 Chapter 11 of Old Time Makers of Medicine. Chapter 11. Guy de Choliac. Part 1 of 2. One of the most interesting characters in the history of medieval medicine, and undoubtedly the most important and significant of these old time makers of medicine, is Guy de Choliac. Most of the false notions so commonly accepted with regard to the Middle Ages at once disappear after a careful study of his career. The idea of the careful application of scientific principles in a great practical way is far removed from the ordinary notion of medieval procedure. Some observations we may concede that they did make, but we are inclined to think that these were not regularly ordered, and the lessons of them not drawn so as to make them valuable as experiences. Great art, men may have had, but science, and, above all, applied science, is a later development of humanity. Particularly this is supposed to be true with regard to the science and practice of surgery, which is assumed to be of comparatively recent origin. Nothing could well be less true, and if the thoroughly practical development of surgery may be taken as a symbol of how capable men were of applying science and scientific principles, then it is comparatively easy to show that the men of the later Middle Ages were occupied very much as have been our recent generations with science and its practical applications. The immediate evidence of the value of old-time surgery is to be found in the fact that Guy Descholiac, who is commonly spoken of in the history of medicine as the father of modern surgery, lived his seventy-odd years of life during the fourteenth century and accomplished the best of his work, therefore, some five centuries before surgery in our modern sense of the term is supposed to have developed. A glance at his career, however, will show how old are most of the important developments of surgery, as also in what a thoroughly scientific temper of mind this subject was approached more than a century before the close of the Middle Ages. The life of this French surgeon, indeed, who was a cleric and occupied the position of Chamberlain and physician-in-ordinary to three of the Avion Popes, is not only a contradiction of many of the traditions as to the backwardness of our medieval forebears in medicine, that are readily accepted by many presumably educated people, but it is the best possible antidote for that insistent misunderstanding of the Middle Ages, which attributes profound ignorance of science, almost complete failure of observation, and an absolute lack of initiative in applications of science to the men of those times. Guy Descholiac's life is modern in nearly every phase. He was educated in a little town of the south of France, made his medical studies at Montpellier, and then went on a journey of hundreds of miles into Italy in order to make his postgraduate studies. Italy occupied the place in science at that time that Germany has taken during the 19th century. A young man who wanted to get into touch with the great masters in medicine naturally went down into the peninsula. Traditions as to the attitude of the Church to science notwithstanding, Italy where education was more completely under the influence of the Popes and Ecclesiastics than in any other country in Europe, continued to be the home of postgraduate work in science for the next four centuries. Almost needless to say, the journey to Italy was more difficult of accomplishment and involved more expense and time than would even the voyage from America to Europe in our time. Choliac realized, however, that both time and expense would be well rewarded, and his ardor for the rounding out of his education was amply recompensed by the event. Nor have we any reason for thinking that what he did was very rare, much less unique in his time. Many a student from France, Germany, and England made the long journey to Italy for postgraduate opportunities during the Middle Ages. Even this postgraduate experience in Italy did not satisfy Choliac, however, for, after having studied several years with the most distinguished Italian teachers of anatomy and surgery, he spent some time in Paris, apparently so as to be sure that he would be acquainted with the best that was being done in his specialty in every part of the world. He then settled down to his own life work, carrying his Italian and French master's teachings well beyond the point where he received them, and after years of personal experience, he gathered together his master's ideas, tested by his own observations, into his Shirogio Magna, a great textbook of surgery, which sums up the whole subject succinctly, yet completely for succeeding generations. When we talk about what he accomplished for surgery, we are not dependent on traditions nor vague information gleaned from contemporaries and successors, who might perhaps have been so much impressed by his personality as to be made over-enthusiastic in their critical judgment of him. We know the man in his surgical works, and they have continued to be classics in surgery ever since. It is an honorable distinction for the medicine of the later 14th, the 15th, and 16th centuries that Guy de Choliac's book was the most read volume of the time in medicine. Evidently, the career of such a man is of import, not alone to physicians, but to all who are interested in the history of education. Choliac derives his name from the little town of Choliac in the diocese of Mend, almost in the center of what is now the Department of Lozari. The records of births and deaths were not considered so important in the 14th century as they are now, and so we are not sure of either in the case of Choliac. It is usually considered that he was born sometime during the last decade of the 13th century, probably toward the end of it, and that he died about 1370. Of his early education, we know nothing, but it must have been reasonably efficient since it gave him a good working knowledge of Latin, which was the universal language of science and especially of medicine at that time. And though his own style, as must be expected, is no better than that of his contemporaries, he knew how to express his thoughts clearly in straightforward