Medieval Medicine

“The tokenys of a wood dogge ben these; the furste is he knoweth not his lord ne his mayster and he falleth into a voyd goyinge allone with boowynge of his heed and hangynge of the erys [ears] as other wyse than ne he hadde hemin his helthe and the yene [eyes] of him ben rede and the fome cometh out at the mowth and he wole berke at his oune schadowe and he hath ane hos [hoarse] berkynge, and other houndes fleene from hyme and berken towardys hyme. And yf a schyvere [slice] of breed be folden or wette in the bytynge of the sore and yoven a dogge to ete, yf that he ete it, it is a token that the dogge is not wood, for and the dogge be wood tha other dogge that the breed is yoven to wole not ete it, but that he be over moche hungry, and yf he denye to ete the seyde breed, out-take [unless on] the condicione aforeseyd, thane is the dogge wood.”

Ardern’s description of a case of traumatic tetanus is very interesting, because it contains so many elements that are familiar in the history of this affection. The fact that it occurred in a gardener from a hook, so likely to be infected with tetanus bacilli from hay or grass, and that the wound was made where the thumb joins the hand and where, as we know now, the construction of the tissues is so favourable to that burying of the tetanus bacilli away from the free oxygen of the air, giving it a chance to grow anaerobically, all show the disease exactly as in our own time. The other details of the case probably indicate a wound of an important bloodvessel, secondary hæmorrhage after suppuration had been established, and then the development of fatal subacute tetanus.

“A gardinere whyle that he wrowghte in the vynes kytte his owne hande with ane hooke uppone a ffryday after the ffeste of Seynt Thomas of Caunterbury in somere so that the thoombe was altogydere departyd from the hande saff only in the juncture that was joyned to the hande, and he myghte boowe bakward the thoombe to his arme and ther stremyd out therof moche blood.

“And so touchynge to the cure. The thoombe was furst reduced in to his furste ordre and sowyd and the blood was restreyned with the reed pouder of launfrankes [Lanfranc’s red powder] and with the heerys [hairs] of ane hare and it was not remevyd une-to the iiide day when it was remevyd tther apperyd no blood. Thanne was ther putte therto tho medicines that engendren blood, every day ones repeyrynge the wounde, and tho it begane to purge itselffe and to gadere mater. And in the iiiithe nyght after the blood brak out abowte mydnyght in the wheyghte of ii poundes. And whane the blod was restreyned the wounde was repeyred frome day to day as it was furste.

“Also in the xithe nyght abowte the forseyd oure the blood brake owt ayene [again] in more quantyte thane it dyde afore tyme, nevertheless the blood was staunched, and by the morne the pacient was so taken with the crampe in the chekes [cheeks] and in the arme that he myght resseyve no mete in-to his mowth ne neyther opene the mowyth (lockjaw) and so vexynge the pacient in the xv day the blood brake out ayene owt of mesure and alwey the crampe endured forth and in the xx day he dyde.”

Another important surgeon of the West of Europe whose book has come down to us was John Yperman, who owes his name to the fact that he was a native of the town of Ypres (in Flemish Ypern) in Flanders. Yperman was sent by his fellow-townsmen to Paris in order to study surgery, apparently at the expense of the municipality, because they wanted to have a good surgeon in their town, and Paris seemed the best school at that time. Ypres, so familiar now as the scene of bloody battles, had become even before the war one of the less important cities even of Belgium, with less than 20,000 people. It was in the thirteenth century one of the greatest commercial cities of Europe, and probably had several hundred thousand inhabitants. The great hall of the Cloth Guild, one of the architectural triumphs of the time, and such an attraction for visitors to the town ever since (destroyed in the war) was built at this time, and is another tribute to the community feeling of the citizens, who determined upon the very sensible procedure of assuring the best possible surgery for themselves and fellow-citizens by having one of their townsmen specially educated for that purpose. Yperman’s book on surgery was well known in his own time, but remained unprinted until about half a century ago (1854), when Carolus of Ghent issued an edition. Subsequent editions were issued by Broeckx, the Belgian historian (Antwerp, 1863), and by van Leersum (1913), who gathered some details of the great Flemish surgeon’s life. After his return from Paris, Yperman obtained great renown, which maintains in the custom extant in that part of the country even yet of calling an expert surgeon “an Yperman.” 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 that time. He treats of dropsy, rheumatism, under which occur the terms coryza and catarrh (the flowing diseases), icterus, phthisis (he calls the tuberculous, tysiken), apoplexy, epilepsy, frenzy, lethargy, fallen palate, cough, shortness of breath, lung abscess, hæmorrhage, blood-spitting, liver abscess, hardening of the spleen, affections of the kidney, bloody urine, diabetes, incontinence of urine, dysuria, strangury, gonorrhœa, and involuntary seminal emissions—all these terms are quoted directly from Pagel’s account of his work.

