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BRUNSCHWIG’S SURGICAL ARMAMENTARIUM
From Gurlt’s “Geschichte der Chirurgie”
Hans von Gerssdorff and Hieronymus Brunschwig, who flourished in the latter half of the fifteenth century in Germany, have both left early printed treatises on Surgery which give excellent woodcuts showing pictures of instruments, operations, and costumes, at the end of the medieval period.
ORAL SURGERY AND THE MINOR SURGICAL SPECIALITIES
The surgical specialities, as they are called—that is, the surgery of the mouth, throat, and nose, and of the eye and ear, as well of course as of certain other portions of the body—have developed to a striking extent in our time. As a consequence of this recent development, there is an impression prevalent that this is the first time that serious attention has been paid by surgeons to these phases of their work. The feeling is probably that the minor operations usually required in the surgical specialities were either thought so trivial, or involved such delicate technique, that they never received due attention, rather than that they were deliberately neglected.
Because of this very general persuasion, even among physicians, it is all the more interesting to trace the phases of attention during the Middle Ages to these special subjects in surgery, which was far from lacking at any time, and which led at various periods to some rather important developments. While specialism is considered newby most people, it must not be forgotten that at every time in the world’s history, when men have had much chance to think about themselves rather than the actual necessities of the situation in which they were placed, and the things they were compelled to do for actual self-preservation, specialism has enjoyed a period of more or less intense evolution. It is rather easy to trace this in the Ebers Papyrus near the beginning of the second millenniumB.C.; and Herodotus called attention to the fact that the old Egyptians had divided the practice of medicine into many specialities. His passage on the subject is well known.[11]
If the surgical specialities had been neglected in the Middle Ages, then that fact would have constituted the surest evidence of that backwardness of medical and surgical progress which is usually supposed to have existed at that time. But the real story is exactly to the contrary, and has many surprises in it because of the anticipations of very recent advances which it represents.[12]
It would be surprising, then, if we were to find no attention paid to dentistry during the Middle Ages. As a matter of fact, a number of the old surgeons include in their textbooks of surgery the discussion of oral surgery. Aëtius evidently knew much about the hygiene of the teeth, and discusses extraction and the cure of fistulæ of the gums as well as the surgical treatment of many other lesions of the mouth. Paul of Ægina in the century after Aëtius has even more details; and while they bothquote mainly from older authors, there seems no doubt that they themselves must have had considerable practical experience in the treatment of the teeth and had made not a few observations. The Arabians took up the subject, and discussed dental diseases and their treatment rationally and in considerable detail. Abulcassis particularly has much that is of significance and interest. We have pictures of two score of dental instruments that were used by him. The Arabs not only treated and filled carious teeth, and even replaced those that were lost, but they also corrected deformities of the mouth and the dental arches. Orthodontia is usually thought of as of much later origin, yet no one who knows Abulcassis’s work can speak of efforts at straightening the teeth asinventedafter his time.
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SURGICAL INSTRUMENTS OF THE ARABS, ACCORDING TO ABULCASIM
After plates in Gurlt’s “Geschichte der Chirurgie”
The great surgeons of the later Middle Ages in their textbooks of surgery usually include remarks on oral surgery, and suggest treatment for the various diseases of the teeth. Guy de Chauliac in “La Grande Chirurgie” lays down certain rules for the preservation of the teeth, and shows that the ordinary causes of dental decay were well recognized in his time. Emphasis was laid by him on not taking foods too hot or too cold, and above all on the advisability of not having either hot or cold food followed by something very different fromit in temperature. The breaking of hard things with the teeth was warned against as responsible for such fissures in the enamel as gave opportunity for the development of decay. The eating of sweets, and especially the sticky sweets, preserves, and the like, were recognized as an important source of caries. The teeth were supposed to be cleaned frequently, and not to be cleaned too roughly, for this would do more harm than good.
Chauliac is particularly emphatic in his insistence on not permitting alimentary materials to remain in the cavities, and suggests that if cavities between the teeth tend to retain food material they should even be filled in such a way as to prevent these accumulations. His directions for cleansing the teeth were rather detailed. His favourite treatment for wounds was wine, and he knew that he succeeded by means of it in securing union by first intention. It is not surprising, then, to find that he recommends rinsing of the mouth with wine as a precaution against dental decay. A vinous decoction of wild mint and of pepper he considered particularly beneficial, though he thought that dentifrices, either powder or liquid, should also be used. He seems to recommend the powder dentifrices as more efficacious. His favourite prescription for a tooth-powder, while more elaborate, resembles to such an extent at least, some, if not indeed most,of those that are used at the present time, that it seems worth while giving his directions for it. He took equal parts of cuttle-bones, small white seashells, pumice-stone, burnt stag’s horn, nitre, alum, rock salt, burnt roots of iris, aristolochia, and reeds. All of these substances should be carefully reduced to powder and then mixed.