Latin, with only such a mixture of foreign terms as his studies suggested and the exigencies of a new development of science almost required. Later in life, he seems to have known Arabic very well, for he is evidently familiar with Arabian books and does not depend merely on translations of them. Pagel, in the first volume of Pushman's Handbook of the History of Medicine, says, on the authority of Nikais and others, that Choliac received his early education from the village clergymen. His parents were poor, and but for ecclesiastical interest in him, it would have been difficult for him to obtain his education. The church supplied at that time, to a great extent, for the foundations and scholarships, home and traveling, of our day, and Choliac was amongst the favored ones. How well he deserved the favor, his subsequent career shows, as it completely justifies the judgment of his patrons. He went first to Toulouse, as we know from his affectionate mention of one of his teachers there. Toulouse was more famous for law, however, than for medicine, and after a time, Choliac sought Montpelier to complete his medical studies. For English-speaking people, an added interest in Gaide Choliac will be the fact that one of his teachers at Montpelier was Bernard Gordon, very probably a scotchman, who taught for some 35 years at this famous university in the south of France, and died near the end of the first quarter of the 14th century. One of Choliac's fellow students at Montpelier was John of Gadinson, the first English royal physician by official appointment of whom we have any account. John is mentioned by Chaucer in his Doctor of Physics, and is usually looked upon as one of the fathers of English medicine. Choliac did not think much of him, though his reason for his dislike of him will probably be somewhat startling to those who assume that the men of the Middle Ages always clung civilly to authority. Choliac's objection to Gadinson's book is that he merely repeats his masters and does not dare to think for himself. It is not hard to understand that such an independent thinker as Choliac should have been utterly dissatisfied with a book that did not go beyond the forefathers in medicine that the author quotes. This is the explanation of his well-known expression, quote, Let of all arose the sentless Rose of England, Rosa Angale, was the name of John of Gadinson's book, in which, on its being sent to me, I hope to find the odor of sweet originality, but instead of that, I encountered only the fictions of Hispanus, of Gilbert, and of Theodoric, end quote. The presence of a Scotch professor and an English fellow student, afterwards a royal physician at Montpellier, at the beginning of the 14th century, shows how much more cosmopolitan was university life in those times than we are prone to think, and what attraction a great university medical school possessed, even for men from long distances. After receiving his Doctor of Medicine at Montpellier, Choliac went, as we have said, to Bologna. Here he attracted the attention and received the special instruction of Bertuzio, who was attracting students from all over Europe at this time, and was making some excellent demonstrations in anatomy, employing human dissections very freely. Choliac tells of the methods that Bertuzio used in order that bodies might be in as good condition as possible for demonstration purposes, as mentions the fact that he saw him do many dissections in different ways. In Roth's life of Vesalius, which is usually considered one of our most authoritative medical historical works, not only with regard to details of Vesalius's life, but also in all that concerns anatomy about that time, and for some centuries before, there is a passage quoted from Choliac himself, which shows how freely dissection was practiced at the Italian universities in the 14th century. This passage deserves to be quoted at some length, because there are even serious historians who still cite a bull of Pope Boniface VIII, issued in 1300, forbidding the boiling and dismembering of bodies in order to transport them to long distances for burial in their own country, as being, either rightly or wrongly, interpreted as a prohibition of dissection, and, wherefore, preventing the development of anatomy. In the notes to his history of dissection during this period in Bologna, Roth says, quote, Without doubt, the passage in Gaide Choliac, which tells of having frequently seen dissections, must be considered as referring to Bologna. This passage runs as follows. My master Bertucius conducted the dissection very often after the following manner. The dead body, having been placed upon a bench, he used to make four lessons on it. In the first, the nutritional portions were treated, because they are so likely to become putrified. In the second, he demonstrated the spiritual members. In the third, the animate members. In the fourth, the extremities, end quote. Roth, Enrius Vesalius, Basil, 1896. Bertuccio's master, Mondino, is hailed in the history of medicine as the father of dissection. His book on dissection was for the next three centuries in the hands of nearly every medical scholar in Europe who is trying to do good work in anatomy. It was not displaced until Vesalius came, the father of modern anatomy, who revolutionized the science in the Renaissance time. Mondino had devoted himself to the subject with unfailing ardor and enthusiasm, and from everywhere in Europe, the students came to receive inspiration in his disacting room. Within a few years, such was the enthusiasm for dissection aroused by him in Bologna, that there were many legal prosecutions for body snatching, the consequence doubtless of a regulation in the medical department of the University of Bologna, that if the students brought a body to any of their teachers, he was bound to dissect it for them. Bertuccio, Mondino's disciple and successor, continued this great work, and now Sholiac, the third in the tradition, was to carry the Bolognese methods back to France, and his position as Chamberlain to the Pope was to give them a wide vogue throughout the world. The great French surgeon's attitude toward anatomy and