gordon or de Gordon, whose name is, however, also written Gourdon. He was a teacher at Montpellier at the end of the thirteenth and the beginning of the fourteenth century. His textbook of medicine, in accordance with the custom of the time, is calledby the flowery title “Lilium Medicinæ,” the Lily of Medicine. While much of his information was derived from the Arabs, some of his teaching was an advance on theirs, and he described the acute fevers, leprosy, scabies, anthrax, as well as erysipelas, and still more strangely phthisis, as contagious. Dr. Garrison has called attention in his “History of Medicine” to the fact that the book is notable as containing the first description of a modern truss, and a very early mention of spectacles under the Latin nameoculus berellinus. In recent years it has come to be the custom to think of Gordon or Gourdon as probably not of Scotch but of French origin—that is, born somewhere in the confines of what we now call France. There are a number of French places of the name of Gourdon from any of which he might have come.
Montpellier represented for the West of Europe then very nearly what Salerno did for Italy and Eastern Europe. It very probably attracted many of the English and Scotch students of medicine, though not all the names supposed to be of British origin have proved to be so with the development of our knowledge. Montpellier has survived, however, while Salerno disappeared as a force in medical education. Its story would well deserve telling in detail, and doubtless the new national spirit of the French after the war will prove an incentive to the writing of it.
LATER MEDIEVAL MEDICINE
Medicine in the later Middle Ages, that is, from the tenth to the middle of the fifteenth centuries, was greatly influenced by the medical schools which arose in Italy and the West of Europe during this period. These were organized mainly in connection with universities, Salerno, Montpellier, Bologna, Paris, Padua, in the order of their foundations, so far as they can be ascertained. These university medical schools represented serious scientific teaching in medicine, and certainly were not more prone to accept absurdities of therapeutics and other phases of supposed medical knowledge than have been the universities of any other corresponding period of time. Five centuries represent a very long interval in the history of humanity, and provide opportunities for a great many curious developments and ups and downs of interest, all of which must not be considered as representing any particular generation or evencentury in the history of that time. The absurdities came and went quite as in more modern times; but all the while there was an undercurrent of solid medical knowledge, founded on observation and definite clinical research, superadded to the information obtained from the classics of medicine.
Even as early as the tenth century the thoroughly conservative teaching of Salerno in medicine made itself felt, and above all counteracted the Oriental tendencies to over-refinement of drugging, which had led to the so-called calendar prescription. This was the most noteworthy element in the medical practice of the later Middle Ages, but its significance has been dwelt on in the chapter on Salerno and the Beginnings of Medical History. While Arabic polypharmacy is the most striking feature of Mohammedan influence on medicine at this time, there were a number of Arabian and Jewish physicians who made a deep impression on the medicine of the later Middle Ages—that is, subsequent to the tenth century. Their work was felt not only in their own time, but for many subsequent centuries even down to and beyond the Renaissance, and they therefore must find a place in medieval medical history. This influence was exerted ever so much more outside of Italy than in the Italian peninsula, where the tradition of their contact with the original Greek authors still remained, and wherethey were making medicine and surgery for themselves quite apart from Arabian influence.
The more one knows about the conditions in Italian medicine the less question is there of Arabian contributions to it. De Renzi in his History of Italian Medicine makes it very clear that the Arabs exercised no significant influence either at Salerno or elsewhere. The Benedictines and Cassiodorus afford evidence of the study of the Greek medical classics in Latin translations. Muratori cites a manuscript which he had consulted in the Medicean Library at Florence, and which, though written between the eighth and ninth centuries, says not a word of the Arabs and bears the title of “Abstracts from Hippocrates, Galen, Oribasius, Heliodorus, Asclepiades, Archigenes, Dioclis, Amyntas, Apollonius, Nymphiodorus, Ruffius, Ephesinus, Soranus, Ægineta, and Palladius.” These and not the Arabs were the masters of the Italians, and it was fortunate, for the world was thus saved many Arabian mistakes and their tendency to neglect surgery. Before Salerno began to exert its real influence, some of the Arabian physicians came to occupy places of prominence in the medicine of the time.
The most important of these was Avicenna, born toward the end of the tenth century in the Persian province of Chorasan, at the height of Arabianinfluence. He is sometimes spoken of as the Arabian Galen. His famous book, “The Canon,” was the most consulted medical book throughout Europe for centuries. There are very few subjects in medicine that did not receive suggestive treatment at his hands. He has definite information with regard to Bubonic plague and thefilaria medinensis. He has special chapters with regard to obesity, emaciation, and general constitutional conditions. He has chapters on cosmetics and on affections of the hair and nails that are interesting reading. The Renaissance scholars wrote many commentaries on his work, and for long after the introduction of printing his influence was felt widely.
