"We are accustomed to think of the practice of dissection as having been re-created by Mondino, and at once fully developed, springing into acceptance. The year 1315 is the generally accepted date for the first public anatomical demonstration upon a human body made by Mondino, and yet it is true that among the laws promulgated by Frederick II, more than seventy-five years before (a.d.1231), was included a decree that a human body should be dissected at Salernum at least once in five years in the presence of the assembled physicians and surgeons of the kingdom, and that in the regulations established for admission to the practice of medicine and surgery in the kingdom it was decreed that no surgeon should be admitted to practise unless he should bring testimonials from the masters teaching in the medical faculty, that he was 'learned in the anatomy of human bodies, and had become perfect in that part of medicine without which neither incisions could safely be made nor fractures cured.'"Salernum was notable in its legalization of the dissection of human bodies before the first public work of Mondino, for, according to a document of the Maggiore Consiglio of Venice of 1308, it appears that there was a college of medicine at Venice which was even then authorized to dissect a body every year. Common experience tells us that the embodiment of such regulations into formal law would occur only after a considerable preceding period of discussion, and in this particular field of clandestine practice. It is too much to ask us to believe that in all this period, from the date of the promulgation of Frederick's decree of 1231 to the first public demonstration by Mondino, at Bologna in 1315, the decree had been a dead letter and no human body had been anatomized. It is true there is not, as far as I am aware, any record of any such work, and commentators and historians of a later date have, without exception, accepted the view that none was done, and thereby heightened the halo assigned to Mondino as the one who ushered in a new era. Such a view seems to me to be incredible. Be that as it may, it is undeniable that at the beginning of the 14th century the idea of dissecting the human body was not a novel one; the importance of a knowledge of the intimate structure of the body had already been appreciated by divers ruling bodies, and specific regulations prescribing its practice had been enacted. It is more reasonable to believe that in the era immediately preceding that of Mondino human bodies were being opened and after a fashion anatomized. All that we know of the work of Mondino suggests that it was not a new enterprise in which he was a pioneer, but rather that he brought to an old practice a new enthusiasm and better methods, which, caught on the rising wave of interest in medical teaching at Bologna, and preserved by his own energy as a writer in the first original systematic treatise written since the time of Galen, created for him in subsequent uncritical times the reputation of being the Restorer of the practice of anatomizing the human body, the first one to demonstrate and teach such knowledge since the time of the Ptolemaic anatomists, Erasistratus and Herophilus."The changes have been rung by medical historians upon a casual reference in Mondino's chapter on the uterus to the bodies of two women and one sow which he had dissected, as if these were the first and the only cadavers dissected by him. The context involves no such construction. He is enforcing a statement that the size of the uterus may vary, and to illustrate it remarks that 'a woman whom Ianatomized in the month of January last year, viz., 1315 Anno Christi, had a larger uterus than one whom I anatomized in the month of March of the same year.' And further, he says that 'the uterus of a sow which I dissected in 1316 (the year in which he was writing) was a hundred times greater than any I have seen in the human female, for she was pregnant and contained thirteen pigs.' These happen to be the only reference to specific bodies that he makes in his treatise. But it is a far cry to wring out of these references the conclusion that these are the only dissections he made. It is quite true that if we incline to enshroud his work in a cloud of mystery and to figure it as an unprecedented awe-inspiring feature to break down the prejudices of the ages, it is easy to think of him as having timidly profaned the human body by his anatomizing zeal in but one or two instances. His own language, however, throughout his book is that of a man who was familiar with the differing conditions of the organs found in many different bodies; a man who was habitually dissecting."(Quotations from the work of Mundinus showing his familiarity with dissections. The leaf and line references are to the Dryander edition, Marburg, 1541.)"I do not consider separately the anatomy of component parts, because their anatomy does not appear clearly in the fresh subject, but rather in those macerated in water." (Leaf 2, lines 8-13.)"... these differences are more noticeable in the cooked or perfectly dried body, and so you need not be concerned about them, and perhaps I will make an anatomy upon such a one at another time and will write what I shall observe with my own senses, as I have proposed from the beginning." (Leaf 60, lines 14-17.)"What the members are to which these nervescome cannot well be seen in such a dissection as this, but it should be liquefied with rain water, and this is not contemplated in the present body." (Leaf 60, lines 31-33.)"After the veins you will note many muscles and many large and strong cords, the complete anatomy of which you will not endeavor to find in such a body but in a body dried in the sun for three years, as I have demonstrated at another time; I also declared completely their number, and wrote the anatomy of the muscles of the arms, hands, and feet in a lecture which I gave over the first, second, third, and fourth subjects." (Leaf 61, lines 1-7.)
"We are accustomed to think of the practice of dissection as having been re-created by Mondino, and at once fully developed, springing into acceptance. The year 1315 is the generally accepted date for the first public anatomical demonstration upon a human body made by Mondino, and yet it is true that among the laws promulgated by Frederick II, more than seventy-five years before (a.d.1231), was included a decree that a human body should be dissected at Salernum at least once in five years in the presence of the assembled physicians and surgeons of the kingdom, and that in the regulations established for admission to the practice of medicine and surgery in the kingdom it was decreed that no surgeon should be admitted to practise unless he should bring testimonials from the masters teaching in the medical faculty, that he was 'learned in the anatomy of human bodies, and had become perfect in that part of medicine without which neither incisions could safely be made nor fractures cured.'