dissection can be judged from his famous expression that, quote, the surgeon ignorant of anatomy carves the human body as a blind man carves wood, end quote. The whole subject of dissection at this time has been fully discussed in the first three chapters of my Popes and Science, where those who are interested in the matter may follow it to their satisfaction. After his Bologna experience, Sholiac went to Paris. Evidently, his indefatigable desire to know all that there was to be known would not be satisfied until he had spent some time at the great French University where Lanfrank, after having studied under William of Salisette in Italy, had gone to establish that tradition of French surgery which, carried on so well by Mondaville his great successor, was to maintain Frenchmen as the leading surgeons of the world until the 19th century, Pagel. Lanfrank, himself an Italian, had been exiled from his native country apparently because of political troubles, but was welcomed at Paris because the faculty realized that they needed the inspiration of the Italian medical movement in surgery for the establishment of a good school of surgery in connection with the university. The teaching so well begun by Lanfrank was magnificently continued by Mondaville and Arnold of Villanova in their disciples. Sholiac was fortunate enough to come under the influence of Petrus de Argenteria, who was worthily maintaining the tradition of practical teaching in anatomy and surgery so well founded by his great predecessors of the 13th century. After this grand tour, Sholiac was himself prepared to do work of the highest order, for he had been in touch with all that was best in the medicine and surgery of his time. Like many another distinguished member of his profession, Sholiac did not settle down in the scene of his ultimate labors at once, but was something of a wanderer. His own words are, quote, et permulta tempora operatus fui in multis partibus, end quote, perhaps out of gratitude to the clerical patrons of his native town, to whom he owed so much, or because of the obligations he considered that he owed them for his education, he practiced first in his native diocese of men, as he removed to Leones, where we know that he lived for several years. For in 1344, he took part as a canon in a chapter that met in the church of Saint Just in that city. Just when he was called to Avignon, we do not know, though when the Black Death ravaged that city in 1348, he was the body physician of Pope Clement VI, for he has spoken of, in a papal document, as, quote, venerabilis et circumspectus vir dominus guido de caliaco, conicus et prepositus ecclesiae sancti justi lugdini, medicusche domini nostri pope, end quote. All the rest of his life was passed in the papal capital, which Avignon was for some 70 years of the 14th century. He served as Chamberlain physician to three Popes, Clement VI, Innocent VI, and Urban V. We do not know the exact date of his death, but when Pope Urban V went to Rome in 1367, Sholiak was putting the finishing touches on his Shirogeo magna, which, as he tells us, was undertaken as a solatium senectudis, a solace in old age. When Urban returned to Avignon for a time in 1370, Sholiak was dead. His life work is summed up for us in this great treatise on surgery, full of anticipations in surgical procedures that we are prone to think much more modern. Nikes has emphasized the principles which guided Guy de Sholiak in the choice and interpretation of his authorities by a quotation from Guy himself, which is so different in its tone from what is usually supposed to have been the attitude of mind of the men of science of the time, that it would be well for all those who want to understand the Middle Ages better to have it near them. Speaking of the surgeons of his own, and immediately preceding generations, Guy says, quote, One thing particularly is a source of annoyance to me in what these surgeons have written, and it is that they follow one another like so many cranes, for one always says what the other says. I do not know whether it is from fear or from love, that they do not deign to listen except to such things as they are accustomed to, and as have been proved by authorities. They have to my mind understood very badly Aristotle's second book of metaphysics, where he shows that these two things, fear and love, are the greatest obstacles on the road to the knowledge of the truth. Let them give up such friendships and fears. Quote, Because while Socrates or Plato may be a friend, truth is a greater friend, end quote. Truth is a holy thing and worthy to be honored above everything else. Let them follow the doctrine of Galen, which is entirely made up of experience and reason, and in which one investigates things and despises words, end quote. After all, this is what great authorities in medicine have always insisted on. Once every hundred years or so, one finds a really great observer who makes new observations and wakes the world up. He is surprised that men should not have used their powers of observation for themselves, but should have been following old time masters. His contemporaries often refuse to listen to him at first. His observations, however, eventually make their way. We blame the Middle Ages for following authority, but what have we been always doing but following authority, except for the geniuses who come and lift us out of the rut and illuminate a new portion of the realm of medicine? After they have come, however, and done their work, their disciples proceed to see with their eyes and to think that they are making observations for themselves when they are merely following authority. When the next master in medicine comes along, his discovery is neglected, because men have not found it in the old books, and usually he has to suffer for daring to have opinions of his own. The fact of the matter is that at any time, there is only a very limited number of men who think for themselves. The rest think other people's thoughts and think they are thinking and doing things. As for observation, John Ruskin once said, quote, Nothing is harder than to see something and tell it simply as you saw it, end quote. This is as