Chapter 10 of Old Time Makers of Medicine. This is a LibriVox recording. All LibriVox recordings are in the public domain. For more information or to volunteer, please visit LibriVox.org. Recording by Adam Marsatich, September 2009, Alexandria, Virginia. Old Time Makers of Medicine by James Joseph. Chapter 10. Great Surgeons of the Medieval Universities. Part 1 of 3. 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 postgraduate 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. Only the 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, quote, 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, end quote. 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 13th and 14th 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 13th and 14th 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 textbooks 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 13th 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, whereas 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. A girl in his History of Surgery, Vol. 1, page 701, completely contradicts this idea and says with regard to the first of the great Italian writers on surgery, Rogero, that, quote, though Arabian works on surgery had been brought over to Italy by Constantine Africanus a hundred years before Roger's time, these exercise 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, end quote. 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 at Salerno itself had developed simple, 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 13th and 14th centuries, Salerno must be credited with the incentive that led up to the marvelous development that came. With this, however, Arabian influence has nothing to do. Girl, besides calling attention to the fact that the author of the first great textbook on the subject not only did not draw his inspiration from Arab sources, insisted that, quote, instead of any Arabisms being found in his, Roger's, writings, many Greciisms occur, end quote. The Salernitan School of Surgery drank at the fountainhead 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, quote, 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, end quote. Roger, Roland, and the Four Masters. Ruggero, or Rogero, who is known as Rogerio and Rogerus with the adjective Parmensis, or Salernitanus, or Parma, or of Salerno, and often in German and English history simply as Roger, lived at the end of the 12th or the beginning of the 13th century, and probably wrote his textbook about 1180. The textbook 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 Rincey in his Collectio Salernitana. Roland was a pupil of Rogers, 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 textbook in surgery for a good while in the 13th 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 textbook of surgery written somewhat in the way that we now make textbooks 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. Geralt says, 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 Geralt or from the accounts of their teaching in Darenberg or Derinzy 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 textbook 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 trefine 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 war-like 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 contracoup. They say that, quote, quite frequently, though the percussion comes in the anterior part of the cranium, the cranium is fractured on the opposite part, end quote. They even seem to have known of accidents such as we now discuss in connection with the laceration of the middle menangial artery. They warn surgeons of the possibilities of these cases. They tell the story of, quote, 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 open, and a large amount of black blood was found coagulated about his dura mater, end quote. 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 trefine and an elevating instrument called a spatumin used to relieve the pressure. Great care should be taken, however, 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, porem at pupum at commissarius. Since at these points, the dura mater is likely to be adherent. Perhaps the most striking expression, the word, in fact, being italicized by growth, is, quote, in elevating the cranium, be solicitous lest you should, in fact, or injure the dura mater, end quote. For wounds of the scalp, sutures of silk are recommended because this resists putrefaction of the wound edges together. Interrupted sutures about a finger breath apart are recommended, quote, the lower part of the wound should be left open so that the cure may proceed properly, end quote. Red powder was strewed over the wound and the leaf of a plant set above it. In the lower angle of the wound, a pledgeet of lint for drainage purposes was inlaid. Hemorrhage was prevented by pressure with a binding on of burnt wool firmly and by the ligature of veins and by the cottery. There are rather interesting discussions for the prognosis of wounds of the head, especially such as may be determined from general symptoms in this commentary of the four masters on Rogers and Rolando's treatises. If an acute febrile condition develops, the wound is mortal. If the patient loses the use of the hands or 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 wintertime, 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 expression. 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.  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 the 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, quote, said Hawk Ali-Quando Follett, but this sign sometimes fails, end quote. 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 foremasters 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 of treatment and many fissure fractures require trefination, 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 trefine must be looked upon as, quote, fools and idiots, end quote. Idiotti 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 trefination. For obvious reasons, I prefer to quote it in the Latin, quote, et nota quad di ilia, cavendum est medico, a coito et malas sibis, aria corem ptebus, utsunt alia, sepe et fujos mode, et colloquio muleris, menstruose et manis eges debent ese mondae, et cetera, end quote. My quotation is from GERLT, Volume 1, page 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 contraindications 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 careful precautions and considerable self-denial, indeed this whole subject, the virtual anticipation of our 19th century principles of aseptic surgery in the 13th century is not a dream, nor a far-fetched explanation when one knows enough about the directions that were laid down in the surgical textbooks of that time. The North Italian Surgeons After Roger and Rolando, the Four Masters, who owe the inspiration for their work to Celerno and the south of Italy, comes a group of North Italian surgeons, Bruno da Loganburgo, usually called simply Bruno, Theodoric and his father, Hugo of Lutza, and William of Salisette. Immediately following them came two names that belong, one almost feels, to a more modern period. Mondino, the author of the first textbook on dissection, and Laune Franck, the disciple of William of Salisette, who taught at Paris and, quote, gave that primacy to French surgery which had maintained all the centuries down to the 19th, end quote, Pagel. It might very well be thought that this group of 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 down to us to show how utterly false any such opinion is. To Hugo da Lutza, and his son Theodoric, we owe the introduction and the gradual bringing into practical use of various methods of anesthesia. 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 it must be attributed most of their surprising success as surgeons at this early date. We are so accustomed to think that anesthesia was discovered about the middle of the 19th century in America that we forget that literature is full of references in Tom Middleton's 17th century phrase to quote, the mercies of old surgeons who put their patients to sleep before they cut them, end quote. Anesthetics were experimented with almost as zealously during the latter half of the 13th century at least, as during the latter half of the 19th 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 Delucas particularly had invented a method that left very little to be desired in this matter of anesthesia. A reference to the sketch of Guy Descholiac in this volume will show how practical the method was in his time. Nearly the same story as with regard to anesthetics has to be repeated for what are deemed so surely modern developments, asepsis and antisepsis. I have 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 Salisette. Professor Clifford Abbott 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 addressing. 