"Salernum was notable in its legalization of the dissection of human bodies before the first public work of Mondino, for, according to a document of the Maggiore Consiglio of Venice of 1308, it appears that there was a college of medicine at Venice which was even then authorized to dissect a body every year. Common experience tells us that the embodiment of such regulations into formal law would occur only after a considerable preceding period of discussion, and in this particular field of clandestine practice. It is too much to ask us to believe that in all this period, from the date of the promulgation of Frederick's decree of 1231 to the first public demonstration by Mondino, at Bologna in 1315, the decree had been a dead letter and no human body had been anatomized. It is true there is not, as far as I am aware, any record of any such work, and commentators and historians of a later date have, without exception, accepted the view that none was done, and thereby heightened the halo assigned to Mondino as the one who ushered in a new era. Such a view seems to me to be incredible. Be that as it may, it is undeniable that at the beginning of the 14th century the idea of dissecting the human body was not a novel one; the importance of a knowledge of the intimate structure of the body had already been appreciated by divers ruling bodies, and specific regulations prescribing its practice had been enacted. It is more reasonable to believe that in the era immediately preceding that of Mondino human bodies were being opened and after a fashion anatomized. All that we know of the work of Mondino suggests that it was not a new enterprise in which he was a pioneer, but rather that he brought to an old practice a new enthusiasm and better methods, which, caught on the rising wave of interest in medical teaching at Bologna, and preserved by his own energy as a writer in the first original systematic treatise written since the time of Galen, created for him in subsequent uncritical times the reputation of being the Restorer of the practice of anatomizing the human body, the first one to demonstrate and teach such knowledge since the time of the Ptolemaic anatomists, Erasistratus and Herophilus.
"The changes have been rung by medical historians upon a casual reference in Mondino's chapter on the uterus to the bodies of two women and one sow which he had dissected, as if these were the first and the only cadavers dissected by him. The context involves no such construction. He is enforcing a statement that the size of the uterus may vary, and to illustrate it remarks that 'a woman whom Ianatomized in the month of January last year, viz., 1315 Anno Christi, had a larger uterus than one whom I anatomized in the month of March of the same year.' And further, he says that 'the uterus of a sow which I dissected in 1316 (the year in which he was writing) was a hundred times greater than any I have seen in the human female, for she was pregnant and contained thirteen pigs.' These happen to be the only reference to specific bodies that he makes in his treatise. But it is a far cry to wring out of these references the conclusion that these are the only dissections he made. It is quite true that if we incline to enshroud his work in a cloud of mystery and to figure it as an unprecedented awe-inspiring feature to break down the prejudices of the ages, it is easy to think of him as having timidly profaned the human body by his anatomizing zeal in but one or two instances. His own language, however, throughout his book is that of a man who was familiar with the differing conditions of the organs found in many different bodies; a man who was habitually dissecting."
(Quotations from the work of Mundinus showing his familiarity with dissections. The leaf and line references are to the Dryander edition, Marburg, 1541.)
"I do not consider separately the anatomy of component parts, because their anatomy does not appear clearly in the fresh subject, but rather in those macerated in water." (Leaf 2, lines 8-13.)
"... these differences are more noticeable in the cooked or perfectly dried body, and so you need not be concerned about them, and perhaps I will make an anatomy upon such a one at another time and will write what I shall observe with my own senses, as I have proposed from the beginning." (Leaf 60, lines 14-17.)
"What the members are to which these nervescome cannot well be seen in such a dissection as this, but it should be liquefied with rain water, and this is not contemplated in the present body." (Leaf 60, lines 31-33.)
"After the veins you will note many muscles and many large and strong cords, the complete anatomy of which you will not endeavor to find in such a body but in a body dried in the sun for three years, as I have demonstrated at another time; I also declared completely their number, and wrote the anatomy of the muscles of the arms, hands, and feet in a lecture which I gave over the first, second, third, and fourth subjects." (Leaf 61, lines 1-7.)
Very probably the best evidence that we have of the comparative frequency at least of dissection at this time is to be found in the records of a trial for body-snatching that occurred in Bologna. The details would remind one very much of what we know of the difficulties with regard to dissection in America a couple of generations ago, when no bodies were provided by law for dissection purposes. In the course of some studies for the history of the New York State Medical Society (New York, 1906) I found that nearly every one of the first half dozen presidents of the New York Academy of Medicine, which is not much more than sixty years old, had had body-snatching experiences when they were younger. Dr. Samuel Francis, the medico-historical writer, tells of a personal expedition across the ferry in the winter time, bringing a body from a Long Island graveyard. In order to avoid the constables on the Long Island side and the police on the New York side, because there had been a number of cases of body-snatching recently and the authorities wereon the lookout, the corpse was placed sitting beside the physician who drove the wagon, with a cloak wrapped around it, as if it were a living person specially protected against the cold. Similar experiences were not unusual. The lack of bodies for dissection is sometimes attributed to religious scruples, but they have very little to do with it, as at all times men have refused to allow the bodies of their friends to be treated as anatomical material. This is the natural feeling of abhorrence and not at all religious. It is only when there are many unclaimed bodies of strangers and the poor, as happens in large cities, that there can be an abundance of anatomical material.
The details of this body-snatching case are strangely familiar to those who know the history of similar cases before the middle of the nineteenth century. The case occurred in 1319 in Bologna, just four years after Mondino's public dissections. Four students were involved in the charge of body-snatching, all of them from outside the city of Bologna itself, three from Milan and one from Piacenza. In modern experience, too, as a rule, students from outside of the town where the medical college was situated, were always a little readier than natives to violate graveyards. These four students were accused of having gone at night to the Cemetery of St. Barnabas, outside the gate of San Felice,—suburban graveyards were usually the scene of such exploits,—and to have dug up the body of a certain criminal named Pasino, who had been hanged a few days before. They carried the body to the school in the Parish of San Salvatore, where Alberto Zancariwas teaching. The resurrection had been accomplished without witnesses, but there were several witnesses who testified that they recognized the body of Pasino in the school and students occupied with its dissection. If evidence for the zeal of the medical students of that time for dissection were needed, surely we have it in the testimony at this trial. At a time when body-snatching has become a criminal offence usually there have been many repeated occurrences of it before the parties are brought to trial, so that it seems not unlikely that a good many dissections of illegally secured bodies were being done at Bologna at this time.