true in science as in art, and only genius succeeds in doing it well. Sholayak's book is confessedly a compilation. He has taken the good wherever he found it, though he adds, modestly enough, that his work also contains whatever his own measure of intelligence enabled him to find useful, quote, juxtamada ketatum, may ingenie uttila reputavi. Indeed, it is the critical judgment displayed by Sholayak in selecting from his predecessors that best illustrates at once the practical character of his intellect and his discerning spirit. What the men of his time are said to have lacked is the critical faculty. They were encyclopedic in intellect and gathered all kinds of information without discrimination, is a very common criticism of medieval writers. No one can say this of Sholayak, however, and, above all, he was no respecter of authority, merely for the sake of authority. His criticism of John of Gadinson's book shows that the blind following of those who had gone before was his special bête noir. His bitterest reproach for many of his predecessors was that, quote, they follow one another like cranes, whether for love or fear, I cannot say, end, quote, end of Part 1 of 2. Chapter 11 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 Marcicic, September 2009, Alexandria, Virginia, Old Time Makers of Medicine by James Joseph. Chapter 11, Guy de Sholayak, Part 2 of 2. Sholayak's right to the title of Father of Surgery will perhaps be best appreciated from the brief account of his recommendations as to the value of surgical intervention for conditions in the three most important cavities of the body, the skull, the thorax, and the abdomen. These cavities have usually been the dread of surgeons. Sholayak not only used the trefine, but laid down very exact indications for its application. Expectant treatment was to be the rule in wounds of the head, yet when necessary, interference was counseled as of great value. His prognosis of brain injuries was much better than that of his predecessors. He says that he had seen injuries of the brain followed by some loss of brain substance, yet with complete recovery of the patient. In one case that he notes, a considerable amount of brain substance was lost, yet the patient recovered with only a slight defect of memory and even this disappeared after a time. He lays down exact indications for the opening of the thorax that Nolayme Tanjere, of surgeons at all times, even our own, and points out the relations of the ribs and the diaphragm so as to show just where the opening should be made in order to remove fluid of any kind. In abdominal conditions, however, Sholayak's anticipation of modern views is most surprising. He recognized that wounds of the intestines were surely fatal unless leakage could be prevented. Accordingly, he suggested the opening of the abdomen and the sewing up of such intestinal wounds as could be located. He describes a method of suture for these cases and seems like many another abdominal surgeon even to have invented a special needle holder. To most people, it would seem absolutely out of the question that such surgical procedures could be practiced in the 14th century. We have the definite record of them, however, in a textbook that was the most read volume on the subject for several centuries. Most of the surprise with regard to these operations will vanish when it is recalled that in Italy during the 13th century, as we have already seen, methods of anesthesia by means of opium and mandragora were in common use, having been invented in the 12th century and perfected by Ugo de Luzza and Sholayak must not only have known but must have frequently employed various methods of anesthesia. In discussing amputations, he has described in general certain methods of anesthesia in use in his time and especially the method by means of inhalation. It would not seem to us in the modern time that this method would be very successful, but there is an enthusiastic accord of authorities attesting that operations were done at this time with the help of this inhalant without the infliction of pain. Sholayak says, quote, A new sponge is soaked by them and these juices are left to dry in the sun and when they have need of it, they put this sponge into warm water and then hold it under the nostrils of the patient until he goes to sleep. Then they perform the operation, end quote. Many people might be prone to think that the hospitals of Sholayak's time would not be suitable for such surgical work as he describes. It is, however, only another amusing assumption of this self-complacent age of ours to think that we were the first whoever made hospitals worthy of the name and of the great humanitarian purpose they sub-serve. As a matter of fact, the old-time hospitals were even better than ours or, as a rule, better than any we had until the present generation. In The Popes and Science, in the chapter on the foundation of city hospitals, I call attention to the fact that architects of the present day go back to the hospitals of the Middle Ages in order to find the models for hospitals for the modern times. Mr. Arthur Dillon, a well-known New York architect, writing of a hospital built at Tonere in France toward the end of the 13th century, 1292, says, quote, it was an admirable hospital in every way, and it is doubtful if we today surpass it. It was isolated, the ward was separated from the other buildings, it had the advantage we so often lose of being but one story high, and more space was given to each patient than we can now afford. The ventilation by the great windows and ventilators in the ceiling was excellent, it was cheerfully lighted, and the arrangement of the gallery shielded the patients from dazzling light and from droughts from the windows and afforded an easy means of supervision. While the division by the ruthless low partitions isolated the sick and obviated the depression that comes from the sight of others in pain, it was, moreover, in great contrast to the cheerless white wards of today. The vaulted ceiling was very beautiful, the woodwork was richly carved, and the great windows over the altars were filled with colored glass. Altogether it was one of