His favourite liquid dentifrice contained the following ingredients: Half a pound each of sal ammoniac and rock salt, and a quarter of a pound of saccharin alum. All these were to be reduced to powder and placed in a glass alembic and dissolved. The teeth should be rubbed with it, using a little scarlet cloth for the purpose. Just why this particular colour of cleansing cloth was recommended is not quite clear.
He recognized, however, that cleansing of the teeth properly often became impossible by any scrubbing method, no matter what the dentifrice used, because of the presence of what he called hardened limosity or limyness (limosité endurcie). When that condition is present he suggests the use of rasps and spatumina and other instrumental means very similar to those we make use of for removing tartar.
Guy de Chauliac was also interested in mechanical dentistry and the artificial replacement of lost teeth; and, indeed, dental prosthesis represents, astreated by him, a distinct anticipation of dental procedures usually thought quite modern.
When teeth become loose he advises that they be fastened to the healthy ones with a gold chain. Guerini, in his “History of Dentistry” (Philadelphia, 1907), suggests that he evidently means a gold wire. If the teeth fall out Chauliac recommends that they be replaced by the teeth of another person, or with artificial teeth made from ox-bone, which may be fixed in place by a fine metal ligature. He says that such teeth may be serviceable for a long while. This is a rather curt way of treating so large a subject as dental prosthesis, but it contains a lot of suggestive material. He was quoting mainly the Arabian authors, and especially Abulcassis and Ali Abbas and Rhazes—and these of course, as we have said, mentioned many methods of artificially replacing teeth, as also of transplantation and of treatment of the deformities of the dental arches.
Guerini called particular attention to the fact that Chauliac recognized the dentists as specialists. He observes that operations on the teeth are in a class by themselves, and belong to thedentatoresto whom they had been entrusted. He remarks, however, that the operations on the mouth should be performed under the direction of a surgeon. It is in order to give surgeons the general principlesby means of which they may be able to judge of the advisability or necessity for dental operations, that his brief presentation of the subject is made. If their advice is to be of value, physicians should know the various methods of treatment suitable for dental diseases, including “mouth washes, gargles, masticatories and ointments, rubbings, fumigations, cauterizations, fillings, filings,” as well as the various dental operations. He says that thedentatormust be provided with appropriate instruments, among which he named scrapers, rasps, straight and curved, spatumina, elevators, simple and with two branches, toothed tenacula, and many different forms of probes and cannulas. He should have also small scalpels, tooth trephines, and files.
After Guy de Chauliac, the most important contributor to dentistry is Giovanni of Arcoli—or simply Arcolano, but sometimes better known by his Latin name Johannes Arculanus—who was Professor of Medicine and Surgery at Bologna just before and after the middle of the fifteenth century. He is sometimes treated in history as belonging rather to the Renaissance, but he owed his training to the Middle Ages and was teaching before they closed, so he has a place in Medieval Medicine. Guerini, in his “History of Dentistry,” says that Arculanus treats the subject of dentistry rather fully and with great accuracy. The Italian historianmakes a summary of Arculanus’s rules for dental hygiene which shows how thoroughly he appreciated the care of the teeth. The medieval surgeon arranged his rules in ten distinct canons, creating in this way a kind of decalogue of dental hygiene.
These rules are: (1) It is necessary to guard against the corruption of food and drink within the stomach; therefore, easily corruptible food—milk, salt fish, etc.—must not be partaken of, and after meals all excessive movement, running exercises, bathing, coitus, and other causes that impair the digestion, must also be avoided. (2) Everything must be avoided that may provoke vomiting. (3) Sweet and viscous food—such as dried figs, preserves made with honey, etc.—must not be partaken of. (4) Hard things must not be broken with the teeth. (5) All food, drink, and other substances that set the teeth on edge must be avoided, and especially the rapid succession of hot and cold, andvice versa. (7) Leeks must not be eaten, as such a food, by its own nature, is injurious to the teeth. (8) The teeth must be cleaned at once after every meal from the particles of food left in them; and for this purpose thin pieces of wood should be used, somewhat broad at the ends, but not sharp-pointed or edged; and preference should be given to small cypress-twigs, or the wood of aloes, or pine, rosemary, or juniper, and similarsorts of wood, which are rather bitter and styptic; care must, however, be taken not to search too long in the dental interstices, and not to injure the gums or shake the teeth. (9) After this it is necessary to rinse the mouth, using by preference a vinous decoction of sage, or one of cinnamon, mastich, gallia, moschata, cubeb, juniper seeds, root of cyperus, and rosemary leaves. (10) The teeth must be rubbed with suitable dentifrices before going to bed, or else in the morning before breakfast. Although Avicenna recommended various oils for this purpose, Giovanni of Arcoli appears very hostile to oleaginous frictions, because he considers them very injurious to the stomach. He observes, besides, that whilst moderate frictions of brief duration are helpful to the teeth, strengthen the gums, prevent the formation of tartar, and sweeten the breath, too rough or too prolonged rubbing is, on the contrary, harmful to the teeth, and makes them liable to many diseases.
