Monday, October 21, 2019

Great Surgeons Of The Medieval Universities | Roger, Roland, And The Four Masters

Great Surgeons Of The Medieval Universities | Roger, Roland, And The Four Masters

Great Surgeons Of The Medieval Universities | Roger, Roland, And The Four Masters

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 at the 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 new as 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 external penetrating 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 by contrecoup.

They say that “quite frequently though the percussion comes in the anterior part of the cranium, the cranium is fractured on the opposite part." They even seem to have known of accidents such as we now discuss in connection with the laceration of the middle meningeal artery. They warn surgeons of the possibilities of these cases.

They tell the story of “a youth who had a very small wound made by a thrown stone and there seemed no serious results or bad signs. He died the next day, however. His cranium was opened and a large amount of black blood was found coagulated about his dura mater.”
There are many interesting things said 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 word infect being 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 of burnt wool firmly, and by the ligature of veins and by the cautery.

There are rather interesting discussions of the prognosis 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 should be 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 know about 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 after due 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.

Excerpt From – Old-Time Makers Of Medicine By James Joseph Walsh