the best examples of the best period of Gothic architecture, end quote. The fine hospital thus described was but one of many. Virchow, in his article on hospitals quoted in the same chapter, called attention to the fact that in the 13th and 14th centuries, every town of 5,000 or more inhabitants had its hospital founded on the model of the great Santo Spirito Hospital in Rome, and all of them did good work. The surgeons of Guy de Choliac's time would indeed find hospitals wherever they might be called in consultation, even in small towns. They were more numerous in proportion to population than our own, and, as a rule, at least as well organized as ours were until the last few years. It is no wonder that with such a good hospital organization, excellent surgery was accomplished. Hernia was Choliac's specialty, and in it his surgical judgment is admirable. Mondaville, before his time, did not hesitate to say that many operations for Hernia were done not for the benefit of the patient, but for the benefit of the surgeon, a very striking anticipation of remarks that one sometimes hears even at the present time. Choliac discussed operations for Hernia very conservatively. His rule was that a trust should be worn and no operation attempted unless the patient's life was endangered by the Hernia. It is to him that we owe the invention of a well-developed method of taxes or manipulation of a Hernia to bring about its reduction, which was in use until the end of the 19th century. He suggested that trusses could not be made according to rule, but must be adapted to each individual case. He invented several forms of truss himself, and in general it may be said that his manipulative skill and his power to apply his mechanical principles to his work are the most characteristic of his qualities. This is particularly noteworthy in his chapters on fractures and dislocations, in which he suggests various methods of reduction and realizes very practically the mechanical difficulties that were to be encountered in the correction of the deformities due to these pathological conditions. In a word, we have a picture of the skilled surgeon of the modern time in this treatise of a 14th century teacher of surgery. Scholiac discusses six different operations for the radical cure of Hernia. As Groot points out, he criticizes them from the same standpoint as that of recent surgeons. The object of radical operations for Hernia is to produce a strong, firm tissue support over the ring through which the cord passes so that the intestines cannot descend through it. It is rather interesting to find that the surgeons of this time tried to obliterate the canal by means of the cottery or inflammation-producing agents, arsenic and the like, a practice that recalls some methods still used more or less irregularly. They also used gold wire, which was to be left in the tissues and is supposed to protect and strengthen the closure of the ring. At this time, all these operations for the radical cure of Hernia involved the sacrifice of the testicle because the old surgeons wanted to obliterate the ring completely and thought this the easiest way. Scholiac discusses the operation in this respect and says that he has seen many cases in which men possessed of but one testicle have procreated, and this is a case where the lesser of two evils is to be chosen. Of course, Guy de Scholiac would not have been able to operate so freely on Hernia and suggest, following his own experience, methods of treatment, of penetrating wounds of the abdomen, only that he had learned the lessons of antiseptic surgery which had been gradually developed among the great surgeons of Italy during the preceding century. The use of the stronger wines as addressing together with insistence on the most absolute cleanliness of the surgeon before the operation and careful details of cleanliness during the operation made possible the performance of many methods of surgical intervention that would otherwise surely have been fatal. Probably nothing is harder to understand than that after these practical discoveries men should have lost sight of their significance and after having carefully studied the viscous exudation which produces healthy natural union should have come to the thought of the necessity for the formation of laudable pus before union might be expected. The mystery is really no greater than that of many another similar incident in human history but it strikes us more forcibly because the discovery and gradual development of antiseptic surgery in our own time has meant so much for us. Already even in Sholiac's practice, however, some of the finer elements of the technique that made surgery antiseptic to a marked degree. If not positively aseptic in many cases, we're not being emphasized as they were by his predecessors and there was a beginning of surgical metalsomeness reasserting itself. It must not be thought, however, that it was only with the course applications of surgery that Sholiac concerned himself. He was very much interested in the surgical treatment of eye diseases and wrote a monograph on cataract that gathers what was known before his time and discusses it in the light of his own experience. The writing of such a book is not so surprising at this time if we recall that in the preceding century, the famous Pope John XXI who had been a physician before he became Pope and under the name of Peter of Spain was looked up to as one of the distinguished people of the time, had written a book on eye diseases that has recently been the subject of much attention. Pope John had much to say of cataract dividing it into traumatic and spontaneous and suggesting the needling of cataract, a gold needle being used for the purpose. Sholiac's method of treating cataract was by depression. His care in the selection of patients may be appreciated as treatment of John of Luxembourg, king of Bavaria, blind from cataract, who consulted Sholiac in 1336 while on a visit to Avignon with the king of France. Sholiac refused to operate, however, and put off the king with dietary regulations. In the chapter of John of Arcoli and Medieval Dentistry we call attention to the fact that Sholiac