There is not much to be said of the surgery of Germany during the Middle Ages, though toward the end of this period a series of important documents for the history of surgery were written which serve to show how much was being accomplished, though the subsequent religious and political disturbances in Germany doubtless led to the destruction of many other documents that would have supplied valuable information. Heinrich von Pfolspeundt’s book, which is a work on bandaging—“Bundth-Ertzney”—was published in 1460, and the experience for it was therefore all obtained in the Middle Ages. While its main purpose is bandaging, it contains many hints of the surgical knowledge of the time. There are chapters devoted to injuries and wounds, though it is distinctly stated that the book is for “wound physicians” (Wund Aertzte) and not for cutting physicians (Schneide Aertzte)—that is, for those who do operations apart from wounds. There are two operations described, however, that have particular interest. One of them involves the plastic surgery of the nose, and the other the repair of a hare-lip.

Pfolspeundt suggested that stitches should be placed on the mucous surface as well as on the skin surface, after the edges of the cleft in hare-lip had been freshened in order to be brought closely together for healing with as little deformity as possible. Perhaps his most interesting surgical hint for us is a description of a silver tube with flanges to be inserted in the intestines whenever there were large wounds, or when the intestines had been divided. The ends of the gut were brought together carefully over the tube and stitched together, the tube being allowed to remain in situ. Pfolspeundt says that he had often seen these tubes used and the patient live for many years afterwards. While this resembles some of the mechanical aids to surgery of the intestines that have been suggested in our time, this was not the first mechanical device of this kind that had been thought of. One of the later medieval surgeons in Italy, one of the Brancas, had employed the trachea of an animal as the tube over which the wounded intestines were brought together. This had the advantage of not having to be passed, for after a time it became disintegrated in the secretions, but it remained intact until after thorough agglutination of the intestines had occurred.

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BRUNSCHWIG’S SURGICAL ARMAMENTARIUM

From Gurlt’s “Geschichte der Chirurgie”

Hans von Gerssdorff and Hieronymus Brunschwig, who flourished in the latter half of the fifteenth century in Germany, have both left early printed treatises on Surgery which give excellent woodcuts showing pictures of instruments, operations, and costumes, at the end of the medieval period.

CHAPTER VIII

ORAL SURGERY AND THE MINOR SURGICAL SPECIALITIES

The surgical specialities, as they are called—that is, the surgery of the mouth, throat, and nose, and of the eye and ear, as well of course as of certain other portions of the body—have developed to a striking extent in our time. As a consequence of this recent development, there is an impression prevalent that this is the first time that serious attention has been paid by surgeons to these phases of their work. The feeling is probably that the minor operations usually required in the surgical specialities were either thought so trivial, or involved such delicate technique, that they never received due attention, rather than that they were deliberately neglected.

Because of this very general persuasion, even among physicians, it is all the more interesting to trace the phases of attention during the Middle Ages to these special subjects in surgery, which was far from lacking at any time, and which led at various periods to some rather important developments. While specialism is considered new by most people, it must not be forgotten that at every time in the world’s history, when men have had much chance to think about themselves rather than the actual necessities of the situation in which they were placed, and the things they were compelled to do for actual self-preservation, specialism has enjoyed a period of more or less intense evolution. It is rather easy to trace this in the Ebers Papyrus near the beginning of the second millennium b.c.; and Herodotus called attention to the fact that the old Egyptians had divided the practice of medicine into many specialities. His passage on the subject is well known.[11 - “Physicke is so studied and practised with the Egyptians that every disease hath his several physicians, who striveth to excell in healing that one disease and not to be expert in curing many. Whereof it cometh that every corner of that country is full of physicians. Some for the eyes, others for the head, many for the teeth, not a few for the stomach and the inwards.”]