We know of a regulation of the University in force at this time, which required the teachers at the University to do an anatomy or dissection for students if they secured a body for that purpose. The students seem to have used all sorts of influence, political, monetary, diplomatic, and ecclesiastical, in order to secure the bodies of criminals. Sometimes when they failed in their purpose they waited until after burial and then took the body without leave. When we recall the awfully deterrent condition in which bodies must have been that were thus provided for dissecting purposes, it is easy to understand that the enthusiasm of the students for dissection must have been at a very high pitch. Certainly it was far higher than at the present day, when, in spite of the fact that our dissecting-rooms have very few of the old-time dangers and unpleasantnesses, dissection is only practised with assiduity if special care is exercised in requiring attendance and superintending the work of the department.
In my book on "The Popes and Science" I have gathered the traditions relating to Mondino's assistants in the chair of anatomy at Bologna. They furnish abundant evidence of the fact that dissections, far from being uncommon, must have been not at all infrequent at the north Italian universities at this time. Curiously enough, one of these assistants was a young woman who, as was not infrequently the custom at this time in the Italian universities, was matriculated as a student at Bologna. She took up first philosophy, and afterwards anatomy, under Mondino. While it is not generally realized, co-education was quite common at the Italian universities of the thirteenth and fourteenth centuries, and at no time since the foundation of the universities has a century passed in Italy without distinguished women occupying professors' chairs at some of the Italian universities. This young woman, Alessandra Giliani, of Persiceto, a country district not far from Bologna, took up the study of anatomy with ardor and, strange as it may appear, became especially enthusiastic about dissection. She became so skilful that she was made the prosector of anatomy, that is, one who prepares bodies for demonstration by the professors.
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 fordemonstration she would fill them with various colored 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 color them so naturally that, added to the wonderful explanations and teachings of the master, they brought him great fame and credit." The whole passage shows a wonderful anticipation of our most modern methods—injection, painting, hardening—of making anatomical preparations for class and demonstration purposes.
Some of the details of the story have been doubted, but her memorial tablet, erected at the time of her death in the Church of San Pietro e Marcellino of the Hospital of Santa Maria de Mareto, gives all the important facts, and tells the story of the grief of her fiancé, who was himself Mondino's other assistant.[17]This was Otto Agenius, who had made for himself a name as an assistant to the chair of anatomy in Bologna, and of whom there were great hopes entertained because he had already shown signs of genius as an investigator in anatomy. These hopes were destined to grievous disappointment, however, for Otto died suddenly, before he had reached his thirtieth year. The fact that both these assistants of Mondino died young and suddenly, would seem to pointto the fact that probably dissection wounds in those early days proved even more fatal than they occasionally did a century or more ago, when the proper precautions against them were not so well understood. The death of Mondino's two prosectors in early years would seem to hint at some such unfortunate occurrence.
As regards the evidence of what the young man had accomplished before his untimely death, probably the following quotation, which Medici has takenfrom one of the old chroniclers, will give the best idea:
"What advantage indeed might not Bologna have had from Otto Agenius Lustrulanus, whom Mondino had used as an assiduous prosector, if he had not been taken away by a swift and lamentable death before he had completed the sixth lustrum of his life!"
"What advantage indeed might not Bologna have had from Otto Agenius Lustrulanus, whom Mondino had used as an assiduous prosector, if he had not been taken away by a swift and lamentable death before he had completed the sixth lustrum of his life!"
How well the tradition created by Mondino continued at the university will be best understood from what we know of Guy de Chauliac's visit to the medical school here about the middle of the century. The great French surgeon tells us that he came to Bologna to study anatomy under the direction of Mondino's successor, Bertruccius. When he wrote his preface to his great surgery he recalled this teaching of anatomy at Bologna and said, "It is necessary and useful to every physician to know, first of all, anatomy. For this purpose the study of books is indeed useful, but it is not sufficient to explain those things which can only be appreciated by the senses and which need to be seen in the dead body itself." He advises his students to consult Mundinus' treatise but to demonstrate its details for themselves on the dead body. He relates that he himself had often,multitoties, done this, especially under the direction of Bertruccius at Bologna. Curiously enough, as pointed out by Professor Pilcher, Mondino had used this same wordmultitotiens(the variant spelling makes no difference in the meaning) in speaking about his own work. In describing the hypogastric lesion he mentions that he had demonstrated certain veins in it many times,multitotiens.
Mondino was just past fifty when he finished his little book and permitted copies of it to be made. Though the book occurs so early in the history of modern book-making the author offers his excuses to the public for writing it, and quotes the authority of Galen, to whom he turns in other difficult situations, for justification. As prefaces go, Mondino's is so like that of many an author of more recent date that his words have a bibliographic, as well as a personal, interest. He said:
"A work upon any science or art—as saith Galen—is issued for three reasons: first, that one may satisfy his friends. Second, that he may exercise his best mental powers. Third, that he may be saved from the oblivion incident to old age. Therefore, moved by these three causes, I have proposed to my pupils to compose a certain work on medicine."And because a knowledge of the parts to be subjected to medicine (which is the human body, and the names of its various divisions) is a part of medical science, as saith Averrhoes in his first chapter, in the section on the definition of medicine, for this reason among others, I have set out to lay before you the knowledge of the parts of the human body which is derived from anatomy, not attempting to use a lofty style, but the rather that which is suitable to a manual of procedure."