discussed dental surgery briefly, yet with such practical detail as to show very clearly how much more was known about this specialty in his time than we have had any idea of until recent years. He recognized the dentist as specialist, calls them dentatories, but thinks that they should operate under the direction of a physician. Hence the physician should know much about teeth and especially about their preservation. He enumerates instruments that dentists should have and shows very clearly that the specialty had reached a high state of development. A typical example of Sholiac's common sense and dependence on observation and not tradition is to be found in what he has to say with regard to methods of removing the teeth without the use of extracting instruments. It is characteristic of his method of dealing with traditional remedies even though of long standing that he brushes them aside with some impatience if they have not proved themselves in his experience. These ancients mention many medicaments which draw out the teeth without iron instruments or which make them more easy to draw out such as the milky juice of the tithimal with pyrethrum, the roots of the mulberry and caper, citrine arsenic, aquafortis, the fad of forest frogs, but these remedies promise much and accomplish but little. My eels donate, bucoe, de promisee, et piu de operations." It is no wonder that Sholiac has been enthusiastically praised. Nikais has devoutly gathered many of these praises into a sheaf of eulogies at the end of his biography of the great French surgeon. He tells us that Phalopias compared him to Hippocrates. John Calvo of Valencia who translated the great surgery into Spanish looks upon him as the first law giver of surgery. Frined, the great English in 1725 called him the Prince of Surgeons. Ackerman said that Guy de Sholiac's textbook will take the place of all that has been written on the subject down to his time. So that even if all the other works had been lost, his would replace them. Desimeris commenting on this says that quote, if one should take this appreciation literally this surgeon of the 14th century would be the first and, up to the present time the only author who ever merited such an eulogy. At least, he adds, we cannot refuse him the distinction of having made a work infinitely superior to all those which appeared up to this time and even for a long time afterwards. Posterity rendered him this justice for he was for three centuries the classic par excellence. He rendered the study easy and profitable and all the foreign nations the tributaries of our country end quote. Pirelli suggested Guy's surgery as the most valuable and complete work of all those in the same kind that had been published since Hippocrates and added that the reading of it was still useful at this time in 1784. Begin in his work on Embro's Paré says, quote, that Guy has written an immortal book to which are attached the destinies of French surgeons, end quote. Malgané in his history of surgery does not hesitate to say quote, I do not fear to say that Hippocrates alone accepted there is not a single treatise on surgery Greek, Latin, or Arabic which I place above or even on the same level with this magnificent work the surgery of Guy Descholiak end quote. Derenberg said quote, Guy seems to us a surgeon above all erudite yet expert in without ever being rash, he knows above all how to choose best in everything, end quote. Vernuel in his conference erudites says, quote, the services rendered by the great surgery were immense, by it there commenced for France an era of splendor. It is with justice then that posterity has decreed to Guy Descholiak the title of father of French surgery end quote. The more one reads of Choliak's work, the less one is surprised at the estimation in which he has been held wherever known. It would not be hard to add a further sheaf of compliments to those collected by Nikkei's. Modern writers on the history of medicine have all been enthusiastic in their admiration of him just in proportion to the thoroughness of their acquaintance with him. Portal, in his history of anatomy and surgery, says, quote finally it may be a word that Guy Descholiak said nearly everything which modern surgeons say and that his work is of infinite price, but unfortunately too little read, too little pondered, end quote. Mulgani declares Choliak's surgery a magna to be a masterpiece of learned and luminous writing. Professor Clifford Albert the Regist Professor of Physics at the University of Cambridge says of Choliak's treaties, quote this great work I have studied carefully and not without prejudice, yet I cannot wonder that Philopius compared the author to Hippocrates or that John Freind calls him the Prince of Surgeons. Ephoristic, orderly, and precise, end quote. If to this account of his professional career it be added that Choliak's personality is, if possible, more interesting than his surgical accomplishment, some idea of the significance of the life of the great father of modern surgery will be realized. We have already quoted the distinguished words of praise accorded him by Clemence VI, that they were well-deserved. Choliak's conduct during the Black Death with Traveged Avignon in 1348, shortly after his arrival in the Papal City would have been sufficient of itself to attest. The occurrence of the plague in a city usually gave rise to an exhibition of the most errant cowardice and all who could fled. In many of the European cities the physicians joined the fugitives and the ailing were left to care for themselves. With a few notable exceptions this was the case at Avignon, but Guy was among those who remained faithful to his duty and took on himself the self-sacrificing labor of caring for the sick, doubly harassing because so many of his brother physicians were absent. He denounces their conduct as shameful, yet does not boast of his own courage, but on the contrary says that he was in constant fear of the disease. Toward the end of the epidemic he was attacked by the plague and, for a time, his life was despaired of. Fortunately he recovered to become the most influential among his colleagues, the most highly admired of