If there was difficulty in bringing about the reposition of the intestines, they were first to be pressed back with a sponge soaked in warm wine. Other manipulations are suggested, and if necessary the wound must be enlarged. If the omentum finds its way out of the wound, all of it that is black or green must be cut off. In cases where the intestines are wounded they are to be sewed with a small needle and a silk thread, and care is to be exercised in bringing about complete closure of the wound. This much will give a good idea of Bruno’s thoroughness. Altogether, Gurlt, in his “History of Surgery,” gives about fifteen large octavo pages of rather small type to a brief compendium of Bruno’s teachings.
One or two other remarks of Bruno are rather interesting in the light of modern development 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.
The most interesting feature of the work of the North Italian surgeons of the later Middle Ages is their discovery and development of the two special advances of our modern surgery in which we are inclined to take most pride. These are, union by first intention, and anæsthesia. It is of course very startling to think that surgeons of seven centuries ago should have made advances in these important phases of surgery—which were afterwards to be forgotten; but human history is not a story of constant progress, but of ups and downs, and the mystery of human history is the decadence that almost inevitably follows any period of supremely great accomplishment by mankind. The later Middle Age enjoyed a particularly great period of efflorescence and achievement in surgery, and this, quite as with literature and other phases of human accomplishment, was followed by distinct descent of interest in surgical theory, and decadence in surgical practice, until the Renaissance came to provide another climax of surgical development. It would be perilous to say, however, that the acme of the curve of Renaissance surgical progress was higher than its predecessor, though once more there is the surprise to find that this high point was followed by another descent, until the curve ascended again in our time.
What we have said already with regard to the requirement of cleanliness in operating upon the skull, insisted upon by the Salernitan School, will suggest that some of the practical value of asepsis had come home to these old-time surgeons. The North Italian surgeons went, however, much farther in their anticipations of asepsis. They insisted that if a surgeon made a wound through an unbroken surface and did not secure union by first intention, it was usually his own fault.
It is to them we owe the expression “union by first intention”—unio per primam intentionem—which means nothing to us except through its Latin equivalent. They boasted of getting linear cicatrices which could scarcely be seen, and evidently their practice fostered the best of surgical technique and was founded on excellent principles. The North Italian surgeons replaced the use of ointments by wine, and evidently realized its cleansing—that is, antiseptic—quality. What is often not realized is, that the very old traditional treatment of wounds by the pouring of wine and oil into them represented a mild antiseptic and a soothing protective dressing. The wine inhibited the growth of ordinary germs, the oil protected the wound from dust and dirt. They were not ideal materials for the purpose, but they were much better when discreetly used than many surgical dressings of much more modern times founded on elaborate theories.
Professor Clifford Allbutt, reviewing the practice of these North Italian surgeons of the thirteenth century, says:[9]
“They washed the wound with wine, scrupulously removing every foreign particle; then they brought the edges together, not allowing wine nor anything else to remain within—dry adhesive surfaces were their desire. Nature, they said, produces the means of union in a viscous exudation—or natural balm, as it was afterwards called by Paracelsus, Paré, and Wurtz. In older wounds they did their best to obtain union by cleansing, desiccation, and refreshing of the edges. Upon the outer surface they laid only lint steeped in wine. Powder they regarded as too desiccating, for powder shuts in decomposing matters; wine, after washing, purifying, and drying the raw surfaces, evaporates.”
Theodoric wrote in 1266 on that question that so much disturbed the surgeons of the generations before ours, as to whether pus was a natural development in the healing of wounds or not. While laudable pus was for centuries after his time supposedly a scientific doctrine, Theodoric did not think so, and emphatically insisted that such teaching represented a great error. He said: “For it is not necessary, as Roger and Roland have written, as many of their disciples teach, and as all modern surgeons profess, that pus should be generated in wounds. No error can be greater than this. Such a practice is indeed to hinder nature, to prolong the disease, and to prevent the conglutination and consolidation of the wound.” The italics in the word modern are mine, but the whole expression might well have been used by some early advocate of antisepsis, or even by Lord Lister himself. Just six centuries almost to the year would separate the two declarations, yet they would be just as true at one time as at another. When we learn that Theodoric was proud of the beautiful cicatrices which his father had obtained without the use of any ointment—pulcherrimas cicatrices sine unguento inducebat—then, further, that he impugned the use of poultices and of oils in wounds, while powders were too drying, and besides had a tendency to prevent drainage (the literal meaning of the Latin words he employs, saniem incarcerare, is to “incarcerate sanious material”), it is easy to understand that the claim that antiseptic surgery was anticipated six centuries ago is no exaggeration and no far-fetched explanation, with modern ideas in mind, of certain clever modes of dressing hit upon accidentally by medieval surgeons.
After Bruno, who brought with him the methods and principles of surgery from the South of Italy, his contemporary of the North, Hugh of Lucca—Ugo da Lucca, or Luccanus, as he is also called—deserves to be mentioned. He was called to Bologna in 1214 as City Physician, and was with the regiment of crusaders from Bologna at Damietta in 1220. He returned to Bologna in 1221 and occupied the post of legal physician. The Civic Statutes of Bologna are, according to Gurlt, the oldest monument of legal medicine in the Middle Ages. Hugh seems to have been deeply intent on chemical experiments, and especially anodyne and anæsthetic drugs. He is said to have been the first to have taught the sublimation of arsenic. Like many another distinguished practitioner of medicine and surgery, he left no writings. All that we know of him and his work, and above all his technique, we owe to the filial devotion of his son Theodoric.
Anæsthesia is perhaps an even greater surprise in the Middle Ages than practical antisepsis. A great many of these surgeons of the time seem to have experimented with substances that might produce anæsthesia. Mandragora was the base of most of these anæsthetics, though a combination with opium seems to have been a favourite. They succeeded apparently, even with such crude means, in producing insensibility to pain without very serious dangers. One of these methods of Da Lucca was by inhalation, and seems to have been in use for a full century. Guy de Chauliac describes the method as it was used in his day, and a paragraph with regard to it will be found in the chapter on Surgeons of the West of Europe. It is quite clear that the extensive operations which are described in their textbooks of surgery at this time could not possibly have been performed, only that the surgeons were able to secure rather a deep and prolonged insensibility to pain. With anæsthesia combined with antisepsis, it is easy to understand how well equipped the surgeons of this time were for the development of their speciality.