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 13th century will make clear 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 in the 10th century Bologna, Reggio and Modena came into existence toward the end of the 12th century. Viquenza, Padua, Naples, Vercelli and Piacenza as well as Arezzo during the first half of the 13th century. Rome, Perugia, Treviso, Pisa, Florence, Siena, Luzza, Pavia and Ferrara during the next century. The 13th century was the special flourishing period of the universities and the medical departments far from being behind were leaders in accomplishment. See my The 13th Greatest of Centuries New York 1908 End of Part 1 of 3 Chapter 10 of Old Time Makers of Medicine This is a LibriVox recording All LibriVox recordings are in the public domain. For more information or to volunteer please visit LibriVox.org Recording by Adam Marsatich September 2009 Alexandria, Virginia Old Time Makers of Medicine by James Joseph Chapter 10 Great Surgeons of the Medieval Universities Part 2 of 3 Bruno da Longo Bergo The first of this important group of North Italian surgeons who taught at these universities Bruno of Longo Bergo While he was born in Calabria and probably studied in Salerno, his work was done at Via Senza, Padua and Verona. His textbook, the Surgeria Magna dedicated to his friend Andrew of Pia Senza was completed at Padua in January 1252. Girl notes that he is the first of the Italian surgeons 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. Girl 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, surgery tracing it to the Greek and emphasizing that it means handwork. Then he 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 quote, to bring together separated parts, to separate those that have become abnormally united and to extirpate what is superfluous, end quote. 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 because putrefactio est major in estete quam in haime 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 deep wounds 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 open 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 sawed in camps and on the field 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 momentum 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 cares to be exercised in bringing about complete closure of the wound. This much will give a good idea of Bruno's thoroughness. Altogether girl in his history of surgery gives about 15 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 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 herniol 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 caudary. He divides rectal fistulae into penetrating and non-penetrating and suggests salves for the non-penetrating for those that penetrate. He warns against the possibility of producing incontinence by the incision of deep fistulae for this would leave the patient in a worse state than before. Hue of Lutsa 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. He was Hugo de Lutsa or Hugo Lutsanus sometimes known in the modern times in German histories of medicine as Hugo de Lutsa and in English Hue of Lutsa. He flourished early in the 13th century. In 1214 he was called to Bologna to become the city physician and join the Bolognese volunteers in the crusade in 1218 being present at the siege of Dometa. He returned to Bologna in 1221 and was given the post of legal physician to the city. The civic statues of Bologna are, according to girl the oldest monument of legal medicine in the middle ages. Hugo died not long after the middle of the century and is said to have been nearly 100 years old. 3 became physicians. The most celebrated of these was Theodoric who wrote a textbook of surgery in which are set down the traditions of surgery that had been practiced 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 of employment of any ointments. Hugo seems to have occupied himself much with chemistry. To him we owe a series of discoveries with regard to anodyne and anesthetizing 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 23 entered the Dominican order then only recently established but continued his practice of medicine undisturbed. His ecclesiastical preferment was rapid. He attracted the attrition of the bishop of Valencia and became his chaplain in Rome. At the age of about 50 he was made a bishop in South Italy and later transferred to the bishopric of Servia not far from Ravenna. Most of his life seems to have been passed in Bologna however and he continued to practice medicine devoting his fees however entirely to charity. His textbook of surgery was written about 1266 and is signed with his full name as Bishop of Servia. 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 that 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 have been 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 textbooks 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. These 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 proceeding our own. With regard to their treatment of wounds Professor Clifford Albut says quote 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, pare and warts. 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 powders they regarded as too desiccating for powder shuts in decomposing matters wine after washing purifying and drying the raw surfaces evaporates end quote. Theodoric comes nearest to us of all these old surgeons the surgeon who in 1266 wrote quote for it is not necessary as Roger and Rowland 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 end quote. There's more than half a millennium ahead of his time. The italics in the word modern are mine but 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 sacrifices which he obtained without the use of any ointment Pulcheramus Cicatrisis Cine Unguento Alicuo Indusibat then further that he impugned the use of poultices and of oils on wounds while powders were too drying and besides had a tendency to prevent drainage the literal meaning of the Latin words Sonium is to incarcerate sonius 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 Theodoric's treatment of many practical problems is very interesting for the modern time for instance in his discussion of cancer he says that there are two forms of the affection one of them is due to a melancholy humor a constitutional tendency as it were and occurs especially in the breasts of women or latent in the womb this is difficult of treatment and usually fatal the other class consists of temperament edges occurring particularly on the legs difficult to cure and ready of relapse but for which the outlook is not so bad his description of Nole Me Tungere and of Lupus is rather practical Lupus is quote eating herpes occurs mainly on the nose or around the mouth slowly increases and either follows a preceding ericipolus or comes from some internal cause Nole Me Tungere is a corroding ulcer so called perhaps because irritation of it causes it to spread more rapidly he thinks that deep cauterization is the best treatment since these are in the department of skin diseases this seems to place the mention described salivation as occurring after the use of mercury for certain skin diseases he has already shown that he knows of certain genital ulcers and sores on the genital regions and of distinctions between them William of Salisette the third of the great surgeons in northern Italy was William of Salisette he was a pupil of Bruno's and the master of Lan Franck the first part of his life was passed at Bologna and the latter part as the municipal and hospital physician of Verona he probably died about 1280 he was a physician as well as a surgeon and was one of those who insisted that the two modes of practicing medicine should not be separated or if they were both medicine and surgery would suffer he thought that the physician learned much by seeing the interior of the body during life while the surgeon was more conservative if he were a physician it is curiously interesting to find that the regius professors at both Oxford and Cambridge in our time have expressed themselves somewhat similarly Professor Clifford Albut is quite emphatic in this matter and Professor Ulcer is on record to the same effect following Theodoric William of Salisette did much to get away from the Arabic abuse of the caudary and brought the knife back to its proper place again as the ideal surgical instrument unlike those who had written before him William quoted very little from preceding writers whenever he quotes his contemporaries it is in order to criticize them he depended on his own experience and considered that it was only what he had actually learned from experience that he should publish for the benefit of others a very good idea of the sort of surgery that William of Salisette practiced may be obtained even from the beginning of the first chapter of his first book this is all with regard to surgery of the head he begins with the treatment of hydrocephalus or as he calls it water collected in the heads of children newly born he rejects opening of the head by an incision because of the danger of it in a number of cases however he had had success by puncturing the scalp and membranes with a caudary though but a very small opening was made