Shortly after Arculanus, when the Middle Ages are over—if they end with the middle of the fifteenth century, though perhaps not if the later date of the discovery of America is to be taken as the medieval terminal—John de Vigo has in a few lines a very complete description of the method of filling teeth with gold-leaf which deserves to be quoted. Only that it was a common practice hewould surely have described it more in detail, though he could have added nothing to the significance of what he has to say: “By means of a drill or file the putrefied or corroded part of the teeth should be completely removed. The cavity left should then be filled with gold-leaf.”
Much more is known about the medieval anticipation of other specialities—those of the throat and nose, and eye and ear—and the surprise is with regard to dentistry, which is usually quite unknown. The fact, however, that dentistry developed so much more than is usually thought prepares the mind for the anticipations in other departments. Following that of dentistry should come naturally the mouth and throat, and it happens that the men whose writings in dentistry are known also touched on these subjects.
The medical writers of the early Middle Ages, particularly Aëtius, Alexander of Tralles, and Paul of Ægina, have not a little to say with regard to affections of the throat and nose, and the eye and ear. Alexander’s chapter on the Treatment of Affections of the Ear, Gurlt considers ample evidence of large practical experience and power of observation. Alexander describes the ordinary mode of getting water out of the external auditory canal by standing on the leg corresponding to the side in which the water is, and kicking out with theopposite leg. Foreign bodies should be removed by an ear spoon, or a small instrument wrapped in wool and dipped in sticky material. He suggests sneezing with the head leaning toward the side on which the foreign body is present. Insects or worms that find their way into the ear may be killed by injections of dilute acid and oil or other substances.
Paul of Ægina has a very practical technique for the removal of fish-bones or other objects caught in the throat. He also gives the detailed technique of opening the larynx or trachea, with the indications for this operation. He also describes how wounds of the neck should be sewed after attempts at suicide. In a word, the more one knows of these old-time medieval writers of the sixth and seventh centuries the clearer it becomes that they had learned their lessons well from the ancients, and passed on an excellent tradition to their colleagues of succeeding generations. If these lessons were not properly taken, it was because the disturbance of civilization caused by the coming down of the Teutonic invaders into Italy took away interest in the things of the mind and of the body, until the coming of another upward turn in progress.
Arculanus has some very interesting paragraphs with regard to the treatment of conditions in the nose. For instance, in the treatment of polyps, he says that they should be incised and cauterized.Soft polyps should be drawn out with a toothed tenaculum as far as can be without risk of breaking them off. The incision should be made at the root, so that nothing or just as little as possible of the pathological structure be allowed to remain. It should be cut off with fine scissors; or with a narrow file just small enough to permit ingress into the nostrils; or with a scalpel without cutting edges on the sides, but only at its extremity, and this cutting edge should be broad and well sharpened. If there is danger of hæmorrhage, or if there is fear of it, the instruments with which the section is made should be fired (igniantur)—that is, heated at least to a dull redness. Afterwards the stump, if any remains, should be touched with a hot iron or else with cauterizing agents, so that as far as possible it should be obliterated.
After the operation, a pledget of cotton dipped in the green ointment described by Rhazes should be placed in the nose. This pledget should have a string fastened to it, hanging from the nose, in order that it may be easily removed. At times it may be necessary to touch the root of the polyp with a stylet, on which cotton has been placed that has been dipped inaqua fortis(nitric acid). It is important that this cauterizing fluid should be rather strong, so that after a certain number of touches a rather firm eschar is produced. In allthese manipulations in the nose Arculanus recommends that the nose should be held well open by means of a nasal speculum. Pictures of all these instruments occur in his extant works, and indeed this constitutes one of their most interesting and valuable features. They are to be seen in Gurlt’s “History of Surgery.”
In some of the cases he had seen, the polyp was so difficult to get at, or was situated so far back in the nose, that it could not be reached by means of a tenaculum or scissors, or even the special knife devised for that purpose. For these patients Arculanus describes an operation that is to be found in the older writers on surgery—Paul of Ægina (Æginetas), Avicenna, and some of the other Arabian surgeons. For this, three horse-tail hairs are twisted together and knotted in three or four places, and one end is passed through the nostrils and out through the mouth. The ends of this are then pulled on backward and forward after the fashion of a saw. Arculanus remarks, evidently with the air of a man who has tried it and not been satisfied, that this operation is quite uncertain, and seems to depend a great deal on chance, and much reliance must not be placed on it. Arculanus suggests a substitute method by which latent polyps—or occult polyps, as he calls them—may be removed.
Among the affections of the upper air passages mentioned by Arculanus are various forms of sore throat, which he calls Synanche or Cynanche, or angina. A milder form of the affection was called Parasynanche. The medieval teaching with regard to an angina that was causing severe difficulty of breathing was to perform tracheotomy. Arculanus goes into some detail with regard to affections of the uvula, which was made much more responsible for throat affections than at the present time. The popular tradition in our time of the uvula and its fall is evidently a remnant of the medieval teaching with regard to it. Arculanus’s description of the removal of the uvula, or at least of the tip of it, gives a very good idea of how thorough the teaching of surgical technique was in his time. His directions are: “Seat the patient upon a stool in a bright light, while an assistant holds the head; after the tongue has been firmly depressed by means of a speculum, let the assistant hold this speculum in place. With the left hand then insert an instrument, a stilus, by which the uvula is pulled forward; and then remove the end of it by means of a heated knife or some other process of cauterization. The mouth should afterwards be washed out with fresh milk.”