"A work upon any science or art—as saith Galen—is issued for three reasons: first, that one may satisfy his friends. Second, that he may exercise his best mental powers. Third, that he may be saved from the oblivion incident to old age. Therefore, moved by these three causes, I have proposed to my pupils to compose a certain work on medicine.
"And because a knowledge of the parts to be subjected to medicine (which is the human body, and the names of its various divisions) is a part of medical science, as saith Averrhoes in his first chapter, in the section on the definition of medicine, for this reason among others, I have set out to lay before you the knowledge of the parts of the human body which is derived from anatomy, not attempting to use a lofty style, but the rather that which is suitable to a manual of procedure."
Some of the early editions of Mondinus' book are said, according to old writers, to have contained illustrations. None of these copies have come down to us, but the assertion is made so definitely that it seems likely to have been the case. The editions that we have contain wood engravings of the method of making a dissection as frontispiece, so that itwould not be difficult to think of further such illustrations having been employed in the book itself. As we note in the chapter on "Great Surgeons of the Medieval Universities," Mondeville, according to Guy de Chauliac, had pictures of anatomical preparations which he used for teaching purposes. It is easy to understand that the value of such aids would be recognized at a time when the difficulty of preserving bodies made it necessary to do dissections hurriedly so as to get the rapidly decomposing material out of the way.
Beyond his book and certain circumstances connected with it we know very little about Mondino. What we know, however, enables us to conclude that, like many another great teacher, he must have had the special faculty of inspiring his students with an ardent enthusiasm for the work that they were taking under him. Hence the body-snatching and other stories. Mondino continued to be held in high estimation by the Bolognese for centuries after his death. Dr. Pilcher calls attention to the fact that his sepulchral tablet, which is in the portico of the Church of San Vitari in Bologna, and a replica of which he was allowed to have made in order to bring it to America, is the only one of the sepulchral tablets in the great churches of Florence, San Domenico, San Martino, the Cathedral and the Cloister of San Giacomo degli Ermitani, which has not been removed from its original location and placed in the halls of the Civic Museum. Their removal he considers "a kind of desecration which does violence to one's sense of sanctity and propriety." "Fortunately, thus far, the Mondino Tablet has escaped the spoiler." Veryprobably Dr. Pilcher's replica of the tablet which he was required to deposit in the Civic Museum at the time when the copy was made to be brought to America may save the tablet to be seen in its original position for many generations.
Mondino's career is of special interest because it foreshadows the life and accomplishment of many another maker of medicine of the after time. He did a great new thing in medicine in organizing regular public dissections, and then in making a manual that would facilitate the work. He waited patiently for years before completing his book in order that it might be the fruit of long experience, and so be more helpful to others. He was so modest as to require urging to secure the publication. He had the reward of his patience in the popularity of his little work for centuries after his time. The glimpse that we get of his relations to his young assistants, Agenius and Alessandra, seems to show us a teacher of distinct personal magnetism. Undoubtedly the reputation of his book did much for not only the medical school of the University of Bologna, but also for the medical schools of other north Italian universities, and helped to bring to them the crowds of students that flocked there during the fourteenth and fifteenth centuries.
Taddeo and Mondino turned the attention of the medical students of their generations Bolognawards. Before that time they had mainly gone to Salerno. After their time most of the ardent students of medicine felt that they must study for a time at least at Bologna. Other important medical schools of Italian universities at Padua, at Vicenza, at Piacenza, aroseand prospered. During the time when the political troubles of Italy reached a climax about the middle of the fourteenth century, while the Popes were at Avignon, there was a remission in the attendance at all the Italian universities, but with the Popes' return to Rome and the coming of even comparative peace to Italy, Bologna once more became the term of medical pilgrimages for students from all over the world. In the meantime Mondino's book went forth to be the most used text-book of its kind until Vesalius' great work came to replace it. To have ruled in the world of anatomy for two centuries as the best known of teachers is of itself a distinction that shows us at once the teaching power and the scientific ability of this professor of anatomy of Bologna in the early fourteenth century.
Strange as it may appear to those who have not watched the development of our knowledge of the Middle Ages in recent years the most interesting feature in the medical departments and, indeed, of the post-graduate work generally of the medieval universities, is that in surgery. There is a very general impression that this department of medicine did not develop until quite recent years, and that particularly it failed to develop to any extent in the Middle Ages. A good many of the historians of this period, indeed, though never the special historians of medicine, have even gone far afield in order to find some reason why surgery did not develop at this time. They have insisted that the Church by its prohibition of the shedding of blood, first to monks and friars, and then to the secular clergy, prevented the normal development of surgery. Besides they add that Church opposition to anatomy completely precluded all possibility of any genuine natural evolution of surgery as a science.
There is probably no more amusing feature of quite a number of supposedly respectable and presumably authoritative historical works written in English than this assumption with regard to the absence of surgery during the later Middle Ages. Onlythe most complete ignorance of the actual history of medicine and surgery can account for it. The writers who make such assertions must never have opened an authoritative medical history. Nothing illustrates so well the expression of the editors of the "Cambridge Modern History" referred to more than once in these pages that "in view of changes and of gains such as these [the jointing of original documents] it has become impossible for historical writers of the present day to trust without reserve even to the most respected secondary authority. The honest student finds himself continually deserted, retarded, misled by the classics of historical literature." Fortunately for us this sweeping condemnation does not hold to any great extent for the medical historical classics. All of the classic historians of medicine tell us much of the surgery of the thirteenth and fourteenth centuries, and in recent years the republication of old texts and the further study of manuscript documents of various kinds have made it very clear that there is almost no period in the history of the world when surgery was so thoroughly and successfully cultivated as during the rise and development of the universities and their medical schools in the thirteenth and fourteenth centuries.