His Arabic colleague in the West was Avenzoar, to call him by the transformation of his Arabic family name, Ibn-Zohr. He was born near Seville, and probably died there, in 1162, well past ninety years of age. He was the teacher of Averröes, who always speaks of him with great respect. He is interesting as probably the first to suggest nutrition per rectum. His apparatus for the purpose consisted of the bladder of a goat with a silver cannula fastened into its neck. Having first carefully washed out the rectum with cleansing and purifying clysters, he injected the nutriment—eggs, milk, and gruel—into the gut. His idea wasthat the intestine would take this and, as he said, suck it up, carrying it back to the stomach, where it would be digested.
The bladders of animals were very commonly used by these Moorish physicians and by their disciples, and the profession generally, for generations, for a great many purposes for which we now use rubber bags. Abulcasis, for instance, used a sheep’s bladder introduced into the vagina and filled with air as a colpeurynter for supporting the organs in the neighbourhood, and also in fractures of the pubic arch.
Avenzoar suggested feedingper rectumin cases of stricture of the œsophagus, but he also treated the œsophageal stricture directly. He inserted a cannula of silver through the mouth until its head met an obstruction. This was pushed firmly, but withdrawn whenever there was a vomiting movement, until it became engaged in the stricture. Through it thenfreshly milkedmilk, or gruel made from farina or barley, was to be poured. He had evidently seen cases improve this way, and therefore must have had experience with functional stricture of the œsophagus. He adds that some physicians believe that nutrition may be absorbed through the pores of the whole body, and that therefore in these cases the patient might be put in a warm milk or gruel bath; but he has not verymuch faith in the procedure, and says that the reasons urged for it are weak and rather frivolous. It is easy to understand that a man who could recommend manipulative modes of treatment of such kinds, and discuss questions of nutrition so sensibly, knew his medicine very practically and wrote of it judiciously.
Maimonides (1135-1204) was one of these wise old Jews who quotes with approval from a Rabbi of old who had counselled his students: “Teach thy tongue to say, I do not know.” Knowing thus the limitations of his own knowledge, it is not surprising that Maimonides should have left a series of practical observations for the maintenance of health which represent the common sense of all time in the matter. Maimonides anticipated the modern rule for taking fruits before meals, as we all do now at breakfast, and so often as fruit cocktails at the beginning of other meals. He thought that grapes, figs, melons, should be taken before meals, and not mixed with other food. He set down as a rule that what was easily digestible should be eaten at the beginning of the meal, to be followed by what was more difficult of digestion. He declared it to be an axiom of medicine “that so long as a man is able to be active and vigorous, does not eat until he is over full, and does not suffer from constipation, he is not liable to disease.”
Salerno’s influence was felt much more deeply on surgery than on medicine, as can be seen very clearly from the chapter on Medieval Surgeons—Italy. These great surgeons of the period were also the leaders in medicine—for almost needless to say, there was no separation between the two modes of practice—men were as a rule both physicians and surgeons, even though for us their most important work by far was done in surgery. Certain passages from the works of these great surgeons that have come down to us deserve a place in the treatment of the more distinctly medical questions of the time.
Lanfranc the great French surgeon’s description of the treatment of the bite of a rabid dog is interesting. He suggests that a large cupping-glass should be applied over the wound, so as to draw out as much blood as possible. After this the wound should be dilated and thoroughly cauterized to its depths with a hot iron. It should then be covered with various substances that were supposed “to draw,” in order as far as possible to remove the poison. His description of how one may recognize a rabid animal is rather striking in the light of our present knowledge, for he seems to have realized that the main diagnostic element is a change in the disposition of the animal, but above all a definite tendency to lack playfulness.Lanfranc had manifestly seen a number of cases of true rabies, and describes and suggests treatment for them, though evidently without very much confidence in the success of the treatment.
The treatment of snake-bites and the bites of other animals supposed to be poisonous, or at least suspicious, followed the principles laid down for handling the bite of a mad dog. This was the case particularly as to the encouragement of free bleeding and the use of the cautery.
A characteristic example of the power of clinical observation of the medieval physicians, and one which illustrates much better than many of the absurd tales told as typical of their superstitious tendencies, but really representing that tendency always present in mankind to believe wonders, is to be found in how much they learned of rabies. Even in our own time there are many absurd beliefs with regard to this disease, with some denials of its existence and many grossly exaggerated tales, widely believed; yet the medieval people seem to have reached some quite rational notions with regard to it. Bartholomæus Anglicus is the author of a popular encyclopedia which was very widely read in the medieval period. He was an English Franciscan of the thirteenth century, who gathered together a lot of information and wrote a volume that for centuries after his time,even down to Shakespeare’s boyhood, was popular in England.
Here is his description of rabies as he knew it. The most important element is his recognition of the uncertainty of the length of the incubation period, but it contains two other ideas that are very interesting, because medicine in subsequent centuries has come back to them over and over again. One is that free bleeding may remove the virus, and the other that the cautery may help in preventing the infection.
“The biting of a wood-hound is deadly and venomous, and such venom is perilous. For it is long hidden and unknown, and increaseth and multiplieth itself, and is sometimes unknown to the year’s end, and then the same day and hour of the biting it cometh to the head, and breedeth frenzy. They that are bitten of a wood-hound have in their sleep dreadful sights, and are fearful, astonished, and wroth without cause. And they dread to be seen of other men, and bark as hounds, and they dread water most of all things, and are afeared thereof, full sore and squeamous also. Against the biting of a wood-hound wise men and ready use to make the wounds bleed with fire or with iron, that the venom may come out with the blood that cometh out of the wound.”