The application of a cauterizing solution by means of a cotton swab wrapped round the end ofa sound may be of service in patients who refuse the actual cautery. To be successful, he insists that the application must be firmly made and must be frequently repeated.
With regard to ophthalmology the older history has always been thoroughly appreciated. Even as early as the time of Hammurabi (2200B.C.) some rather extensive and interesting surgery of the eye was practised, for the fees for these operations are mentioned in the code. All of the early medieval writers on medicine and surgery—Aëtius, Alexander of Tralles, and Paul of Ægina—have paragraphs at least, and sometimes more, with regard to eye operations and the care of the eyes.
Operations above all for cataract have been practised from very early times, and are mentioned also by many medieval writers on medicine and surgery. It is not surprising, then, to find that the medieval surgeons particularly discussed a number of eye diseases and the operations for them. Pope John XXI., who before he became Pope was known asPetrus Hispanus(the Spaniard), and who had been a professor of surgery and a papal physician, wrote a book on eye diseases in the latter half of the thirteenth century, which has come down to us. He had much to say of cataract, dividing it into traumatic and spontaneous, and suggesting operation by needling, a gold needle being usedfor that purpose. Pope John describes a form of hardness of the eye which would seem to be what we now call glaucoma, and has a number of external applications for eye diseases. Most of his collyria had some bile in them, the bile of various kinds of animals and birds being supposed to be progressively more efficient for the cure of external affections of the eye. This very general use of bile, or of an extract of the livers of animals or fishes, seems to be a heritage from biblical times, when old Toby was cured of his blindness by the gall of the fish.[13]The Pope ophthalmologist (seeOpthalmology, Milwaukee, January, 1909) recommended the urine of infants as an eye-wash, experience having evidently shown that this fluid, which is usually bland and unirritating, a solution of salts of a specific gravity such that it would not set up osmotic processes in the eye, was empirically of value. In the Middle Ages the idea of using it would be much less deterrent, because it was quite a common practice for physicians to taste urine in order to test it for pathological conditions.
Spectacles were rather commonly used in the Middle Ages, probably having been invented in the second half of the thirteenth century by Salvinode Armato of Florence. Bernard de Gordon mentions them under the nameoculus berellinusearly in the fourteenth century. They were originally made from a kind of smoky crystal,berillus, whence the German nameBrillenand the Frenchbesicles(Garrison). Guy de Chauliac suggests that when collyria failed to improve the sight spectacles should be employed. Almost needless to say, this use of spectacles meant very much for the comfort and convenience of old people. Up to that time most of those who reached the age of three-score would be utterly unable to read, and would have to depend either on others or on their memory for teaching and many other purposes. External eye troubles, as those due to trichiasis and to various disturbances of the lachrymal apparatus, were treated by direct mechanical means. Some very ingenious suggestions and manipulations were made with regard to them.
MEDICAL EDUCATION FOR WOMEN
Among the rather startling surprises that have developed, as the growth of our knowledge of medieval history, through consultation of the documents in recent years, is constantly contradicting traditions founded on lack of information, perhaps the greatest has been to learn that women were given opportunities for the higher education at practically all of the Italian universities, and that they became not only students, but professors, at many of these institutions. No century from the twelfth down to the nineteenth was without some distinguished women professors at Italian universities, and in the later Middle Ages there was a particularly active period of feminine education.
The most interesting feature of this development for us is that the application of women to medical studies from the twelfth to the fourteenth centuries was not only not discouraged, but was distinctly encouraged, and we find evidence that a numberof women studied and taught medicine, wrote books on medical subjects, were consulted with regard to medico-legal questions, and in general were looked upon as medical colleagues in practically every sense of the word. The very first medical school that developed in modern times, that of Salerno, which came into European prominence in the eleventh century, was quite early in its history opened to women students, and a number of women professors were on its faculty.
Considering the modern idea that ours is the first time when women have ever had any real opportunity for the higher education, and above all professional education, it is a source of no little astonishment to find that at Salerno not only an opportunity was afforded to women to study medicine, but the department of women’s diseases was handed over entirely to them, and as a consequence we have a Salernitan School of Women Physicians, some of whom wrote textbooks on the subject relating to this speciality. De Renzi, in his “Storia della Scuola di Salerno,” has brought to light many details of the history of this phase of medical education for women at the first important medical school that developed in modern Europe. The best known of these medieval women physicians was Trotula, to whom is attributed a series of books on medical subjects—thoughdoubtless some of these were due rather to disciples, but became identified with the more famous master, as so often happened with medieval books. Trotula’s most important book bears two sub-titles: “Trotula’s Unique Book for the Curing of Diseases of Women, Before, During, and After Labour,” and the other sub-title, “Trotula’s Wonderful Book of Experiences (experimentalis) in the Diseases of Women, Before, During, and After Labour, with Other Details Likewise Relating to Labour.”