If the surgical specialities had been neglected in the Middle Ages, then that fact would have constituted the surest evidence of that backwardness of medical and surgical progress which is usually supposed to have existed at that time. But the real story is exactly to the contrary, and has many surprises in it because of the anticipations of very recent advances which it represents.[12 - The Ebers Papyrus shows that special attention was paid to diseases of the eyes, the nose, and throat, and we have traditions of operations upon these from very early times. Conservative surgery of the teeth, and the application of prosthetic dental apparatus, being rather cosmetic than absolutely necessary, might possibly be expected not to have developed until comparatively recent times; but apart from the traditions in Egypt with regard to this speciality, which are rather dubious, we have abundant evidence of the definite development of dentistry from the long ago. The old Etruscans evidently paid considerable attention to prosthetic dentistry, for we have specimens from the Etruscan tombs which show that they did bridge work in gold, supplied artificial teeth, and used many forms of dental apparatus. At Rome the Laws of the Twelve Tables (circa 450 b.c.) forbade the burying of gold with a corpse except such as was fastened to the teeth, showing that the employment of gold in the mouth for dental repair must have been rather common. We have specimens of gold caps for teeth from the early Roman period; and there is even a well-confirmed tradition of the transplantation of teeth, a practice which seems to have been taken up again in the later Middle Ages, and then allowed to lapse once more until our own time.]

It would be surprising, then, if we were to find no attention paid to dentistry during the Middle Ages. As a matter of fact, a number of the old surgeons include in their textbooks of surgery the discussion of oral surgery. Aëtius evidently knew much about the hygiene of the teeth, and discusses extraction and the cure of fistulæ of the gums as well as the surgical treatment of many other lesions of the mouth. Paul of Ægina in the century after Aëtius has even more details; and while they both quote mainly from older authors, there seems no doubt that they themselves must have had considerable practical experience in the treatment of the teeth and had made not a few observations. The Arabians took up the subject, and discussed dental diseases and their treatment rationally and in considerable detail. Abulcassis particularly has much that is of significance and interest. We have pictures of two score of dental instruments that were used by him. The Arabs not only treated and filled carious teeth, and even replaced those that were lost, but they also corrected deformities of the mouth and the dental arches. Orthodontia is usually thought of as of much later origin, yet no one who knows Abulcassis’s work can speak of efforts at straightening the teeth as invented after his time.

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SURGICAL INSTRUMENTS OF THE ARABS, ACCORDING TO ABULCASIM

After plates in Gurlt’s “Geschichte der Chirurgie”

The great surgeons of the later Middle Ages in their textbooks of surgery usually include remarks on oral surgery, and suggest treatment for the various diseases of the teeth. Guy de Chauliac in “La Grande Chirurgie” lays down certain rules for the preservation of the teeth, and shows that the ordinary causes of dental decay were well recognized in his time. Emphasis was laid by him on not taking foods too hot or too cold, and above all on the advisability of not having either hot or cold food followed by something very different from it in temperature. The breaking of hard things with the teeth was warned against as responsible for such fissures in the enamel as gave opportunity for the development of decay. The eating of sweets, and especially the sticky sweets, preserves, and the like, were recognized as an important source of caries. The teeth were supposed to be cleaned frequently, and not to be cleaned too roughly, for this would do more harm than good.

Chauliac is particularly emphatic in his insistence on not permitting alimentary materials to remain in the cavities, and suggests that if cavities between the teeth tend to retain food material they should even be filled in such a way as to prevent these accumulations. His directions for cleansing the teeth were rather detailed. His favourite treatment for wounds was wine, and he knew that he succeeded by means of it in securing union by first intention. It is not surprising, then, to find that he recommends rinsing of the mouth with wine as a precaution against dental decay. A vinous decoction of wild mint and of pepper he considered particularly beneficial, though he thought that dentifrices, either powder or liquid, should also be used. He seems to recommend the powder dentifrices as more efficacious. His favourite prescription for a tooth-powder, while more elaborate, resembles to such an extent at least, some, if not indeed most, of those that are used at the present time, that it seems worth while giving his directions for it. He took equal parts of cuttle-bones, small white seashells, pumice-stone, burnt stag’s horn, nitre, alum, rock salt, burnt roots of iris, aristolochia, and reeds. All of these substances should be carefully reduced to powder and then mixed.