It is interesting to trace the succession of great contributors to surgery during these two centuries. We know their teaching not from tradition, but from their text-books so faithfully preserved for us by their devoted students, who must have begrudged no time and spared no labor in copying, for many of the books are large, yet exist in many manuscript copies.
Modern surgery may be said to owe its origin to a school of surgeons, the leaders of whom were educated at Salerno in the early part of the thirteenth century, and who, teaching at various north Italian universities, wrote out their surgical principles and experiences in a series of important contributions to that department of medical science. The fact that the origin of the school was at Salerno, where, as is well known, Arabian influence counted for much and for which Constantine's translations of Arabian works proved such a stimulus a century before, makes most students conclude that this later medieval surgical development is simply a continuation of the Arabian surgery that, as we have seen, developed very interestingly during the earlier Middle Ages. Any such idea, however, is not founded on the realities of the situation, but on an assumption with regard to the extent of Arabian influence. Gurlt in his "History of Surgery" (Vol. I, page 701) completely contradicts this idea, and says with regard to the first of the great Italian writers on surgery, Rogero, that "though Arabian works on surgery had been brought over to Italy by Constantine 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."
It is in the history of medicine particularly that it is possible to trace the true influence of the Arabs on European thought in the later Middle Ages. We have already seen in the chapter on Salerno that Arabian influence did harm to Salernitan medical teaching. The school of Salerno itself had developedsimple, dietetic, hygienic, and general remedial measures that included the use of only a comparatively small amount of drugs. Its teachers emphasized nature's curative powers. With Arabian influence came polypharmacy, distrust of nature, and attempts to cure disease rather than help nature. In surgery, which developed very wonderfully in the thirteenth and fourteenth centuries, Salerno must be credited with the incentive that led up to the marvellous development that came. With this, however, Arabian influence has nothing to do. Gurlt, besides calling attention to the fact that the author of the first great text-book on the subject not only did not draw his inspiration from Arab sources, insisted that "instead of any Arabisms being found in his [Roger's] writings many Græcisms occur." The Salernitan school of surgery drank at the fountain-head of Greek surgery. Apart from Greek sources Roger's book rests entirely upon his own experiences, those of his teachers and his colleagues, and the tradition in surgery that had developed at Salerno. This tradition was entirely from the Greek. Roger himself says in one place, "We have resolved to write out deliberately our methods of operation such as they have been derived from our own experience and that of our colleagues and illustrious men."
Ruggero, or Rogero, who is also known as Rogerio and Rogerus with the adjective Parmensis, or Salernitanus, of Parma or of Salerno, and often in German and English history simply as Roger, lived atthe end of the twelfth or the beginning of the thirteenth century and probably wrote his text-book about 1180. This text-book was, according to tradition, originally drafted for his lessons in surgery at Salerno. It attracted much attention and after being commented on by his pupil Rolando, the work of both of them being subsequently annotated by the Four Masters, this combined work became the basis of modern surgery. Roger was probably born either in Palermo or Parma. There are traditions of his having taught for a while at Paris and at the University of Montpellier, though these are not substantiated. His book was printed at Venice in 1546, and has been lately reprinted by De Renzi in his "Collectio Salernitana."
Roland was a pupil of Roger's, and the two names that often occur in medieval romance became associated in a great historic reality as a consequence of Roland's commentary on his master's work, which was a favorite text-book in surgery for a good while in the thirteenth century at Salerno. Some space will be given to the consideration of their surgical teaching after a few words with regard to some disciples who made a second commentary, adding to the value of the original work.
This is the well-known commentary of the Four Masters, a text-book of surgery written somewhat in the way that we now make text-books in various departments of medicine, that is, by asking men who have made specialties of certain subjects to write on that subject and then bind them all together in a single volume. It represents but another striking reminder that most of our methods are old, not newas we are likely to imagine them. The Four Masters took the works of Roger and Rolando, acknowledged their indebtedness much more completely than do our modern writers on all occasions, I fear, and added their commentaries.
Gurlt says ("Geschichte der Chirurgie," Vol. I, p. 703) that "in spite of the fact that there is some doubt about the names of the authors, this volume constitutes one of the most important sources for the history of surgery of the later Middle Ages and makes it very clear that these writers drew their opinions from a rich experience." It is rather easy to illustrate from the quotations given in Gurlt or from the accounts of their teaching in Daremberg or De Renzi some features of this experience that can scarcely fail to be surprising to modern surgeons. For instance, what is to be found in this old text-book of surgery with regard to fractures of the skull is likely to be very interesting to surgeons at all times. One might be tempted to say that fewer men would die every year in prison cells who ought to be in hospitals, if the old-time teaching was taken to heart. For there are rather emphatic directions not to conclude because the scalp is unwounded that there can be no fracture of the skull. Where nothing can be felt care must be exercised in getting the history of the case. For instance, if a man is hit by a metal instrument shaped like the clapper of a bell or by a heavy key, or by a rounded instrument made of lead—this would remind one very much of the lead pipe of the modern time, so fruitful of mistakes of diagnosis in head injuries—special care must be taken to look for symptoms in spite of the lack of an externalpenetrating wound. Where there is good reason to suspect a fracture because of the severity of the injury, the scalp should be incised and a fracture of the cranium looked for carefully. That is carrying the exploratory incision pretty far. If a fracture is found the surgeon should trephine so as to relieve the brain of any pressure of blood that might be affecting it.