and the fluid was allowed to escape only drop by drop he then takes up eye diseases a department of surgery rather well developed at that time as can be seen from our account of the work of Pope John 21 as an ophthalmologist during the 13th century C. Ophthalmology January 1909 reprinted in Catholic Churchmen in Science Philadelphia The Dolphin Press January 1909 William devotes six chapters to the diseases of the eyes and the eyelids then there are two chapters on the affections of the ears foreign bodies and an accumulation of earwax are removed by means of instruments a polyp is either cut off or it's pedicle bound with a ligature and it is allowed to shrivel the next chapter is on the nose then it is grasped with a sharp tenaculum cum tenacillus acutus and either wholly or partially extracted ranula was treated by being lifted well forward by means of a sharp iron hook and then split with a razor it is evident that the tendency of these to fill up again was recognized and accordingly it was recommended be placed in the cavity for a time after evacuation in order to produce adhesive inflammation in the same chapter on the mouth one finds that William did not hesitate to perform what cannot but be considered rather extensive operations within the oral cavity for instance he tells of removing a large epulus and gives an account in detail of the case to quote his own words quote I cured a certain woman from Piacenza who is suffering from fleshy tumor on the gums of the upper jaw the tumor having grown to such a size above the teeth and the gums that it was as large or perhaps larger than a hen's egg I removed it at four operations by means of heated iron instruments at the last operation I removed the teeth that were loose with certain parts of the jawbone in the next chapter there is an account of the treatment of a remarkable case of abscesses of the uvula in the following chapter the swelling of cervical glands is taken up in his experience expectant treatment of these was the best he advises internal medication with the building up of the general health allowing the inflamed glands to empty themselves after postulation after much meddlesome surgery we are almost back to his methods again he did not hesitate to treat goiter surgically though he considered there were certain internal remedies that would benefit it in obstinate cases he suggests the complete extirpation of cystic goiter but if the sac is allowed to remain it should be thoroughly rubbed over on the inside with green ointment he warns about the necessity for avoiding the veins and arteries in this operation and says that in this affection many large veins make their appearance and they find their way everywhere through the fleshy mass end quote what I have given here is to be found in a little more girl's abstract of the first 20 chapters of Salisette's first book altogether girl has more than 10 pages of rather small print with regard to William most of it is as interesting and as practical and as representative of anticipations of what is done in the modern time as what I have here quoted William as I have said depended much more upon his own observations than upon what was to be found in textbooks he knew the old textbooks very well however but as a rule did not quote from them unless he had tried the recommendations for himself or in less similar cases to these mentioned had come under his own observation he was evidently a thoroughly observant physician a skilled surgeon who is practical enough to see the simplest way of doing things and he proceeded to do them it is no wonder that he influenced succeeding generations so much nor that his great pupil Lanfranc continuing his tradition founded a school of surgery in Paris the influence of which was to endure almost down to our time and give France a primacy in surgery until the 19th century Lanfranc in Sallisette's lifetime the focus of interest in surgery changes from Italy to France and what is still more complimentary to William it is through a favorite disciple of his that the change takes place this was Lanfranc or Lanfranco sometimes spoken of as Alan Francus who practiced as a physician and surgeon in Milan at the time Matteo Visconti about 1290 he then went to Lyons where in the course of his practice he attracted so much attention that he was offered the opportunity to teach surgery in Paris he attracted what girls calls an almost incredible number of scholars to his lessons in Paris and by hundreds they accompanied him to the bedside of his patients and attended his operations the dean of the medical faculty John de Passivand urged him to write a textbook of surgery not only for the benefit of his students at Paris, but for the sake of the prestige which this would confer on the medical school deans still urged the same reasons for writing Lanfranc completed his surgery called surgery a magna in 1296 he handed it to Philippe Lebel then the reigning French king ten years later he died, but in the meantime he had transferred Italian prestige in surgery from Italy to France and laid the foundations in Paris of a thoroughly scientific as well as a practical surgery though this department of the medical school had been in a sadly backward state when he came in the second chapter of his textbook the first containing the definition of surgery in general introduction Lanfranc describes the qualities that in his opinion a surgeon should possess he says it is necessary that a surgeon should have a temperate and moderate disposition that he should have well-formed hands long slender fingers a strong body not inclined to tremble not trained to the capable fulfillment of the wishes of his mind he should be of deep intelligence and of a simple, humble, brave but not audacious disposition he should be well-grounded in natural science and should know not only medicine but every part of philosophy should know logic well so as to be understand what is written to talk properly and to support what he has to say and quote he suggests that it would be well for the surgeon to have spent some time teaching grammar and dialectics and rhetoric especially if he is to teach others in surgery for this practice will add greatly to his teaching power some of his expressions might be well repeated to young surgeons in the modern time the surgeon should not love difficult cases and should not allow himself to be tempted to undertake those that are desperate he should help the poor as far as he can but he should not hesitate to ask for good fees from the rich end quote many generations since Lonfrank's time have used the word nerves for tendons Lonfrank, however made no such mistake he says that the wounds of nerves since the nerve is an instrument of sense and motion are on account of the greater sensitiveness which these structures possess likely to involve much pain wounds along the length of the nerves are less dangerous than those across them when a nerve is completely divided by a cross wound Lonfrank is of the opinion though theodoric and some others are opposed to it that the nerve ends should be stitched together he says that this suture ensures the re-dintegration of the nerve much better after this operation the restoration of the usefulness of the member is more complete and assured his description of the treatment of the bite of a rabid dog is interesting a large cupping glass should be applied over the wound so as to draw out as much blood after this the wound should be dilated and thoroughly cauterized to its depths with a hot iron it should then be covered with various substances that were supposed to draw in order as far as possible to remove the poison his descriptions of how one may recognize a rabid animal is rather striking in the light of our present knowledge for he seems to have realized that the main diagnostic element is a change in the disposition of the animal but above all a definite tendency to lack playfulness Lanfranc had seen a number of cases of true rabies and describes and suggests treatment for them though evidently without very much confidence in the success of the treatment the treatment of snake bites and the bites of other poisonous animals was supposed to follow the principles laid down of a mad dog especially as regards the encouragement of free bleeding and the use of the cottery Lanfranc has many other expressions that one is tempted to quote because they show a thinking surgeon of the old time anticipating many supposedly modern ideas and conclusions he is a particular favorite of girls who has more than 25 large octavo closely printed pages with regard to him there is scarcely any development in our modern surgery that Lanfranc has not at least a hint of certainly nothing in the surgery of a generation ago that does not find a mention in his book on most subjects he has practical observations from his own experience to add to what was in surgical literature before his time he quotes all together more than a score of writers on surgery who had preceded him and evidently was thoroughly familiar with general