Probably the most interesting passage in her book for the modern time is that with regard to a torn perineum and its repair, even when prolapse of the uterus is a complication. The passage, which may be found readily in De Renzi or in Gurlt, runs:
“Certain patients, from the severity of the labour, run into a rupture of the genitalia. In some even the vulva and anus become one foramen, having the same course. As a consequence, prolapse of the uterus occurs, and it becomes indurated. In order to relieve this condition, we apply to the uterus warm wine in which butter has been boiled, and these fomentations are continued until the uterus becomes soft, and then it is gently replaced. After this we sew the tear between the anus and vulva in three or four places with silk thread. The woman should then be placed in bed, with the feet elevated, and must retain that position, even foreating and drinking, and all the necessities of life, for eight or nine days. During this time, also, there must be no bathing, and care must be taken to avoid everything that might cause coughing, and all indigestible materials.”
There is a passage almost more interesting with regard to prophylaxis of rupture of the perineum. Trotula says: “In order to avoid the aforesaid danger, careful provision should be made, and precautions should be taken during labour after the following fashion: A cloth folded in somewhat oblong shape should be placed on the anus, and during every effort for the expulsion of the child, that should be pressed firmly, in order that there may not be any solution of the continuity of tissue.”
There are records of other women professors of Salerno, though none of them as famous as Trotula. A lady of the name of Mercuriade is said to have written “On Crises in Pestilent Fever,” and as she occupied herself with surgery as well as medicine, there is also a work on “The Cure of Wounds.” Rebecca Guarna, who belonged to the old Salernitan family of that name, a member of which in the twelfth century was Romuald, priest, physician, and historian, wrote “On Fevers,” “On the Urine,” and “On the Embryo.” Abella acquired a great reputation with her work “On Black Bile,” and curiously enough on “TheNature of Seminal Fluid.” From these books it is clear that, while as professors they had charge of the department of women’s diseases, they studied all branches of medicine. There are a number of licences preserved in the Archives of Naples in which women are accorded the privilege of practising medicine, and apparently these licences were without limitation as to the scope of practice. The preamble of the licence, however, suggests the eminent suitability of women treating women’s diseases. It ran as follows:
“Since, then, the law permits women to exercise the profession of physicians, and since, besides, due regard being had to purity of morals, women are better suited for the treatment of women’s diseases, after having received the oath of fidelity, we permit,” etc.
The story of medical education for women with the free opportunity for practice, and above all the recognition accorded by making them professors at the University of Salerno, will seem all the more surprising to those who recall that the Benedictines largely influenced the foundation at Salerno, and were important factors in its subsequent growth and management. Ordinarily it would be presumed that monastic influence would be distinctly against permitting women to secure such opportunities for education, and, above all, encouraging theiroccupation with medical practice. As a matter of fact, it seems indeed to have been monastic influence which secured this special development. The Benedictines were already habituated to the idea that women were quite capable, if given the opportunity, of taking advantage of the highest education; and besides, they were accustomed to see them occupied, and successfully, with the care of the ailing. When St. Benedict established the monks of the West in retreats, where the men of the earlier Middle Ages could secure, in the midst of troubled times and with men in the cities utterly neglectful of intellectual interests, a refuge from the disturbed life around them, and an opportunity for intellectual development, his sister Scholastica afforded similar opportunities for such women as felt that they were called rather to the intellectual and spiritual life than to the taking up of the burden of domestic duties and a wife’s labours.
In these Benedictine convents for women, as they spread throughout Italy—and afterwards throughout Germany, and France, and England, though the fact is often ignored—the intellectual life was pursued as faithfully as the spiritual. Besides, there gathered around the convent gates as around the monasteries the farmers who worked their estates, and who found it so good “to live under the crozier,” as the rule of the Abbot orAbbess was called, and who always suffered severely whenever, by confiscation or war or like disturbances, the monastic lands passed into the hands of laymen. For their own large numbers as well as for their peasantry, and for the travellers who stayed in their guest-houses, the nuns had to provide medical attendance; and the infirmarians of the convents, situated as they were so often far from cities or towns, acquired considerable medical knowledge and came to apply it with excellent success. The traditions were gathered from many quarters, and passed on for centuries from one house to another; and they gathered simples and treated the ordinary ailments, and nursed the ailing into moods of greater courage and states of mind that predisposed to recovery.
Probably the most important book on medicine that we have from the twelfth century is written by a Benedictine Abbess, since known as St. Hildegarde. She was born of noble parents at Boeckelheim in the county of Sponheim, about the end of the eleventh century. She was educated at the Benedictine cloister of Disibodenberg, and when her education was finished she entered the house as a religious, and at the age of about fifty she became abbess. Her writings, reputation for sanctity, and her wise rule, eminently sympathetic as she was, attracted so many newmembers to the community that the convent became overcrowded. Accordingly, with eighteen of her nuns, Hildegarde withdrew to a new convent at Rupertsburg, which English and American travellers will doubtless recall because it is not far from Bingen on the Rhine, made famous in the later time by Mrs. Hemans’s poem. Here she came to be a sort of centre for the intellectual life of her period. According to traditions, some of which are dubious, she was in active correspondence with nearly every important personage of her generation. She was an intimate friend of St. Bernard of Clairvaux, who was himself perhaps the most influential man of Europe in this century. Her correspondence was enormous, and she was consulted from all sides because her advice on difficult problems of any and every kind was considered so valuable.