His favourite liquid dentifrice contained the following ingredients: Half a pound each of sal ammoniac and rock salt, and a quarter of a pound of saccharin alum. All these were to be reduced to powder and placed in a glass alembic and dissolved. The teeth should be rubbed with it, using a little scarlet cloth for the purpose. Just why this particular colour of cleansing cloth was recommended is not quite clear.

He recognized, however, that cleansing of the teeth properly often became impossible by any scrubbing method, no matter what the dentifrice used, because of the presence of what he called hardened limosity or limyness (limosité endurcie). When that condition is present he suggests the use of rasps and spatumina and other instrumental means very similar to those we make use of for removing tartar.

Guy de Chauliac was also interested in mechanical dentistry and the artificial replacement of lost teeth; and, indeed, dental prosthesis represents, as treated by him, a distinct anticipation of dental procedures usually thought quite modern.

When teeth become loose he advises that they be fastened to the healthy ones with a gold chain. Guerini, in his “History of Dentistry” (Philadelphia, 1907), suggests that he evidently means a gold wire. If the teeth fall out Chauliac recommends that they be replaced by the teeth of another person, or with artificial teeth made from ox-bone, which may be fixed in place by a fine metal ligature. He says that such teeth may be serviceable for a long while. This is a rather curt way of treating so large a subject as dental prosthesis, but it contains a lot of suggestive material. He was quoting mainly the Arabian authors, and especially Abulcassis and Ali Abbas and Rhazes—and these of course, as we have said, mentioned many methods of artificially replacing teeth, as also of transplantation and of treatment of the deformities of the dental arches.

Guerini called particular attention to the fact that Chauliac recognized the dentists as specialists. He observes that operations on the teeth are in a class by themselves, and belong to the dentatores to whom they had been entrusted. He remarks, however, that the operations on the mouth should be performed under the direction of a surgeon. It is in order to give surgeons the general principles by means of which they may be able to judge of the advisability or necessity for dental operations, that his brief presentation of the subject is made. If their advice is to be of value, physicians should know the various methods of treatment suitable for dental diseases, including “mouth washes, gargles, masticatories and ointments, rubbings, fumigations, cauterizations, fillings, filings,” as well as the various dental operations. He says that the dentator must be provided with appropriate instruments, among which he named scrapers, rasps, straight and curved, spatumina, elevators, simple and with two branches, toothed tenacula, and many different forms of probes and cannulas. He should have also small scalpels, tooth trephines, and files.

After Guy de Chauliac, the most important contributor to dentistry is Giovanni of Arcoli—or simply Arcolano, but sometimes better known by his Latin name Johannes Arculanus—who was Professor of Medicine and Surgery at Bologna just before and after the middle of the fifteenth century. He is sometimes treated in history as belonging rather to the Renaissance, but he owed his training to the Middle Ages and was teaching before they closed, so he has a place in Medieval Medicine. Guerini, in his “History of Dentistry,” says that Arculanus treats the subject of dentistry rather fully and with great accuracy. The Italian historian makes a summary of Arculanus’s rules for dental hygiene which shows how thoroughly he appreciated the care of the teeth. The medieval surgeon arranged his rules in ten distinct canons, creating in this way a kind of decalogue of dental hygiene.