There are many warnings, however, of the danger of opening the skull and of the necessity for definitely deciding beforehand that there is good reason for so doing. How carefully their observations had been made and how well they had taken advantage of their opportunities, which were, of course, very frequent in those warlike times when firearms were unknown, hand-to-hand conflict common, and blunt weapons were often used, can be appreciated very well from some of the directions. For instance, they knew of the possibility of fracture 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."[18]They even seem to have known of accidents such as we now discuss in connection with the laceration of the middle meningeal artery. They warn surgeons of the possibilities of these cases. They tell the story of "a youth who had a very small wound made by a thrown stone and there seemed no serious results or bad signs. He died the next day, however. His cranium was opened and a large amount of blackblood was found coagulated about his dura mater."
There are many interesting things said with regard to depressed fractures and the necessity for elevating the bone. If the depressed portion is wedged then an opening should be made with the trephine and an elevating instrument called a spatumen used to relieve the pressure. Great care should be taken, however, in carrying out this procedure lest the bone of the cranium itself, in being lifted, should injure the soft structures within. The dura mater should be carefully protected from injury as well as the pin. Care should especially be exercised at the brow and the rear of the head and at the commissures (proram et pupim et commissuras), since at these points the dura mater is likely to be adherent. Perhaps the most striking expression, the wordinfectbeing italicized by Gurlt, is: "In elevating the cranium be solicitous lest you should infect or injure the dura mater."
For wounds of the scalp sutures of silk are recommended because this resists putrefaction and holds the wound edges together. Interrupted sutures about a finger-breadth apart are recommended. "The lower part of the wound should be left open so that the cure may proceed properly." Red powder was strewed over the wound and the leaf of a plant set above it. In the lower angle of the wound a pledget of lint for drainage purposes was inlaid. Hemorrhage was prevented by pressure, by the binding on ofburntwool firmly, and by the ligature of veins and by the cautery.
There are rather interesting discussions of theprognosis of wounds of the head, especially such as may be determined from general symptoms in this commentary of the Four Masters on Roger's and Rolando's treatises. If an acute febrile condition develops, the wound is mortal. If the patient loses the use of the hands and feet or if he loses his power of direction, or his sensation, the wound is mortal. If a universal paralysis comes on, the wound is mortal. For the treatment of all these wounds careful precautions are suggested. Cold was supposed to be particularly noxious to them. Operations on the head were not to be done in cold weather and, above all, not in cold places. The air where such operations were done must be warmed artificially. Hot plates should surround the patient's head while the operation was being performed. If this were not possible they were to be done by candlelight, the candle being held as close as possible in a warm room. These precautions are interesting as foreshadowing many ideas of much more modern time and especially indicating how old is the idea that cold may be taken in wounds. In popular medicine this still has its place. Whenever a wound does badly in the winter time patients are sure that they have taken cold. Such popular medical ideas are always derived from supposedly scientific medicine, and until we learned about microbes physicians used the same expressions. We have not got entirely away from them yet.
These old surgeons must have had many experiences with fractures at the base of the skull. Hemorrhages from the mouth and nose, for instance, and from the ears were considered bad signs. They were inclined to suggest that openings into the skull shouldbe discovered by efforts to demonstrate a connection between the mouth and nares and the brain cavity. For instance, in their commentary the Four Masters said: "Let the patient hold his mouth and nostrils tight shut and blow strongly." If there was any lessening of the pressure or any appearance of air in the wound in the scalp, then a connection between the mouth and nose was diagnosticated. This is ingenious but eminently dangerous because of the infectious material contained in the nasal and oral cavities, so likely to be forced by such pressure into the skull. They were particularly anxious to detect linear fractures. One of their methods of negative diagnosis for fractures of the skull was that if the patient were able to bring his teeth together strongly, or to crack a nut without pain, then there was no fracture present. One of the commentators, however, adds to this "sed hoc aliquando fallit—but this sign sometimes fails." Split or crack fractures were also diagnosticated by the method suggested by Hippocrates of pouring some colored fluid over the skull after the bone was exposed, when the linear fracture would show by coloration. The Four Masters suggest a sort of red ink for this purpose.
While they have so much to say about fractures of the skull and insist, over and over again, that though all depressed fractures need treatment and many fissure fractures require trepanation, still great care must be exercised in the selection of cases. They say, for instance, that surgeons who in every serious wound of the head have recourse to the trephine must be looked upon as "fools and idiots" (idioti et stolidi). In the light of what we now knowabout the necessity for absolute cleanliness,—asepsis as we have come to call it,—it is rather startling to note the directions that are given to a surgeon to be observed on the day when he is to do a trepanation. For obvious reasons I prefer to quote it in the Latin: "Et nota quod die ilia cavendum est medico a coitu et malis cibis aera corrumpentibus, ut sunt allia, cepe, et hujusmodi, et colloquio mulieris menstruosæ, et manus ejus debent esse mundæ, etc." My quotation is from Gurlt, Vol. I, p. 707. The directions are most interesting. The surgeon's hands must be clean, he must avoid the taking of food that may corrupt the air, such as onions, leeks, and the like; must avoid menstruating and other women, and in general must keep himself in a state of absolute cleanliness.