surgical literature there is scarcely an important surgical topic on which girl does not find some interesting and personal remarks made by Lanfranc all that we can do here is refer those who are interested in Lanfranc to his own works or girls end of part two of three chapter ten of old time makers of medicine this is a LibriVox recording all LibriVox recordings are in the public domain for more information or to volunteer please visit LibriVox.org recording by Adam Marsatich September 2009 Alexandria, Virginia old time makers of medicine by James Joseph chapter ten great surgeons of the medieval universities chapter ten great surgeons of the medieval universities part three of three Mondeville the next of the important surgeons who were to bring such distinction to French surgery for five centuries was Henri de Mondeville writers usually quote him as Henriques his latter name is the only place of his birth which was probably not far from Cain in Normandy it is spelled in so many different ways however by different writers that it is well to realize that almost anything that looks like Mondeville probably refers to him such variants as Mondeville Hermondeville Almondeville Almondeville Mondeville Armandoville Armandoville Amandaviya occur we owe large amount of our information with regard to him to Professor Pagel who issued the first edition of his book ever published Berlin 1892 it may seem surprising that Mondeville's work should have been left thus long without publication but unfortunately he could not live long enough to finish it he was one of the last victims that tuberculosis claimed among physicians in the midst of their work though there are a great number of manuscript copies of his book somehow renaissance interest in it in its incompleted state was never aroused sufficiently to bring about a printed edition certainly it was not because of any lack of interest on the part of his contemporaries or any lack of significance in the work itself for its printing has been one of the surprises afforded us in the modern time as showing how thoroughly a great writer on surgery did his work at the beginning of the 14th century girl in his history of surgery has given over 40 pages much of its small type with regard to Mondeville because of the special interest there is in his writing his life is of particular interest for other reasons besides his subsequent success as a surgeon he was another of the university men of this time who wandered far for opportunities in education though born in the north of France and receiving his preliminary education there he made his medical studies toward the end of the 13th century under theodoric in Italy he studied medicine in Montpelier and surgery in Paris later he gave at least one course of lectures at Montpelier himself and a series of lectures in Paris attracting to both universities during his professorship a crowd of students from every part of Europe one of his teachers at Paris had been his compatriot Jean-Petard the surgeon of Philippe Lebel of whom he speaks as quote most skillful and expert in the art of surgery end quote and it was doubtless to Petard's friendship that he owed his appointment as one of the four surgeons and three physicians who accompanied the king into Flanders besides his lectures Mondeville had a large consultant practice and also had to accompany the king on his campaigns this made it extremely difficult for him to keep continuously at the writing of his book he was delayed in spite of his good intentions and we have the picture that is so familiar in the modern time of a busy man trying to steal or make time for his writing unfortunately in addition to other obstacles Mondeville showed probably before he was 40 the first symptoms of a serious pulmonary disease presumably tuberculosis he bravely fought it and went on with his work as his end approached he sketched in lightly what he had hoped to treat much more formally and then turned to what was to have been the last chapter of his book the antidotarium or suggestions of practical remedies against diseases of various kinds because his students and physician friends were urging him to complete this portion for them we of the modern time are much less interested in that then we would have been in some of the portions of the work that Mondeville neglected in order to provide therapeutic hints for his disciples but then the students and young physicians have always clamored for the practical which so far at least in medical history has always proved of only passing interest it is often said that at this time surgery was mainly in the hands of barbers and the ignorant Henry D. Mondeville however is a striking example in contradiction of this he must have had a fine preliminary education and his book shows very wide reading there is almost no one of any importance who seriously touched upon medicine before his time whom Mondeville does not quote Hippocrates, Aristotle Discordes, Pliny, Galen Roses, Ali Abbas Abulqueses Avicenna, Constantine Africanus Averroes, Maimonides Albertus Magnus Hugo of Luzza Theodoric William of Salisette Lanfrank are all quoted and not once or twice but many times besides he has quotations from poets and philosophers Cato, Diogenes Horace, Ovid Plato, Seneca, and others he was a learned man devoting himself to surgery it is no wonder then that he thought that a surgeon should be a scholar and that he needed to know much more than a physician one of his characteristic passages is that in which he declares quote it is impossible that a surgeon should be expert who does not know not only the principles but everything worthwhile knowing about medicine end quote and then he added quote just as it is impossible for a man to be a good physician who is entirely ignorant of the art of surgery end quote as further quote this our art of surgery which is the third part of medicine the other two parts were diet and drugs is with all due reverence to physicians considered by us surgeons ourselves and by the non-medical as a more certain nobler, secureer more perfect, more necessary and more lucrative art than the other parts of medicine surgeons have always been prone to glory in their specialty Mondeville had a high idea of the training that a surgeon should possess he says, quote a surgeon who wishes to operate regularly ought first for a long time to frequent places in which skilled surgeons operate often and he ought to pay careful attention to their operations and commit their technique to memory then he ought to associate himself with them in doing operations a man cannot be a good surgeon unless he knows both the art and science of medicine and especially anatomy the characteristics of a good surgeon are that he should be moderately bold not given to disputations before those who do not know medicine operate with foresight and wisdom not beginning dangerous operations Mondeville he has provided himself with everything necessary for lessening the danger he should have well shaped members especially hands with long slender fingers mobile and not tremulous and with all his members strong and healthy so that he may perform all the good operations without disturbance of mind he must be highly moral should care for the poor for God's sake he needs himself well paid by the rich should comfort his patients by pleasant discourse and should always accede to their requests if these do not interfere with the cure of the disease it follows from this he says that the perfect surgeon is more than the perfect physician and that while he must know medicine he must in addition know his handicraft end quote and thus it is no wonder that he places his book under his noble patronage is possible he says in the preface that he quote began to write it for the honor and praise of Jesus Christ of the Virgin Mary of the saints and martyrs Cosmos and Damien and of King Philip of France as well as his four children and on the proposal and request distinguished professor in the science of medicine and formally physician to Pope Boniface IV and Benedict and Clement the present pope end quote his first book on anatomy he proposed to found on that of Avicenna and quote on his personal experience as he has seen it end quote the second tractate on treatments of wounds contusions was founded on the second book of Theodoric quote with whatever by recent study has been newly acquired and brought to light through the experience of modern physicians end quote he then confesses his obligations to his great master John Ptard and adds that all the experience that he has gained while operating studying and lecturing for many years on surgery will be made use of in order to enhance the value of the work he hopes however to accomplish all this quote briefly quietly and above all charitably end quote there are many things in the preface that show us the reason for Mondeville's popularity for they exhibit him as very sympathetically human in his interests while Mondeville is devoted to the principle that authority is of great value he says that there was nothing