His directions for the treatment of conditions in the mouth and nose apart from the teeth are quite as explicit and practical, and in many ways quite as great an anticipation of some of our modern notions as what he has to say with regard to the teeth. 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 a fine scissors, or with a narrow file just small enough to permit its 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 hemorrhage, or if there is fear of it, the instruments with which dissection 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 in aqua 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 all these 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 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 (Æginetus), 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.
There is scarcely an important disease for which Arculanus has not some interesting suggestions, and the more one reads of him the more is one surprised to find how many things that we might think of as coming into the purview of medicine long after his time or at least as having been neglected from the time of the Greeks almost down to our own time are here treated explicitly, definitely, and with excellent practical suggestions. He has a good deal to say with regard to the treatment of angina, which he calls synanche, or synanchia, or cynanche, or angina. Parasynanche is a synonymous term, but refers to a milder synanche. He distinguished four forms of it. In one called canine angina, because the patient's tongue hangs out of his mouth, somewhat the same as from an overheated dog in the summer time, while at the same time the mouth is held open and he draws his breath pantingly, Arculanus suggests an unfavorable prognosis, and would seem to refer to those cases of Ludwig's angina in which there is involvement of the tongue and in which our prognosis continues to be of the very worst even to our own day. At times the angina causes such swelling in the throat that the breathing is interfered with completely. For this Arculanus' master, Rhazes, advised tracheotomy. Arculanus himself, however, apparently hesitated about that.
It is not surprising, then, to find that Arculanus is very explicit in his treatment of affections of the uvula. He divides its affections into apostema, ulcus, putredo sive corrosio, et casus. Apostema was abscess, ulcus any rather deep erosion, putredo a gangrenous condition, and casus the fall of the uvula. This is the notorious falling of the soft palate which has always been in popular medical literature at least. Arculanus describes it as a preternatural elongation of the uvula which sometimes goes to such an extent as to make it resemble the tail of a mouse. For shorter elongations he suggests the cautery; for longer, excision followed by the cautery so that the greater portion of the extending part may be cut off. If people fear the knife he suggests following Rhazes, the application of an astringent powder directly to the part by blowing through a tube. His directions for the removal of the uvula are very definite. 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 of a sound may be of service in patients who refuse the actual cautery. To be successful the application must be firmly made and must be frequently repeated.
After this it is not surprising to find that Arculanus has very practical chapters on all the other ordinary surgical affections. Empyema is treated very thoroughly, liver abscess, ascites, which he warns must be emptied slowly, ileus especially when it reaches stercoraceous vomiting, and the various difficulties of urination, he divides them into dysuria, ischuria, and stranguria, are all discussed in quite modern fashion. He gives seven causes for difficulty of urination. One, some injury of the bladder; two, some lesion of the urethra; three, some pathological condition in the power to make the bladder contract; four, some injury of the muscle of the neck of the bladder; five, some pathological condition of the urine; six, some kidney trouble, and seven, some pathological condition of the general system. He takes up each one of these and discusses the various phases, causes, disposition, and predispositions that bring them about. One thing these men of the Middle Ages could do, they reasoned logically, they ordered what they had to say well, and they wrote it out straightforwardly.
That Arculanus' work with regard to dentistry was no mere chance and not solely theoretic can be understood very well from his predecessors, and that it formed a link in a continuous tradition which was well preserved we may judge from what is to be found in the writings of his great successor, Giovanni or John de Vigo, who is considered one of the great surgeons of the early Renaissance, and to whom we owe what is probably the earliest treatise on "Gun-shot Wounds." John of Vigo was a Papal physician and surgeon, generally considered one of the most distinguished members of the medical profession of his time. Two features of his writing on dental diseases deserve mention. He insists that abscesses of the gums shall be treated as other abscesses by being encouraged to come to maturity and then being opened. If they do not close promptly, an irritant Egyptian ointment containing verdigris and alum among other things should be applied to them. In the cure of old fistulous tracts near the teeth he employs not only this Egyptian ointment but also arsenic and corrosive sublimate. What he has to say with regard to the filling of the teeth is, however, most important. He says it with extreme brevity, but with the manner of a man thoroughly accustomed to doing it. "By means of a drill or file the putrefied or corroded part of the tooth should be completely removed. The cavity left should then be filled with gold leaf." It is evident that the members of the Papal court, the Cardinals and the Pope himself, had the advantage of rather good dentistry at John de Vigo's hands even as early as the beginning of the sixteenth century.
John de Vigo, however, is not medieval. He lived on into the sixteenth century and was influenced deeply by the Renaissance. He counts among the makers of modern medicine and surgery, as his authorship of the treatise on gun-shot wounds makes clear. He comes in a period that will be treated of in a later volume of this series on "Our Forefathers in Medicine."