In spite of all this time-taking correspondence she found leisure to write a series of books, most of them on mystical subjects, but two of them, strange as it may seem, on medicine. The first is called “Liber Simplicis Medicinæ,” and the second “Liber Compositæ Medicinæ.” These books were written as a contribution of her views with regard to the medical knowledge of her time, but were evidently due, partly at least, to the Benedictine traditions of interest in medicine.Dr. Melanie Lipinska in her “Histoire des Femmes Médicins,” a thesis presented for the doctorate in medicine at the University of Paris in 1900, which was subsequently awarded a special prize by the French Academy, reviews Hildegarde’s work critically from the medical standpoint. She does not hesitate to declare the Abbess Hildegarde the most important medical writer of her time. Reuss, the editor of the works of Hildegarde as they are published in Migne’s “Patrologia,” the immense French edition of all the important works of the Fathers, Doctors, and Saints of the Church, says:
“Among all the saintly religious who have practised medicine or written about it in the Middle Ages, the most important is without any doubt St. Hildegarde....” With regard to her book he says: “All those who wish to write the history of the medical and natural sciences must read this work, in which this religious woman, evidently well grounded in all that was known at that time in the secrets of nature, discusses and examines carefully all the knowledge of the time.” He adds: “It is certain that St. Hildegarde knew many things that were unknown to the physicians of her time.”
Some of Hildegarde’s expressions are startling enough because they indicate discussion of, and attempts to elucidate, problems which many people of the modern time are likely to think occurredonly to the last few generations. For instance, in talking about the stars and describing their course through the firmament, she makes use of a comparison that seems strangely ahead of her time. She says: “Just as the blood moves in the veins, causing them to vibrate and pulsate, so the stars move in the firmament, and send out sparks as it were of light, like the vibrations of the veins.” This is, of course, not an anticipation of the discovery of the circulation of the blood, but it shows how close were men’s ideas to some such thought five centuries before Harvey’s discovery. For Hildegarde the brain was the regulator of all the vital qualities, the centre of life. She connects the nerves in their passage from the brain and the spinal cord through the body with manifestations of life. She has a series of chapters with regard to psychology, normal and morbid. She talks about frenzy, insanity, despair, dread, obsession, anger, idiocy, and innocency. She says very strongly in one place that “when headache and migraine and vertigo attack a patient simultaneously, they render a man foolish and upset his reason. This makes many people think that he is possessed of a demon, but that is not true.” These are the exact words of the saint as quoted in Mlle. Lipinska’s thesis.
With this story of St. Hildegarde in mind, and the recall of other educational developments amongthe Benedictine nuns, it is easy to understand the developments that took place at Salerno, where monastic influence was so prominent. Just as the medical, and above all the surgical, traditions of Salerno found their way to Bologna at the beginning of the thirteenth century, so also did the regulations regarding standards in medical education, and with them medical education for women. There are definite historical documents which show that women not only studied but taught in the medical department of Bologna. The name of one of them at least is very well known. She was Alessandra Giliani, and, strange as it might appear, was one of the prosectors in anatomy of Mondino, the founder of teaching by human dissection. According to the “Cronaca Persicetana,” quoted by Medici in his “History of the Anatomical School at Bologna”:
“She became most valuable to Mondino because she would cleanse most skilfully the smallest vein, the arteries, all ramifications of the vessels, without lacerating or dividing them, and to prepare them for demonstration she would fill them with various coloured liquids, which, after having been driven into the vessels, would harden without destroying the vessels. Again, she would paint these same vessels to their minute branches so perfectly, and colour them so naturally, that, added to the wonderful explanations and teachings of the master, they brought him great fame and credit.”
This passage with its description, as coming from a woman, of a very early anticipation of our most modern anatomical technique—injection, hardening, and colouring, so as to imitate nature for the making of anatomical preparations, for class and demonstration purposes—is all the more interesting because the next great improvement in anatomical teaching, the use of wax models of dissected specimens coloured to imitate nature, came also from a woman, Madame Manzolini, also of Bologna. Feminine instinct aroused women to use their inventive ability to do away with the necessity for always recurring to the deterrent material of fresh dissections, and yet securing such preparations as would make teaching not less but more effective.
Some doubt has been thrown on certain details of the story of Alessandra Giliani, but the memorial tablet erected at the time of her death in the Hospital Church of Santa Maria de Mareto in Florence gives all the important facts, and tells the story of the grief of her fiancé, who was himself Mondino’s other assistant. Like her, he died young also, when there were high hopes of his ability, and there is more than the suspicion that these two untimely deaths may have been due to dissecting wound infections. She died “consumed by her labours,” so that it may have been phthisis; but he was taken by “a swift and lamentable death.”