perfect in things human and successive generations of younger men often made important additions to what their ancestors had left them while his work is largely a compilation nearly everywhere it shows signs of the modification of his predecessors opinions by the results of his own experience his method of writing is as Pagel declares quote always interesting lively and often full of meat end quote he had a teacher's instinct for in several of the earlier manuscripts his special teaching is put in larger letters in order to attract students attention he seems to have introduced or reintroduced into practice the idea of the use of a large magnet in order to extract portions of iron from the tissues he made several modifications in needles and thread holders and invented a kind of small derrick for the extraction of arrows with barbs besides he suggested the surrounding of the barbs of the arrows with tubes to facilitate extraction in his treatment of wounds Pagel considers that he has a writer and teacher he is far ahead of his predecessors and even of those who came after him in immediately subsequent generations one of his great merits undoubtedly is that Guy Descholiac the father of modern surgery in his textbook turned to him with a confidence that proclaims his admiration and how much he felt that he had gained from him one of the most interesting features of Mondaville's work is his insistence on the influence of the mind on the body and the importance of using this influence to the best advantage it is especially important in Mondaville's opinion to keep a surgical patient from being moody quote, let the surgeon says he take care to regulate the whole regimen of the patient's life and happiness by promising that he will soon be well by allowing his relatives and special friends to cheer him and by having someone to tell him jokes let him be solist also by music on the viol or sultry the surgeon must forbid anger hatred and sadness in the patient and remind him that the body grows fat from joy and thin from sadness he must insist on the patient obeying him faithfully in all things end quote he repeats with approval the expression of avicenna that quote often the confidence of the patient in his physician does more for the cure of his disease than the physician with all his remedies end quote obstinate and conceded patients prone to object to nearly everything that the surgeon wants to do and who often seem to think that they surpass Galen and Hippocrates in science and wisdom are likely to delay their cure very much and they represent the cases with which the surgeon has much difficulty Mondeville thought that nursing was extremely important and that without it surgery often failed of its purpose he says quote for if the assistants are not solicitous and faithful and obedient to the surgeons in each and everything which may make for the cure of the disease they put obstacles and difficulties in the way of the surgeon end quote it is especially important that the patient's nutrition should be cared for and that the bandages should be managed exactly as the surgeon directs he has no use for garylis talkative nurses that sometimes near relatives are particularly likely to disturb patients quote especially are they prone to let drop some hint of bad news which the surgeon may have revealed to them in secret or even the reports that they may hear from others friends or enemies and this provokes the patient to anger or anxiety and is likely to give him fever if the assistants quarrel among themselves or are heard murmuring or if they draw long faces all of these things will disturb the patients and produce worry and anxiety or fear the surgeon therefore must be careful in the selection of his nurses for some of them obey very well while he is present but do as they like and often just exactly the opposite of what he has directed is a way we do not know enough of the details of mondaville's life to be sure whether he was married or not it is probable that he was not for all of these surgeons of the 13th century before mondaville's time theodoric, william of salicet launfrank and guy decholiac after him belong to the clerical order theodoric was a bishop the others however seem only to have been in minor orders it is therefore from the standpoint of a man who views married life from without that mondaville makes his remarks as to the difficulty often encountered when wives nurse their husbands he says that the surgeon has difficulty oftener when husbands or wives care for their spouses than at other times this is much more likely to take place when the wives are caring for the husbands quote in our days, he says in this galican part of the world wives rule their husbands and the men for the most part permit themselves to be ruled whatever a surgeon may order for the cure of a husband will then often seem to the wives to be a waste of good material though the men seem to be quite willing to get anything that may be ordered for the cure of their wives the whole cause of this seems to be that every woman seems to think that her husband is not as good as those of other women whom she sees around her end quote it would be interesting to know how mondaville was brought to a conclusion so different from modern experience in the matter we are particularly interested in medical history one of the sections of henry's book has a special appeal because he gives in it a sketch of the history of surgery we are likely to think as a rule that at this time full two centuries before the close of the middle ages men were interested enough in the doings of those who had gone before them to try to trace the history of the development of their specialty it is characteristic of the way that the scholarly mondaville views his own life work that he should have wanted to know something about his predecessors and teach others with regard to them he begins with galen and as galen divides the famous physicians of the world into three sex the methodists the empirics so mondaville divides modern surgery into three sex first that of salernitins with roger, roland and the four masters second that of william of salisette and lonfranc and third that of hugo de lutsa and his brother theodoric and their modern disciples he states briefly the characteristics of these three sex the first limited patients diet used no stimulants dilated all wounds and got union only after pus formation the second allowed a liberal diet to weak patients though not to the strong but generally interfered with wounds too much the third believed in a liberal diet, never dilated wounds never inserted tense and its members were extremely careful not to complicate wounds of the head by unwise interference his critical discussion of the three schools is extremely interesting another phase of mondaville's work that is sympathetic to the moderns in his discussion of the irregular practice of medicine and surgery as it existed in his time most of our modern medicine and surgery was anticipated in the olden time maybe said that all of the modes of the quack are as old as humanity galen's description of the traveling charlatan who settled down in his front yard not knowing that it belonged to a physician shows this very well there were evidently as many of them and as many different kinds in mondaville's time as in our own in discussing the opposition that had arisen between physicians and surgeons in his time and their failure to realize that they were both members of a great profession he enumerates the many different kinds of opponents that the medical profession had there were quote barbers, soothsayers, loan agents falsifiers alchemists meterases midwives, old women converted jews and indeed most of those who having wasted their substance foolishly now proceed to make physicians or surgeons of themselves in order to make their living under the cloak of healing end quote what surprises however as it has always surprised every physician who knows the situation is that so many educated or at least supposedly well informed people of the better classes indeed even of the so-called best classes allow themselves to be influenced by these quacks and it is even more surprising to him that so many well-to-do intelligent people should for no reason though without knowledge presumed to give advice in medical matters and especially in even dangerous surgical diseases and in such delicate affections as diseases of the eyes quote it thus often happens that diseases in themselves curable grow to be simply incurable or are made much worse than they were before end quote he says that some of the clergymen of his time seem to think that a knowledge of medicine is infused into them with the sacrament of holy orders he was himself probably a clergyman and I have in the modern time more than once known of teachers in the clerical seminaries emphasizing the same idea for the clerical students it is very evident that the world has not changed very much and that to know any time reasonably well is to find in it comments on the morning paper we