the physicians of the generation, and the close personal friend of all the high ecclesiastics who had witnessed his magnificent display of courage and of helpfulness for the plague stricken during the epidemic. He wrote a very clear account of the epidemic, which leaves no doubt that it was true bubonic plague. After this fine example Sholiak's advice to brother physicians in the specialty added weight. In the introductory chapters of his Shirogeumagna he said, quote, the surgeon should be learned, skilled, ingenious, and of good morals. Be bold in things that are sure, cautious in dangers. Avoid evil cures and practices. Be gracious to the sick, obliging to his colleagues. Wise in his predictions. Be chaste, sober, merciful, and merciful, not covetous nor extortionate of money, but let the recompense be moderate, according to the work, the means of the sick, the character of the issue or event, and its dignity, end quote. No wonder that Malgani says of him, quote, never since Hippocrates has medicine heard such language filled with so much nobility and so full of matter and so few words, end quote. Sholiak was in every way worthy of his great contemporaries and the period in which his lot was cast. Ordinarily we are not apt to think of the early 14th century as an especially productive period in human history, but such it is. Dante's Divine Comedy was entirely written during Sholiak's life. Petrarch was born within a few years of Sholiak himself, Boccaccio in Italy and Chosse in England wrote while Sholiak was still alive. Giotto did his great painting and his pupils were laying the deep firm foundations of modern art. Many of the great cathedrals were being finished. Most of the universities were in the first flush of their success as molders of the human mind. There are few centuries in history that can show the existence of so many men whose work was to have an enduring influence for all the after-time as this upon which Sholiak's career shed so bright a light. The preceding century had seen the origin of the universities and the rise of such supremely great men as Albertus Magnus, Roger Bacon, Thomas Aquinas and the other famous scholars of the early days of the mendicant orders and had made the intellectual mold of university training in which men's minds for seven centuries were to be formed, so that Sholiak instead of being an unusual phenomenon is only a fitting expression of the interest of this time in everything including the physical sciences and, above all, medicine and surgery. For some people it may be a source of surprise that Sholiak should have had the intellectual training to enable him to accomplish such judicious work in his specialty. Many people will be apt to assume that he accomplished what he did in spite of his training genius succeeding even in an unfavorable environment and notwithstanding educational disadvantages. Those who would be satisfied with any such explanation, however, know nothing of the educational opportunities provided in the period of which Sholiak was the fruit. He is a typical university man of the beginning of the fourteenth century and the universities must be given due credit for him. It is ordinarily assumed that the universities paid very little attention to science and that scientists would find practically nothing to satisfy in their curricula. Professor Huxley in his address on universities, actual and ideal, delivered as the recitorial address at Aberdeen University in eighteen seventy-four declared that they were probably educating in the real sense of the word better than we do now. C quotation in the medical school at Solerna In the light of Sholiak's life, it is indeed amusing to read the excursions of certain historians into the relationship of the popes and the church to science during the middle ages. Sholiak is typically representative of medical science, a man who gave due weight to authority, yet tried everything by his own experience, and who sums up in himself such wonderful advance in surgery that during the last twenty years the students of the history of medicine have been more interested in him than in anyone who comes during the intervening six centuries. Sholiak, however, instead of meeting with any opposition encountered encouragement, liberal patronage, generous interest, and even enjoyed the intimate friendship of the highest ecclesiastics and the popes of his time. In every way his life may be taken as a type of what we have come to know about the middle ages, when we know them as we should, in the lives of the men who counted for most in them, and do not accept merely the broad generalizations which are always likely to be deceptive, and which in the past have led men into the most absurd and ridiculous notions with regard to a wonderful period in human history. That Guy de Sholiak was no narrow specialist is abundantly evident from his book, for while the great surgery treats of the science and art of surgery as its principal subject, there are remarks about nearly everything else relating to medicine, and most of them show a deep interest, a thorough clarity, and an excellent judgment. Besides, we have certain expressions with regard to intellectual matters generally, which serve to show Guy as a profound thinker, who thoroughly appreciated just how accumulations of knowledge came to men, and how far each generation or member of a generation should go, and yet how limited must, after all, be the knowledge obtained by any one person. With regard to books, for instance, he said, quote, for everyone cannot have all the books, and even if he did have them, it would be too tiresome to read them all, and completely, and would require a god-like memory to retain them all, end quote. He realized, however, that each generation provided it took the opportunities offered it, was able to see a little bit farther than its predecessor, and the figure that he employs to express this is rather striking. Sciences, he said, quote, are made by additions. It is quite impossible that the man who begins a science should finish it. We are like infants, clinging to the neck of a giant, for we can see all the giant seas, and a little more, end quote. One of the most interesting features of the history of Gaide Sholiak is the bibliography of his works, which has been written by Nikkei's. This is admirably complete, labored over with the devotion that characterized Nikkei's attitude of unstinted admiration for the subject. Altogether he has some 60 pages of a quarto volume, with regard to the various editions of Gaide's works. The first manuscript edition of Gaide Sholiak was issued in 1363, the first printed edition in 1478. Even in the 14th century, Gaide's great work was translated into all the languages generally used in Europe. Nikkei's succeeded in placing 34 complete manuscripts of the surgery. 