These rules are: (1) It is necessary to guard against the corruption of food and drink within the stomach; therefore, easily corruptible food—milk, salt fish, etc.—must not be partaken of, and after meals all excessive movement, running exercises, bathing, coitus, and other causes that impair the digestion, must also be avoided. (2) Everything must be avoided that may provoke vomiting. (3) Sweet and viscous food—such as dried figs, preserves made with honey, etc.—must not be partaken of. (4) Hard things must not be broken with the teeth. (5) All food, drink, and other substances that set the teeth on edge must be avoided, and especially the rapid succession of hot and cold, and vice versa. (7) Leeks must not be eaten, as such a food, by its own nature, is injurious to the teeth. (8) The teeth must be cleaned at once after every meal from the particles of food left in them; and for this purpose thin pieces of wood should be used, somewhat broad at the ends, but not sharp-pointed or edged; and preference should be given to small cypress-twigs, or the wood of aloes, or pine, rosemary, or juniper, and similar sorts of wood, which are rather bitter and styptic; care must, however, be taken not to search too long in the dental interstices, and not to injure the gums or shake the teeth. (9) After this it is necessary to rinse the mouth, using by preference a vinous decoction of sage, or one of cinnamon, mastich, gallia, moschata, cubeb, juniper seeds, root of cyperus, and rosemary leaves. (10) The teeth must be rubbed with suitable dentifrices before going to bed, or else in the morning before breakfast. Although Avicenna recommended various oils for this purpose, Giovanni of Arcoli appears very hostile to oleaginous frictions, because he considers them very injurious to the stomach. He observes, besides, that whilst moderate frictions of brief duration are helpful to the teeth, strengthen the gums, prevent the formation of tartar, and sweeten the breath, too rough or too prolonged rubbing is, on the contrary, harmful to the teeth, and makes them liable to many diseases.

Shortly after Arculanus, when the Middle Ages are over—if they end with the middle of the fifteenth century, though perhaps not if the later date of the discovery of America is to be taken as the medieval terminal—John de Vigo has in a few lines a very complete description of the method of filling teeth with gold-leaf which deserves to be quoted. Only that it was a common practice he would surely have described it more in detail, though he could have added nothing to the significance of what he has to say: “By means of a drill or file the putrefied or corroded part of the teeth should be completely removed. The cavity left should then be filled with gold-leaf.”

Much more is known about the medieval anticipation of other specialities—those of the throat and nose, and eye and ear—and the surprise is with regard to dentistry, which is usually quite unknown. The fact, however, that dentistry developed so much more than is usually thought prepares the mind for the anticipations in other departments. Following that of dentistry should come naturally the mouth and throat, and it happens that the men whose writings in dentistry are known also touched on these subjects.

The medical writers of the early Middle Ages, particularly Aëtius, Alexander of Tralles, and Paul of Ægina, have not a little to say with regard to affections of the throat and nose, and the eye and ear. Alexander’s chapter on the Treatment of Affections of the Ear, Gurlt considers ample evidence of large practical experience and power of observation. Alexander describes the ordinary mode of getting water out of the external auditory canal by standing on the leg corresponding to the side in which the water is, and kicking out with the opposite leg. Foreign bodies should be removed by an ear spoon, or a small instrument wrapped in wool and dipped in sticky material. He suggests sneezing with the head leaning toward the side on which the foreign body is present. Insects or worms that find their way into the ear may be killed by injections of dilute acid and oil or other substances.

Paul of Ægina has a very practical technique for the removal of fish-bones or other objects caught in the throat. He also gives the detailed technique of opening the larynx or trachea, with the indications for this operation. He also describes how wounds of the neck should be sewed after attempts at suicide. In a word, the more one knows of these old-time medieval writers of the sixth and seventh centuries the clearer it becomes that they had learned their lessons well from the ancients, and passed on an excellent tradition to their colleagues of succeeding generations. If these lessons were not properly taken, it was because the disturbance of civilization caused by the coming down of the Teutonic invaders into Italy took away interest in the things of the mind and of the body, until the coming of another upward turn in progress.

Arculanus has some very interesting paragraphs with regard to the treatment of conditions in the nose. For instance, in the treatment of polyps, he says that they should be incised and cauterized. Soft polyps should be drawn out with a toothed tenaculum as far as can be without risk of breaking them off. The incision should be made at the root, so that nothing or just as little as possible of the pathological structure be allowed to remain. It should be cut off with fine scissors; or with a narrow file just small enough to permit ingress into the nostrils; or with a scalpel without cutting edges on the sides, but only at its extremity, and this cutting edge should be broad and well sharpened. If there is danger of hæmorrhage, or if there is fear of it, the instruments with which the section is made should be fired (igniantur)—that is, heated at least to a dull redness. Afterwards the stump, if any remains, should be touched with a hot iron or else with cauterizing agents, so that as far as possible it should be obliterated.