are in the midst of just such a series of interferences with medicine on the part of the clergy as this wise common sense surgeon of the 13th century deprecated in every way Mondeville had the instincts of a teacher he took advantage of every aid he was probably the first to use illustrations in teaching anatomy Guy Descholiac whose teacher in anatomy for some time Mondeville was says in the first chapter of the book that pictures do not suffice for the teaching of anatomy and that actual dissection is necessary the passage runs as follows in the bodies of men of apes and of pigs and of many other animals tissues should be studied by dissections and not by pictures as did Henriques who was seen to demonstrate anatomy with 13 pictures end quote what Scholiac blames is the attempt to replace dissections by pictorial demonstrations hurdle however suggests that this invention of Mondeville's was probably very helpful and was brought about by the impossibility of preserving bodies for long periods as well as the difficulty of obtaining them epermen of the old greek philosophers was that good is diffusive of itself as the scholastics put it bonum est diffusium sui this proved to be eminently true of the old universities also and especially of their training in medicine and in surgery we have the accounts of men from many nations who went to the universities and returned to benefit their own people early in the 13th century Richard the Englishman was in Italy having previously been in Paris and probably at Montpelier Bernard Gordon probably also an Englishman was one of the great lights in medicine down at Montpelier and his book Lilium de Medicina is well known two distinguished surgeons whose names have come down to us having studied in Paris after Lanfrank had created the tradition of great surgical teaching there came to their homes to be centers of beneficent influence among their people in this matter one was epermen in the town of Ypres in Belgium the other Ardern of England epermen was sent by his fellow townsmen to Paris in order to study surgery because they wanted to have a good surgeon in their town and Paris seemed the best school at the time Ypres was at this period one of the greatest commercial cities of Europe and probably had a couple of hundred thousand inhabitants the great hall of the cloth guild which has been such an attraction for visitors ever since was built shortly before the town determined upon the sensible procedure of securing good surgery beyond all doubt by having a townsman specially educated for that purpose epermen's work was particularly unknown to us until broke the Belgian historian discovered manuscript copies of his book on surgery and gathered some details of his life after his return from Paris epermen obtained great renown which maintained itself in the custom extant in that part of the country even yet of calling an expert surgeon an epermen he is the author of two works in Flemish one of these is a smaller compendium of internal medicine which is very interesting however because it shows the many subjects that were occupying physicians minds at this time he treats of dropsy rheumatism under which occur the terms choriza and catar the flowing diseases ichteris he calls tuberculosis tisican apoplexy epilepsy frenzy lethargy fallen palate cough shortness of breath lung abscesses hemorrhage blood spitting liver abscesses hardening of the spleen affections of the kidney bloody urine diabetes incontinence of urine dysuria stranguary gonorrhea and involuntary seminal emissions all these terms are quoted directly from Pagel's account of his own work the original is not available in this country John Ardern in English speaking countries of course we are interested in what was done by Englishmen at this time fortunately we have the record of one great English surgeon of the period worthy to be placed beside even the writers already mentioned this is John Ardern whose name is probably a modification of the more familiar Arden whose career well deserves attention I have given a sketch of his work in science he was educated at Montpellier and practiced surgery for a time in France about the middle of the century however according to Pagel he went back to his native land and settled for some 20 years at Newark was in London in Nottinghamshire and then for nearly 30 years longer until about the end of the century was in London the chief representative of English surgery during the middle ages his practica as yet unprinted contains, according to Pagel a short sketch of internal medicine but is mainly devoted to surgery contrary to the usual impression with regard to works in medicine and surgery at this time the book abounds in references to case histories which Ardern had gathered partly from his own and partly from others experience the therapeutic measures that he suggests are usually very simple in the majority of cases quite rational though of course there are many superstitions among them but Ardern always furnished a number of suggestions from which to choose he must have been an expert operator and had excellent success in the treatment of diseases of the rectum he seems to have been the first operator who made careful statistics of his cases and was quite as proud as any modern surgeon of the large numbers that had operated on which he gives very exactly he was the inventor of a new Kleister apparatus fortunately we possess here in America in the surgeon's general library at Washington a very interesting manuscript containing Ardern's surgical writings though it has not yet been published even a little study of this and of the notes on it prepared by an English bibliophile before it's purchased by the surgeon's general library served to show how valuable the work is in the history of surgery there are illustrations scarcely less interesting than the text some of these illustrations were inserted by the original writer or copyist and some of them later in general however they show a rather high development of the mechanics of surgery at that time some of the pages have spaces for illustrations left unfilled so that evidently the copyist did not complete his work the titles of certain of the chapters are interesting as illustrating the fact that medical and surgical problems were stated clearly in the olden time and thinking physicians even six centuries ago met them quite rationally there is, for instance a chapter headed against Koliak and the Iliak passion immediately followed by the subheading method of administering clisters the Iliak passion Pasio Iliaca of the old Latin is usually taken to signify some obstruction of the intestines causing severe pain vomiting and eventually fecal vomiting a good many different forms of severe painful conditions especially all those complicated by peritonitis were included under them and the modern student of surgery is likely to wonder these old observers had not noted that the right Iliak region was particularly prone to be the source of fatal conditions there is a chapter entitled against pain in the lines and the kidneys followed by the chapter subheading against stone in the kidneys there is a chapter with the title against ulceration of the bladder or the kidneys another one with the title against burning of the urine and excoriation of the lower part of the yard gonorrhea is frankly treated under the name shah despis evidently an English alliteration of the corresponding French word as to the instrumentation of such conditions and for probing in general Ardern suggests the use of a lead probe because it may easily be made to bend anyway and not injure the tissues medieval surgery even this brief account of the surgeons who taught and studied at the medieval universities demonstrates what fine work they did it is surely not too much to say that the chapter on university education mainly concerned with them is one of the most interesting in the whole history of the their story alone is quite enough to refute most of the prevalent impressions and patronizing expressions with regard to medieval education their careers served to show how interested were the men of many nations in the development of an extremely important application of science for the benefit of suffering humanity their work utterly contradicts the ideas so frequently emphasized by great students of the middle ages were lacking in practicalness besides, they make very clear that we have been prone to judge the middle ages too much from its speculative philosophies it has been the custom to say that speculation ruled men's minds and prevented them from making observations developing science or applying scientific principles there was much speculation in the middle ages but probably not anymore in proportion than exists at the present day we were either not acquainted with or failed to appreciate properly until comparatively recent years the other side of medieval accomplishment our ignorance led us into misunderstanding of what these generations really did it was our own fault because during the Renaissance all of these books were edited and printed under the direction of the great scholars of the time in fine editions but during the 18th century nearly all interest was lost in them and we are only now beginning to get back a certain amount of the precious knowledge that they had in the Renaissance period of this other side of medieval life we have learned so much about surgery because distinguished scholars devoted themselves to this phase of the history of science doubtless there are many other phases of the history of science which suffered the same fate of neglect and with regard to which the future will bring us equally startling revelations for this reason this marvelous chapter in the history of surgery is a warning as well as a starting record of a marvelous epoch of human progress end of part three of three end of chapter ten