To read a passage like this separated from its context and without knowing anything about the wonderful powers of observation of the men from whom it comes, it would be very easy to think that it is merely a set of general directions which they had made on some general principle, perhaps quite foolish in itself. We know, however, that these men had by observation detected nearly every feature of importance in fractures of the skull, their indications and contra-indications for operation and their prognosis. They had anticipated nearly everything of importance that has come to be insisted on even in our own time in the handling of these difficult cases. It is not unlikely, therefore, that they had also arrived at the recognition by observations on many patients that the satisfactory after-course of these cases which were operated on by the surgeon afterdue regard to such meticulous cleanliness as is suggested in the paragraph I have quoted, made it very clear that these aseptic precautions, as we would call them, were extremely important for the outcome of the case and, therefore, were well worth the surgeon's attention, though they must have required very careful precautions and considerable self-denial. Indeed this whole subject, the virtual anticipation of our nineteenth-century principles of aseptic surgery in the thirteenth century, is not a dream nor a far-fetched explanation when one knows enough about the directions that were laid down in the surgical text-books of that time.
After Roger and Rolando and the Four Masters, who owe the inspiration for their work to Salerno and the south of Italy, comes a group of north Italian surgeons: Bruno da Longoburgo, usually called simply Bruno; Theodoric and his father, Hugo of Lucca, and William of Salicet. Immediately following them come two names that belong, one almost feels, to a more modern period: Mondino, the author of the first text-book on dissection, and Lanfranc (the disciple of William of Salicet), who taught at Paris and "gave that primacy to French surgery which it maintained all the centuries down to the nineteenth" (Pagel). It might very well be thought that this group of Italian surgeons had very little in their writings that would be of any more than antiquarian interest for the modern time. It needs but a little knowledge of their writings as they have come downto us to show how utterly false any such opinion is. To Hugo da Lucca and his son Theodoric we owe the introduction and the gradual bringing into practical use of various methods of anæsthesia. They used opium and mandragora for this purpose and later employed an inhalant mixture, the composition of which is not absolutely known. They seem, however, to have been very successful in producing insensibility to pain for even rather serious and complicated and somewhat lengthy operations. Indeed it is to this that must be attributed most of their surprising success as surgeons at this early date.
We are so accustomed to think that anæsthesia was discovered about the middle of the nineteenth century in America that we forget that literature is full of references in Tom Middleton's (seventeenth century) phrase to "the mercies of old surgeons who put their patients to sleep before they cut them." Anæsthetics were experimented with almost as zealously, during the latter half of the thirteenth century at least, as during the latter half of the nineteenth century. They were probably not as successful as we are, but they did succeed in producing insensibility to pain, otherwise they could never have operated to the extent they did. Moreover the traditions show that the Da Luccas particularly had invented a method that left very little to be desired in this matter of anæsthesia. A reference to the sketch of Guy de Chauliac in this volume will show how practical the method was in his time.
Nearly the same story as with regard to anæsthetics has to be repeated for what are deemed so surely modern developments,—asepsis and antisepsis. Ihave already suggested that Roger seems to have known how extremely important it was to approach operations upon the skull with the most absolute cleanliness. There are many hints of the same kind in other writers which show that this was no mere accidental remark, but was a definite conclusion derived from experience and careful observation of results. We find much more with regard to this same subject in the writings of the group of northern Italian surgeons and especially in the group of those associated with William of Salicet. Professor Clifford Allbutt, Regius Professor of Medicine at the University of Cambridge, England, in his address before the St. Louis World's Fair Congress of Arts and Science in 1904, did not hesitate to declare that William discussed the causes for union by first intention and the modes by which it might be obtained. He, too, insisted on cleanliness as the most important factor in having good surgical results, and all of this group of men, in operating upon septic cases, used stronger wine as a dressing. This exerted, as will be readily understood, a very definite antiseptic quality.
Evidently some details of the teaching of this group of great surgeons in northern Italy in the second half of the thirteenth century will make clearer to us how much the rising universities of the time were accomplishing in medicine and surgery as well as in their other departments. The dates of the origin of some of these universities should perhaps be recalled so as to remind readers how closely related they are to this great group of surgical teachers. Salerno was founded very early, probably inthe tenth century, Bologna, Reggio, and Modena came into existence toward the end of the twelfth century; Vicenza, Padua, Naples, Vercelli, and Piacenza, as well as Arezzo, during the first half of the thirteenth century; Rome, Perugia, Trevizo, Pisa, Florence, Sienna, Lucca, Pavia, and Ferrara during the next century. The thirteenth century was the special flourishing period of the universities, and the medical departments, far from being behind, were leaders in accomplishment. (See my "The Thirteenth Greatest of Centuries," N. Y., 1908.)
The first of this important group of north Italian surgeons who taught at these universities was Bruno of Longoburgo. While he was born in Calabria, and probably studied in Salerno, his work was done at Vicenza, Padua, and Verona. His text-book, the "Chirurgia Magna," dedicated to his friend Andrew of Piacenza, was completed at Padua in January, 1252. Gurlt notes that he is the first of the Italian surgeons who quotes, besides the Greeks, the Arabian writers on surgery. Eclecticism had definitely come into vogue to replace exclusive devotion to the Greek authors, and men were taking what was good wherever they found it. Gurlt tells us that Bruno owed much of what he wrote to his own experience and observation. He begins his work by a definition of surgery,chirurgia, tracing it to the Greek and emphasizing that it means handwork. He then declares that it is the last instrument of medicine to be used only when the other two instruments,diet and potions, have failed. He insists that surgeons must learn by seeing surgical operations and watching them long and diligently. They must be neither rash nor over bold and should be extremely cautious about operating. While he says that he does not object to a surgeon taking a 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."
In his second chapter on healing he talks about healing by first and second intention. Wounds must be more carefully looked to in summer than in winter, becauseputrefactio est major in aestate quam in hyeme, putrefaction is greater in summer than in winter. For proper union care must be exercised to bring the wound edges accurately together and not allow hair, or oil, or dressings to come between them. In large wounds he considers stitching indispensable, and recommends for this a fine, square needle. The preferable suture material in his experience was silk or linen.