After the operation, a pledget of cotton dipped in the green ointment described by Rhazes should be placed in the nose. This pledget should have a string fastened to it, hanging from the nose, in order that it may be easily removed. At times it may be necessary to touch the root of the polyp with a stylet, on which cotton has been placed that has been dipped in aqua fortis (nitric acid). It is important that this cauterizing fluid should be rather strong, so that after a certain number of touches a rather firm eschar is produced. In all these manipulations in the nose Arculanus recommends that the nose should be held well open by means of a nasal speculum. Pictures of all these instruments occur in his extant works, and indeed this constitutes one of their most interesting and valuable features. They are to be seen in Gurlt’s “History of Surgery.”

In some of the cases he had seen, the polyp was so difficult to get at, or was situated so far back in the nose, that it could not be reached by means of a tenaculum or scissors, or even the special knife devised for that purpose. For these patients Arculanus describes an operation that is to be found in the older writers on surgery—Paul of Ægina (Æginetas), Avicenna, and some of the other Arabian surgeons. For this, three horse-tail hairs are twisted together and knotted in three or four places, and one end is passed through the nostrils and out through the mouth. The ends of this are then pulled on backward and forward after the fashion of a saw. Arculanus remarks, evidently with the air of a man who has tried it and not been satisfied, that this operation is quite uncertain, and seems to depend a great deal on chance, and much reliance must not be placed on it. Arculanus suggests a substitute method by which latent polyps—or occult polyps, as he calls them—may be removed.

Among the affections of the upper air passages mentioned by Arculanus are various forms of sore throat, which he calls Synanche or Cynanche, or angina. A milder form of the affection was called Parasynanche. The medieval teaching with regard to an angina that was causing severe difficulty of breathing was to perform tracheotomy. Arculanus goes into some detail with regard to affections of the uvula, which was made much more responsible for throat affections than at the present time. The popular tradition in our time of the uvula and its fall is evidently a remnant of the medieval teaching with regard to it. Arculanus’s description of the removal of the uvula, or at least of the tip of it, gives a very good idea of how thorough the teaching of surgical technique was in his time. His directions are: “Seat the patient upon a stool in a bright light, while an assistant holds the head; after the tongue has been firmly depressed by means of a speculum, let the assistant hold this speculum in place. With the left hand then insert an instrument, a stilus, by which the uvula is pulled forward; and then remove the end of it by means of a heated knife or some other process of cauterization. The mouth should afterwards be washed out with fresh milk.”

The application of a cauterizing solution by means of a cotton swab wrapped round the end of a sound may be of service in patients who refuse the actual cautery. To be successful, he insists that the application must be firmly made and must be frequently repeated.

With regard to ophthalmology the older history has always been thoroughly appreciated. Even as early as the time of Hammurabi (2200 b.c.) some rather extensive and interesting surgery of the eye was practised, for the fees for these operations are mentioned in the code. All of the early medieval writers on medicine and surgery—Aëtius, Alexander of Tralles, and Paul of Ægina—have paragraphs at least, and sometimes more, with regard to eye operations and the care of the eyes.

Operations above all for cataract have been practised from very early times, and are mentioned also by many medieval writers on medicine and surgery. It is not surprising, then, to find that the medieval surgeons particularly discussed a number of eye diseases and the operations for them. Pope John XXI., who before he became Pope was known as Petrus Hispanus (the Spaniard), and who had been a professor of surgery and a papal physician, wrote a book on eye diseases in the latter half of the thirteenth century, which has come down to us. He had much to say of cataract, dividing it into traumatic and spontaneous, and suggesting operation by needling, a gold needle being used for that purpose. Pope John describes a form of hardness of the eye which would seem to be what we now call glaucoma, and has a number of external applications for eye diseases. Most of his collyria had some bile in them, the bile of various kinds of animals and birds being supposed to be progressively more efficient for the cure of external affections of the eye. This very general use of bile, or of an extract of the livers of animals or fishes, seems to be a heritage from biblical times, when old Toby was cured of his blindness by the gall of the fish.[13 - Dr. Petells, discussing this use of livers (Janus, 1898), says that there has been some tendency to revert to the idea of biliary principles as of value in external eye diseases.] The Pope ophthalmologist (see Opthalmology, Milwaukee, January, 1909) recommended the urine of infants as an eye-wash, experience having evidently shown that this fluid, which is usually bland and unirritating, a solution of salts of a specific gravity such that it would not set up osmotic processes in the eye, was empirically of value. In the Middle Ages the idea of using it would be much less deterrent, because it was quite a common practice for physicians to taste urine in order to test it for pathological conditions.