Itaddelevenere is one of the most relevant three-story caves of Italian prehistory, where for millennia, generation left significant trees over the passage. It is located in Apulia, that part of Italy, two kilometers from Parabita, to this near Lice. In a territory frequented by man since Paleolithic. The cave was identified in 1975, and in this year, were found the two Venus figurines that gave the name of the cave. Made of animal bone, they are an invocation to fertility that spread through Europe from 36,000 years ago, with a production of female stituis, usually characterized by that sentuation of sexual attributes. The first real excavation campaign carried out in the Grotta delle Venere, and it was due to the University of Lice in Pisa, and they were carried out from 1966 to 1972. The Grotta delle Venere is characterized by external shelter with a semi-circular plan, and the inner cave divided into a central trunk and two tunnels, north and west. They have two district and complementary stratigraphic deposits. Look to the Paleolithic, the most ancient traces of human presence are found in the external shelter, and consist of Neanderthal lithic tools. The use of the middle Paleolithic Poloid after the collapse of the world, only at the end of Apopaleolithic. In fact, the Epi-Romanelian Thalitic tools and the metal remains left by sapiens date back to this period, as well as 500 stones and 116 engraved bones, which represent an exceptionally testimony of the symbolic universe of Paleolithic interrogators, those one. In this period, between the end of Pleistocene and the beginning of Orocyene, characterized by modification of the habitat, there is a change in the portable art of Gunther Gators, a clear hand of a symbolic universe also in the process of modification, no longer orientated to Mozoomorphic representation by almost exclusively to the incision of geometric linear motives on stones or bones. It's a syntax that is found through Europe, from Provence to the Black Sea, as well as in Salento. And the Grotto della Venere is exhibited an exceptionally wild sample of media with a based repertory of motifs, from bundles of lines to ladder motifs, to lattice to square bends. The inner part of the cave was used only from the Apopaleolithic, when sapiens choose it as a burial place. The use of the cave continued also in the later phase of the Apopaleolithic, as evidenced by flint tools of the Apigrevian age. A level of soil, strictly affected by illegal excavators, sealed the paleolithic occupation on both the outer shelter and the inner cave. It's characterized by the presence of numerous arctic pottery, flay, and obscenium in the middle used in activities related to the cult and referable to a period between the Neolithic and the Middle Ages. Some of them were found together with animal offerings inside holes dug with cult items, intents. These holes, often modeled on the rocky bottom, were filled in part once the ritual was completed with large stones. The excavation of one of these holes radiocarbon dated thanks to the collaboration with Sedat of the University of Salento, to the second half of the fifth millennium BC, under the underlying burial of Apopaleolithic, partially destroying it. Remains of both ships and goats and ceramic fragments were found inside and they were interpreted as an offer deposit by the Neolithic men in honor of individual perceived as their own ancestors. Indeed, the practice of laying down precisely part of both in silos, holes, pits, altars, finds, numerous comparisons in the recent and final Neolithic of Italian suites. The pottery has been analyzed as a fool and many pieces have been revised from the chrono-tepological point of view. The study has allowed us to establish the uninterrupted use of the cavity from the beginning of the sixth millennium BC until the Bronze Age, with different differences in terms of intensity and destination in different periods, as well as to identify some indicators of wine-rage contacts. Those include symbolic artifacts, container with shapes and decoration widespread in Sicily and in the regions of Eastern Adriatic, documenting the ability by the Apolian Salento communities to participate in the wide circulation of ideas and information that prevailed the Mediterranean from the sixth to the second millennium BC. The ceramic complex consists of 17,000 finds, 86% are dated to the Neolithic with almost all the typological elements referring to the sixth millennium BC. In fact, fragments refer to the impressed wear, scratched and painted wear, different ceramic styles, typical of Saudesan peninsula in the ancient and middle phases of the Neolithic. About 200 artifacts refer, however, to the fifth millennium BC, namely the recent and final stages of the Neolithic. Among the indicators of wine-ranging contacts due to the Neolithic period present in the cave, there are some objects with a symbolic meaning that show the sharing of an ideological patrimony common to the entire peninsula and Greek Balkan world. There are three pintaderas, clay stamps, whose decoration shows connection from the stylistic point of view with Greece, Serbia, and Albania, and a lack of rhythm, also attested in the trans-Adriatic world. The obsidian tools are added to the ceramic artifacts, some of which analyzed to XRF analysis at Sedat have proven to be of leapary origin, as documented for all the Neolithic site of Salento. The frequentation of the cave continued during the Copper Age for the third millennium BC, although with less intensity than during the previous millennia. The furnishing fall into the production of daily use with the exception of some carefully crafted vessels such as those with impressed points found at the Grotto d'Allecerbi in Potomadisco, and the widespread of the initial phase of the Copper Age in Sicily, and on the eastern side of Adriatic, and those of the La Terza type decorated with a fine syntax. Also worthy of note is a juglet decorated with horizontal engraved line, which is compared to a similar vase found in La Terza tomb tree, also in Apulia, referred to the literature as coming from the Darmatian castle of Sedina. As for the Bronze Age, the larger quantity of ceramics containers refer to generic forms, not edible to faces or specific periods, apart from some very few exception, vessels of and everyday objects documented in the cavity and in the cohabited sites of the area could suggest a residential, intense use of the cave during the Second Millennium BC. Looking to the metal artifacts, between the Mereolithic and the Metal Age, hundreds of vessels and artifacts related to domestic activity, such as peniles, stone, and obsidian tools, or ceremonial tools such as the pintaderas were placed in the cave. To this one has to head for Ineolid, the object in copper, a raw material absent in Apulia. At least the metal was the foyer. An import, as you can see, Parapita is with the arrow is, and there is no copper in all southern Italy, except for the deep southern calabria. So the metal was the foyer, an import. The comparison of these items were investigated by XRF. The Triangular Flat Axe has a very archaic shape. It was analyzed by XRF, showing it was composed by almost pure copper with traces of arsenic, iron and silver. The long shallow hollow along each side is an indication of manufacture in a two-piece mold. Morphologically similar specimen came from Campegine, Regimilia, Scurgole, Alessium, Rapulano, Tuscany, and Stankovci, Dalmatia, and they were attributed to the late Neolithic or in the very early stage of copper age. Very early copper working in southern Italy were found in Pizzicca Pantanello Metapunto, a crucible for copper melting from an early Neolithic context dating to the 4,420, 2,700 calibrated BC. But anyway, the copper was obviously imported. Another copper Flat Axe belonged also to a very early type that is generally ascribed to the very early phases of copper age. The cutting at the butt is an indication that the two-piece mold was used also in this case. It's made of almost pure copper with traces of arsenic. We got also two holes, again with a similar composition, pure copper with some traces of iron and arsenic. These are artifacts deposited in the cave as offers, perhaps to divinities of the underground world, unlike what's happened in the other Neolithic contexts of central southern Italy, such as Grotta Puccini where copper objects, daggers and razor blade pins constitute the set of collective burials in the cave to underline perhaps the privileged status of some individual over-orders. There are few peninsula caves that preserve, in the copper age, an exclusively cultural function and among this there is Grotta delle Venere. Here, the body deposition of valuable objects may have expressed the desire to maintain beneficial relationship with the spirits of underground world. We are going to the conclusions. Grotta delle Venere has returned evidence of ability to participate in the wine circulation of ideas and information that pervaded the Mediterranean from the 6th to the 2nd millennium BC. Non-local raw materials such as obsidian and copper object of symbolic nature as pintaderas ceramic styles common to a large geographical area are evidence of how the cave and with it the entire Apulia Salento were able to interact with an interconnected world in which important raw had the promises in navigation. Thank you.