Nicaise, in the Introduction to his edition of Guy de Chauliac’s “Grande Chirurgie” (Paris, 1893), has a brief review of the history of women in medicine, with special reference to France. He supplies practically all the information available in very short compass, as well as the references where more details can be obtained.
“Women continued to practise medicine in Italy for centuries, and the names of some who attained great renown have been preserved for us. Their works are still quoted from in the fifteenth century.“There was none of them in France who became distinguished, but women could practise medicine in certain towns at least on condition of passing an examination before regularly appointed masters. An edict of 1311, at the same time that it interdicts unauthorized women from practising surgery, recognizes their rights to practise the art if they have undergone an examination before the regularly appointed master surgeons of the corporation of Paris. An edict of King John, April, 1352, contains the same expressions as the previous edict. Du Bouley, in his ‘History of the University of Paris’ gives another edict by the same king, also published in the year 1352, as a result of the complaints of the faculties at Paris, in which there is also question of women physicians. This responded to a petition: ‘Having heard the petition of the Dean and Masters of the Faculty of Medicine at the University of Paris, who declare that there are very many of both sexes, some of the women with legal title to practise and some ofthem merely old pretenders to a knowledge of medicine, who come to Paris in order to practise, be it enacted,’ etc. (The edict then proceeds to repeat the terms of previous legislation in this matter.)“Guy de Chauliac speaks also of women who practised surgery. They formed the fifth and last class of operators in his time. He complains that they are accustomed to too great an extent to give over patients suffering from all kinds of maladies to the will of Heaven, founding their practice on the maxim, ‘The Lord has given as he has pleased; the Lord will take away when he pleases; may the name of the Lord be blessed.’“In the sixteenth century, according to Pasquier, the practice of medicine by women almost entirely disappeared. The number of women physicians becomes more and more rare in the following centuries, just in proportion as we approach our own time. Pasquier says that we find a certain number of them anxious for knowledge, and with a special penchant for the study of the natural sciences and even of medicine, but very few of them take up practice.”
“Women continued to practise medicine in Italy for centuries, and the names of some who attained great renown have been preserved for us. Their works are still quoted from in the fifteenth century.
“There was none of them in France who became distinguished, but women could practise medicine in certain towns at least on condition of passing an examination before regularly appointed masters. An edict of 1311, at the same time that it interdicts unauthorized women from practising surgery, recognizes their rights to practise the art if they have undergone an examination before the regularly appointed master surgeons of the corporation of Paris. An edict of King John, April, 1352, contains the same expressions as the previous edict. Du Bouley, in his ‘History of the University of Paris’ gives another edict by the same king, also published in the year 1352, as a result of the complaints of the faculties at Paris, in which there is also question of women physicians. This responded to a petition: ‘Having heard the petition of the Dean and Masters of the Faculty of Medicine at the University of Paris, who declare that there are very many of both sexes, some of the women with legal title to practise and some ofthem merely old pretenders to a knowledge of medicine, who come to Paris in order to practise, be it enacted,’ etc. (The edict then proceeds to repeat the terms of previous legislation in this matter.)
“Guy de Chauliac speaks also of women who practised surgery. They formed the fifth and last class of operators in his time. He complains that they are accustomed to too great an extent to give over patients suffering from all kinds of maladies to the will of Heaven, founding their practice on the maxim, ‘The Lord has given as he has pleased; the Lord will take away when he pleases; may the name of the Lord be blessed.’
“In the sixteenth century, according to Pasquier, the practice of medicine by women almost entirely disappeared. The number of women physicians becomes more and more rare in the following centuries, just in proportion as we approach our own time. Pasquier says that we find a certain number of them anxious for knowledge, and with a special penchant for the study of the natural sciences and even of medicine, but very few of them take up practice.”
There seems, however, to have been not nearly so much freedom or so much encouragement for women in medicine in France as in Italy. Indeed, in the whole matter of education for women, medieval France has but little to record compared to Italy’s significant chapter in the history of feminine education. One reason for this was doubtless the Hélöise-Abélard incident early in thehistory of the University of Paris. This seems to have discouraged efforts in the direction of the securing of the higher education for women in most of the Western Universities. Oxford was a daughter university of Paris, and Cambridge of Oxford, and they and all the other universities of the West were more deeply influenced in their customs and organization by Paris than by Italy, and as a consequence we hear little of feminine education in the West generally. One result of this has been the existence of a feeling that, since women had very few opportunities for the higher education in Western Europe, they must have had them nowhere else. This presumption forms the basis of not a little misunderstanding of the Middle Ages in our time. It often takes but a little incident to set the current of history in a very different direction from that in which it might have gone, and this seems to have been the case as regards the higher education for women in France and Spain and England.