The end of the wound was to remain open in order that lint might be placed therein in order to draw off any objectionable material. He is particularly insistent on the necessity for drainage. In deepwounds special provision must be made, and in wounds of extremities the limb must be so placed as to encourage drainage. If drainage does not take place, then either the wound must be thoroughly opened, or if necessary a counter opening must be made to provide drainage. All his treatment of wounds is dry, however. Water, he considered, always did harm. We can readily understand that the water generally available and especially as surgeons saw it in camps and on the battlefield, was likely to do much more harm than good. In penetrating wounds of the belly cavity, if there was difficulty in bringing about the reposition of the intestines, they were first to be pressed back with a sponge soaked in warm wine. Other manipulations are suggested, and if necessary the wound must be enlarged. If the omentum finds its way out of the wound, all of it that is black or green must be cut off. In cases where the intestines are wounded they are to be sewed with a small needle and a silk thread and care is to be exercised in bringing about complete closure of the wound. This much will give a good idea of Bruno's thoroughness. Altogether, Gurlt, in his "History of Surgery," gives about fifteen large octavo pages of rather small type to abriefcompendium of Bruno's teachings.
One or two other remarks of Bruno are rather interesting in the light of modern developments in medicine. For instance, he suggests the possibility of being able to feel a stone in the bladder by means of bimanual palpation. He teaches that mothers may often be able to cure hernias, both umbilical and inguinal, in children by promptly taking up the treatment of them as soon as noticed, bringing the edges of the hernial opening together by bandages and then preventing the reopening of the hernia by prohibiting wrestling and loud crying and violent motion. He has seen overgrowth of the mamma in men, and declares that it is due to nothing else but fat, as a rule. He suggests if it should hang down and be in the way on account of its size it should be extirpated. He seems to have known considerable about the lipomas and advises that they need only be removed in case they become bothersomely large. The removal is easy, and any bleeding that takes place may be stopped by means of the cautery. He divides rectal fistulæ into penetrating and non-penetrating, and suggests salves for the non-penetrating and the actual cautery for those that penetrate. He warns against the possibility of producing incontinence by the incision of deep fistulæ, for this would leave the patient in a worse state than before.
Bruno brought up with him the methods and principles of surgery from the south of Italy, but there seems to have been already in the north at least one distinguished surgeon who had made his mark. This was Ugo da Lucca or Ugo Luccanus, sometimes known in the modern times in German histories of medicine as Hugo da Lucca and in English, Hugh of Lucca. He flourished early in the thirteenth century. In 1214 he was called to Bologna to become the city physician, and joined the Bolognese volunteers in the crusade in 1218, being present at thesiege of Damietta. He returned to Bologna in 1221 and was given the post of legal physician to the city. The civic statutes of Bologna are, according to Gurlt, the oldest monument of legal medicine in the Middle Ages. Ugo died not long after the middle of the century, and is said to have been nearly one hundred years old. Of his five sons, three became physicians. The most celebrated of these was Theodoric, who wrote a text-book of surgery in which are set down the traditions of surgery that had been practised in his father's life. Theodoric is especially enthusiastic in praise of his father, because he succeeded in bringing about such perfect healing of wounds with only wine and water and the ligature and without the employment of any ointments.
Ugo seems to have occupied himself much with chemistry. To him we owe a series of discoveries with regard to anodyne and anæsthetizing drugs. He is said to have been the first who taught the sublimation of arsenic. Unfortunately he left no writings after him, and all that we know of him we owe to the filial devotion of his son Theodoric.
This son, after having completed his medical studies at the age of about twenty-three, entered the Dominican Order, then only recently established, but continued his practice of medicine undisturbed. His ecclesiastical preferment was rapid. He attracted the attention of the Bishop of Valencia, and became his chaplain in Rome. At the age of about fifty he was madea bishop in South Italy and later transferred to the Bishopric of Cervia, not far from Ravenna. Most of his life seems to have been passed in Bologna however, and he continued to practise medicine, devoting his fees, however, entirely to charity. His text-book of surgery was written about 1266 and is signed with his full name and title as Bishop of Cervia. Even at this time however, he still retained the custom of designating himself as a member of the Dominican Order.
The most interesting thing in the first book of his surgery is undoubtedly his declaration that all wounds should be treated only with wine and bandaging. Wine he insists on as the best possible dressing for wounds. It was the most readily available antiseptic that they had at that time, and undoubtedly both his father's recommendation of it and his own favorable experience with it were due to this quality. It must have acted as an excellent inhibitive agent of many of the simple forms of pus formation. At the conclusion of this first book he emphasizes that it is extremely important for the healing of wounds that the patient should have good blood, and this can only be obtained from suitable nutrition. It is essential therefore for the physician to be familiar with the foods which produce good blood in order that his wounded patients may be fed appropriately. He suggests, then, a number of articles of diet which are particularly useful in producing such a favorable state of the tissues as will bring about the rebirth of flesh and the adhesion of wound surfaces. Shortly before he emphasizes the necessity for not injuring nerves, though if nerves havebeen cut they should be brought together as carefully as possible, the wound edges being then approximated.
Probably the most interesting feature for our generation of the great text-books of the surgeons of the medieval universities is the occurrence in them of definite directions for securing union in surgical wounds, at least by first intention and their insistence on keeping wounds clear. The expression union by first intention comes to us from the olden time. They even boasted that the scars left after their incisions were often so small as to be scarcely noticeable. Such expressions of course could only have come from men who had succeeded in solving some of the problems of antisepsis that were solved once more in the generation preceding our own. With regard to their treatment of wounds, Professor Clifford Allbutt says:[19]