This NBA 2K21 demo is a setup. I don't like playing against the AI. Everybody knows that. I'd say most people don't like playing against the AI. What they got is playing against the AI. How am I supposed to gauge how fun the game is? So I recruited a fellow acquaintance, Legend of Winning. How are you doing, Legend of Winning? I'm doing good, man.  Legend of Winning, how are you? Whoa, what are you doing? Hey, first of all, y'all new to the channel you haven't already? Be sure to subscribe, drop a like. Have you dropped a like? Have you subscribed to the channel? Low's link in the description too. Who makes NBA videos? Whoa, whoa, whoa. Hold on, we're not gonna do this right now. Don't try and jockey with me, bro. Don't try and jockey with me. I'm gonna be the Lakers though. I'm the Lakers. You're not a Laker fan. I called this one. Bro, I was just playing. What? What do I mean? Look at me. Exactly, 2K18. I promise you I'm choosing Lakers. No, I got, I have the hat on.  So what am I supposed to pick? The Hawks or something, you from Atlanta. First of all, why is Kobe not at 99? That's a really good question. What's going on? How is Craven at 96?  Get Jerry West off, we're putting LeBron on. Yeah, what's over there? Karim is at power forward. Man, I love these graphics, bro. They feel so familiar. Yeah, yo, these graphics crazy.  God damn. You like all the options they give you in the demo?  Yeah, you gotta make sure you're right. Broadcast, broadcast low, high, no, oh, no, no, no. No, that's not, that's not, that's not dude. God damn, inside, that's easy. Y'all, uh, uh, uh. We fouling, we fouling. Have you make it this unrealistic? It's unrealistic, unrealistic. Man, I'm close to this shop meter, and I still can barely see it. Facts, facts, wait, wait, hold on, hold on. I got something right there. On the back, on the back left of the desk, can you pick that up for me? What is it? It'll help me see better. There we go. So next time you don't see the shop meter. I got you, I got you. You know what I'm saying? I'm gonna leave this right here, okay? I got you, I got you. Oh man, all right, all right, all right. It might have been a close, I've never gotten though. It might have been a close, it might have been a close one. Oh, it's, it, no, no, no. This is Kobe right here in the corner, right? Yup, yup. Oh, that was close, that was close. I saw that one. This really like closing in the skill gap, when you think about it. Exactly, cause you gotta shoot with one hand now. Yeah, huh. Damn, damn. How did you miss the hole? I was looking at the wrong side, that's what's wrong. Oh yes, oh, that's the first time I did the new finishing thing. Where I finished right and then pushed up and aimed it, and it went in. Hey, hey, oh, oh, hey, the cream is horrible. Oh my God, did you? Magic is doing something wild right now. You've done it before. That's how I knew it, that's how I knew it. What? Magic, he's making magic happen. And one, yeah, yeah, you know how I caught you? All right. And then I went in. All right, all right, all right, all right. Missed by more. It's kind of harder when it's like a bigger shot meter. Maybe the small thing, they're on something. It'd be nice if they just didn't, you feel me? Ooh, sometimes I just like being fast. Yeah, that was pretty fast. Yo, yo, yo, LeBron. Oh, he's just, he's putting nuts in faces right now. Ooh, yup. Oh, you can do that though. What was the defense at? All right, cool, say it like, say it like. I didn't see it on that possession. Where was it exactly? I know you can do that. No way, I'm right there. Yup, and we eat those and we throw it up. That's the beam. So what is that? What is that? So you're supposed to like finish as you usually would in any other 2K, but then you have to click up on the stick directly up to aim the shot towards the rim. And if you aim it correctly and you finish properly, you get an extra boost to the shot. That was a good release and I got the boost.  This is actually hurting my brain. You know, I don't play 5-5. Oh, James Worthy, wow, that was a big one. This hurting my brain, I swear I need these breads. I shot it right, that's just wrong. I'm trying to get this right stick shoot down and I just can't do it. Eat those, eat those. Oh, push over the screen, that's clean. Brick. Made it. You wish. Ray Allen only plays good in game six with LeBron against Spurs. You ain't doin' that. You trash. What? That's the McKell D. That's the McKell D. You missin' those two. You missin' those two, I'm outta here. Yeah, I'm not using the stick. I'm out, I'm out, I'm out, I'm out, I'm out. How is that not a stealer? Are you guys not playing defense? Pinned, pinned, and guess who's up? The champion. Are we playing the full game? I know, we're playing till that time. Okay, I was about to say, this is the way you don't want this to hurt. Ah! Not for a full court, man. All right, it's game time. Oh my God, that's not a pin? How's that not turnin' on for me, I don't know. Whoa. Whoa. What happened? Whoa, buddy. Did you hear that? Is that pal? Oh my God, that's pal. That's literally a non-call, ref. Pal, do somethin' with it. Oh, they got him trashin' this game. Oh, yeah, they got him trashin'. Yeah, they got him, wow, that's tough.  Oh, showtime, showtime, showtime. And one, he's garbage. No, he's not.  That's my fault. That's my fault, that's my fault. Hey! Crazy. Finishing thing is hard to get used to. Not even Bill Russell's house! Yeah, I'm just gonna go. Is my set up full of the party?  Yeah, I eat those. That's breakfast, that's lunch, and this right here is dinner. That's not what I want to do. Yeah, it is. Hey, they need to update his hair, LeBron lost most of it. Yeah, a lot of it, actually. What the? I'm like, a lot of it. I was right there for it, too. Oh my God. Cleaner. Ty Gain. Cleaner. Two minutes left. Cash. What? Yup.  Don't run! Don't ever make that shot and then look at me like you're just supposed to make that. Oh, no, no, no. Yeah, we out. This is when we turn it off. Hey, I pop here. Not in Bill's house? Oh my God! How did you keep that in balance? And! The patience inside the paint. You wish, you wish Mike didn't get sauce by this bozo-ass player. You wish. Why is my bench on in the final minutes? Oh! What? That's so crazy how you got fouled.   You, you not. Pick it up for him. He's too big for you.  Here, here, here, here. What you want, huh? Isn't you? Ah! This could be game right here. That's possession. Okay. All right, all right.  What? I'm gone. I'm gone. I'm gone. I gave you those. I gave you those and now I'm by the winning. He's just too good. He sits automatic with Shaq. You're at such a try-hard. It makes no sense.  Advancing it. A moment ago, why would we not go on that hard? What's up with you? Why are you going this hard? It's only 15,000. Are you broke? Oh my God. Oh no, we're gonna do like football. Football rules. All right, fine, all right. All right, let's go. So let me explain to people. He has to score. First person to score, if the other person doesn't respond with a bucket, it's over.  That's me. Oh my God. If you don't respond, it's a victory. Okay. Okay, okay. So now is it neutral or is it the next person to miss? Okay. Cash, look at Shaq and Kareem. Imagine if they played together. That'd be deadly. That would be deadly. Oh my God. Oh, whoa, whoa, whoa, whoa now. If you get a 3D one. No. You choked. Oh my God. You choked. Found me. Did you make both? How does it work? Okay, now, all right. Yeah. Oh, this is a hit. He choked. This is a terrible one. Hey man, $15,000 richer in this very, very real wager, man. Lowe, thank you for joining me today. Tie game. Hey, if y'all new to the channel, you haven't already, be sure to subscribe. Lowe's link in the description. My link is in the description. And I will catch you guys in the next one. Man, it's definitely just like a 2K 20.