MEDIEVAL HOSPITALS
Our recent experience makes it easy to understand that such magnificent advance in surgery as has been described in the preceding chapters would have been quite impossible unless there were excellent hospitals in the medieval period. Good surgery demands good hospitals, and indeed inevitably creates them. Whenever hospitals are in a state of neglect, surgery is hopeless. We have, however, abundant evidence of the existence of fine hospitals in the Middle Ages, quite apart from this assumption of them, because of the surprising surgery of the period. Historical traditions from the earlier as well as the later medieval times demonstrate a magnificent development of hospital organization. While there had been military hospitals and a few civic institutions for the care of citizens in Roman times, and some hospital traditions in the East and in connection with the temples in Egypt, hospital organization as we know it is Christian in origin; and particularly theerection of institutions for the care of the ailing poor came to be looked upon very early as a special duty of Christians. Even the Roman Emperor, Julian the Apostate, declared that the old Olympian religion would inevitably lose its hold on the people, unless somehow it could show such care for others in need as the Christians exhibited wherever they obtained a foothold. It was not, however, until nearly the beginning of the Middle Ages that the Christians were in sufficient numbers in the cities, and were free enough from interference by government, to take up seriously the problem of public hospital organization. The rapidity of the development, once external obstacles were removed, shows clearly how close to the heart of Christianity was the subject of care for the ailing poor. St. Basil’s magnificent foundation at Cæsarea in Cappadocia, called theBasilias, which took on the dimensions of a city (termed Newtown) with regular streets, buildings for different classes of patients, dwellings for physicians and nurses and for the convalescent, and apparently even workshops and industrial schools for the care and instruction of foundlings and of children that had been under the care of the monastery, as well as for what we would now call reconstruction work, shows how far hospital organization, even in the latter part of the fourth century, had developed.
About the year 400 Fabiola at Rome, according to St. Jerome, “established a Nosocomium to gather in the sick from the streets, and to nurse the wretched sufferers wasted from poverty and disease.” A little later Pammachius, a Roman Senator, founded a Xenodochium for the care of strangers which St. Jerome praises in one of his letters. At the end of the fifth century Pope Symmachus built hospitals in connection with the three most important churches of Rome, St. Peter’s, St. Paul’s, and St. Lawrence’s. During the Pontificate of Vigilius, Belisarius founded a Xenodochium in theVia Lataat Rome, shortly after the middle of the sixth century. Christian hospitals were early established in the cities of France; and not long after the conversion of England, in that country.
In connection with these hospitals, it is rather easy to understand the fine development of surgery by early Christian physicians which we have traced. The later medieval period of hospital building, however, is of particular interest in the history of medicine, because we have such details of it as show its excellent adaptation to medical and surgical needs. According to Virchow, in his article on the History of German Hospitals, which is to be found in the second volume of his collected “Essays onPublic Medicine and the History of Epidemics,”[14]the story of the foundation of these hospitals of the Middle Ages, even those of Germany, centres around the name of one man, Pope Innocent III. Virchow was not at all a papistically inclined writer, so that his tribute to the great Pope who solved so finely the medico-social problems of his time undoubtedly represents a merited recognition of a great social development in history.
“The beginning of the history of all these German hospitals is connected with the name of that Pope who made the boldest and farthest-reaching attempt to gather the sum of human interests into the organization of the Catholic Church. The hospitals of the Holy Ghost were one of the many means by which Innocent III. thought to hold humanity to the Holy See. And surely it was one of the most effective. Was it not calculated to create the most profound impression to see how the mighty Pope, who humbled emperors and deposed kings, who was the unrelenting adversary of the Albigenses, turned his eyes sympathetically upon the poor and the sick, sought the helpless and the neglected upon the streets, and saved the illegitimate children from death in the waters! There is something at once conciliating and fascinating in the fact that, at the very time when the fourth crusade was inaugurated through his influence, the thought of founding a great organization of an essentially humane character, which was eventuallyto extend throughout all Christendom, was also taking form in his soul; and that in the same year (1204) in which the new Latin Empire was founded in Constantinople, the newly erected hospital of the Holy Spirit, by the old bridge on the other side of the Tiber, was blessed and dedicated as the future centre of this organization.”
According to tradition, just about the beginning of the thirteenth century Pope Innocent resolved to build a hospital in Rome. On inquiry, he found that probably the best man to put in charge of hospital organization was Guy or Guido of Montpellier, of the Brothers of the Holy Ghost, who had founded a hospital at Montpellier which became famous throughout Europe for its thorough organization. Accordingly he summoned Guido to Rome, and gave into his hands the organization of the new hospital, which was erected on the other side of Tiber in the Borgo not far from St. Peter’s. Indeed, Santo Spirito Hospital, as it came to be called, was probably the direct successor of the hospital which Pope Symmachus (488-514) had had built in connection with St. Peter’s not long after the beginning of the Middle Ages. It is easy to understand that at the time when magnificent municipal structures, cathedrals, town halls, abbeys, and educational institutions of various kinds were being erected, with exemplary devotion to art and use, the Hospital of Santo Spirito under the specialpatronage of the Pope was not unworthy of its time.[15]We know very little, however, about the actual structure.