A very interesting development of therapeutics in the Middle Ages was the employment of the red light treatment to shorten the course and theseverity of the fever in smallpox, and above all to prevent pitting; it was employed successfully by John of Gaddesden in the case of the son of King Edward II. Recent investigation by Cholmeley has shown that both Gilbertus Anglicus (1290) and Bernard de Gordon (1305) antedated John of Gaddesden in references to the red light treatment. All of these men were professors at Montpellier, showing that the medical school of the South of France was a rival in the use of natural methods of cure to its better-known predecessor of Southern Italy. Curiously enough, the “Rosa Anglica” of Gaddesden, in which the reference to the red light is made, is deservedly characterized by Garrison as “a farrago of Arabist quackeries and countrified superstitions”; it well deserves Guy de Chauliac’s bitter criticism of it as “a scentless rose.”
The idea included under the word autointoxication in our time—that is, that the human body has a tendency to produce poisons within itself, which act deleteriously on it and must be eliminated—was a favourite one during the Middle Ages. It became the custom in our time to have recourse to antiseptics or to surgical measures of various kinds for the relief and prevention of autointoxication. In the Middle Ages they thought to reduce its harmfulness at least by direct elimination, hencethe use of drastic purgatives. It seems worth while remarking, however, that the employment of these did not come into general use until the close of the Middle Ages. Basil Valentine, if he really lived in the Middle Ages, and is not merely a name for a writer of the early sixteenth century, as modern historians seem inclined to think, suggested the use of antimony for the removal of the materies morbi from the body that has so much obsessed physicians for many generations. Antimony continued to be used down to the nineteenth century. It was gradually replaced by venesection, which was employed very strenuously during the eighteenth and early nineteenth centuries, in spite of the objection of such men as Morgagni, who refused to allow this mode of treatment to be used on him.
Venesection was succeeded by large doses of calomel, and the calomel era continued on almost to our own generation.
As a rule, however, the medieval physicians trusted nature much more than did their colleagues of modern history—that is, after the Renaissance until the present epoch of medical science began. It has always been difficult, however, for physicians to continue long in the persuasion that nature is a helpful auxiliary, and not a hampering factor to be combated. It is all the more to the credit ofthe medieval physicians to find, then, that in spite of many absurdities they continued for all the later centuries of the Middle Ages to extol the value of the natural means of cure.
I shall have much to say of John of Ardern in the chapter on Medieval Surgeons of the West of Europe, but he deserves a place also in the chapter on Medicine. Ardern’s advice to patients suffering from renal disease, which is contained in a separate tract of his lesser writings with the title in an old English version of “The Governaunce of Nefretykes,” is extremely interesting, because it shows very clearly how long ago thoughtful physicians anticipated most of the directions that we now give such patients. Though we are inclined to think that any real knowledge of renal disease is quite modern, and above all has come since Bright’s time, this paragraph of Ardern’s shows how long before definite pathological knowledge had developed, careful clinical observation worked out empirically the indications of the affection. The paragraph is of special interest, because it contains the first reference to the possible danger that there may be for sufferers from kidney disease using the dark or red meats rather than the white meats. The tradition as to the distinction between the red and white meats has continued ever since his time, and though our modern chemistrydoes not enable us to find any such distinction between these substances as would justify the differentiation thus dwelt on, it has been maintained for no other reason that I have ever been able to find than because of the long years of tradition and clinical observation behind it.[6]
“Nefretykes must putte awey ire, hyghly and moche besynesse and almanere [business and all manner of] thynge that longeth to the soule saff [save] only joye.... They schulle forbere almanere metys that ben to grete of substaunse and viscous, as olde beeff that is myghtyly pooudryd and enharded with salt and also fressch porke but yf it lye in salt iiii dayes afore.... They mowe use grete wyne and the fflessch of calvys that bensoowkynge and also of all ffowlys saff thoo that ben of the lakys and dichys [dykes?] ... and squamous ffyssches, i.e., fyssch of the rivere, of the stony waterys and rennynge ryveres and not of the standyne waterys and they schulle eschywe [eschew] almaner mete made of paast [pastries] and all bred that is dowgh bakene and all fatnesse. And they schulle use the reynes of te beeste other roste or sode. And in especiall he schall use a ffowl that is callyd Cauda tremula or Wagstertte [the wagtail, an English bird] other fressch or salte or bakene withoute drynesse ffor and it be drye it is nought woorth. And note that the use of the powdir or of the flessch of the Wagstertte avayleth gretly to breke the stone in the bladdere.”[7]
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 onlyrelief 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 surgicalhistory 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. TheSalernitan 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 headsurgery 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 bycontrecoup. 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 withregard 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 shouldinfector 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 incold 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 morethan 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 director 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 theintestines 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.