Spectacles were rather commonly used in the Middle Ages, probably having been invented in the second half of the thirteenth century by Salvino de Armato of Florence. Bernard de Gordon mentions them under the name oculus berellinus early in the fourteenth century. They were originally made from a kind of smoky crystal, berillus, whence the German name Brillen and the French besicles (Garrison). Guy de Chauliac suggests that when collyria failed to improve the sight spectacles should be employed. Almost needless to say, this use of spectacles meant very much for the comfort and convenience of old people. Up to that time most of those who reached the age of three-score would be utterly unable to read, and would have to depend either on others or on their memory for teaching and many other purposes. External eye troubles, as those due to trichiasis and to various disturbances of the lachrymal apparatus, were treated by direct mechanical means. Some very ingenious suggestions and manipulations were made with regard to them.

CHAPTER IX

MEDICAL EDUCATION FOR WOMEN

Among the rather startling surprises that have developed, as the growth of our knowledge of medieval history, through consultation of the documents in recent years, is constantly contradicting traditions founded on lack of information, perhaps the greatest has been to learn that women were given opportunities for the higher education at practically all of the Italian universities, and that they became not only students, but professors, at many of these institutions. No century from the twelfth down to the nineteenth was without some distinguished women professors at Italian universities, and in the later Middle Ages there was a particularly active period of feminine education.

The most interesting feature of this development for us is that the application of women to medical studies from the twelfth to the fourteenth centuries was not only not discouraged, but was distinctly encouraged, and we find evidence that a number of women studied and taught medicine, wrote books on medical subjects, were consulted with regard to medico-legal questions, and in general were looked upon as medical colleagues in practically every sense of the word. The very first medical school that developed in modern times, that of Salerno, which came into European prominence in the eleventh century, was quite early in its history opened to women students, and a number of women professors were on its faculty.

Considering the modern idea that ours is the first time when women have ever had any real opportunity for the higher education, and above all professional education, it is a source of no little astonishment to find that at Salerno not only an opportunity was afforded to women to study medicine, but the department of women’s diseases was handed over entirely to them, and as a consequence we have a Salernitan School of Women Physicians, some of whom wrote textbooks on the subject relating to this speciality. De Renzi, in his “Storia della Scuola di Salerno,” has brought to light many details of the history of this phase of medical education for women at the first important medical school that developed in modern Europe. The best known of these medieval women physicians was Trotula, to whom is attributed a series of books on medical subjects—though doubtless some of these were due rather to disciples, but became identified with the more famous master, as so often happened with medieval books. Trotula’s most important book bears two sub-titles: “Trotula’s Unique Book for the Curing of Diseases of Women, Before, During, and After Labour,” and the other sub-title, “Trotula’s Wonderful Book of Experiences (experimentalis) in the Diseases of Women, Before, During, and After Labour, with Other Details Likewise Relating to Labour.”

Probably the most interesting passage in her book for the modern time is that with regard to a torn perineum and its repair, even when prolapse of the uterus is a complication. The passage, which may be found readily in De Renzi or in Gurlt, runs:

“Certain patients, from the severity of the labour, run into a rupture of the genitalia. In some even the vulva and anus become one foramen, having the same course. As a consequence, prolapse of the uterus occurs, and it becomes indurated. In order to relieve this condition, we apply to the uterus warm wine in which butter has been boiled, and these fomentations are continued until the uterus becomes soft, and then it is gently replaced. After this we sew the tear between the anus and vulva in three or four places with silk thread. The woman should then be placed in bed, with the feet elevated, and must retain that position, even for eating and drinking, and all the necessities of life, for eight or nine days. During this time, also, there must be no bathing, and care must be taken to avoid everything that might cause coughing, and all indigestible materials.”

There is a passage almost more interesting with regard to prophylaxis of rupture of the perineum. Trotula says: “In order to avoid the aforesaid danger, careful provision should be made, and precautions should be taken during labour after the following fashion: A cloth folded in somewhat oblong shape should be placed on the anus, and during every effort for the expulsion of the child, that should be pressed firmly, in order that there may not be any solution of the continuity of tissue.”