22 of these are in Latin, 4 in French, 3 are in English, 2 only in Provençal, although that was the language spoken in the region where much of Sholiak's life was passed, and one each in Italian, in Low Dutch, and in Hebrew. One of the English manuscripts, one is a number 25 English of the Bibliotech de Nile, Paris. A second is number 3666 English of the Sloan collection in the British Museum, and a third is in the library of the University of Cambridge. Pauline Paris, probably one of the best of recent authorities on the age and significance of old manuscripts, says in the third volume of his Manuscripts page 346 quote, this manuscript of Guy de Sholiak's great surgery was made if not during the life, then certainly very shortly after the death of the author. It is one of the oldest that can be cited, and the fact that an English translation was made so near to the time of the original composition of the book, a test to the great reputation enjoyed by Guy de Sholiak at this time in which posterity has fully confirmed. The Sloan copy in the British Museum contains some medical recipes at the end by Francis Verney. He was probably written in the 15th century. Its title is quote, the inventory or the collectory in surgical part of medicine compiled and complete in the year of our lord 1363, with some editions of other doctors necessary to the foresaid art or craft end quote. What we find in the period of manuscripts, however, is as nothing compared to the prestige of Guy de Sholiak's work once the age of printing began. Nikaz was able to find 60 different printed editions of the great surgery, nine letters that are mentioned by authors have disappeared and apparently no copies of them are in existence. Besides there are 60 editions of portions of the work, of compendiums of it and commentaries on it. Altogether, 129 editions are extant. Of these are 16 Latin editions, 43 French, 5 Italian, 4 low Dutch, 5 Van and 1 English. 14 appeared in the 15th century, 38 in the 16th century and 17 in the 17th century. The 14 editions belonging to the incunabula of printing issued, that is, before the end of the 15th century, show what lively interest there was in the French surgeon of the preceding century since printing presses at this precious time were occupied only with the books that were considered indispensable for scholars. The first edition of the great surgery was printed in 1478 at Lyons. Printing had only been introduced there five years before. This first edition, Primus Primarius or Edicio Princips was a French translation by Nicholas Poniz in 1480 and Italian edition was printed at Venice. The first Latin edition was printed also in Venice in 1490. It would be only natural to expect that the successors of Guy Descholiac and especially those who had come personally in contact with him would take advantage of his thorough work to make still further advances in surgery. As a matter of fact decadence in surgery is noted immediately after his death. Three men taught at the University of Montpelier at the end of the 14th and the beginning of the 15th century. John de Tornemia, Velasco de Taranta, and John Falcon. They cannot be compared, girls says with Guy Descholiac, though they were physicians of reputation in their time. Falcon made a compendium of Guy's work for students. Somehow there seemed to be the impression that surgery had now reached a point of development beyond which it could not advance. Unfortunate political conditions, wars, the withdrawal of the popes from Avignon to Rome and other disturbances distracted men's minds and surgery deteriorated to a considerable extent and a new spirit at the time of the Renaissance came to inject fresh life into it. End of Part 2 of 2 End of Chapter 11 Chapter 12 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 Marcicic September 2009 Alexandria, Virginia Old Time Makers of Medicine by James Joseph Chapter 12 Medieval Dentistry Giovanni of Arcoli Part 1 of 2 If there is one phase of our present day medicine and surgery that most of us are likely to be quite sure is a very recent development, it is dentistry. Probably most people would declare once, that they had every reason to think that the science and art of dentistry, as we have it now, developed for the first time in the world's history during the last generation or two. It is extremely interesting to realize then, in the light of this almost universal persuasion founded to a great extent on the conviction that man is in process of evolution and that as a consequence we must actually be doing things now that men never did before to find that dentistry, both as in art and science, is old. That it had developed at a number of times in the world's history and that is fortunately for history, its work was done mainly in indestructible materials, the teeth themselves and metal prosthetic apparatus, we have actual specimens of what was accomplished at a number of periods of golden times. Surprising as it will seem to those who hear of it for the first time, dentistry reached high perfection even in what we know as ancient history. It is rather easy to trace scientific and craftsmen-like interest in it during the medieval period and in the magnificent development of surgery that came just at the end of the Middle Ages, dentistry shared to such a degree that some of the textbooks of the writers on surgery of this time furnish abundant evidence of anticipations of many of the supposedly most modern developments of dentistry. There are a number of historical traditions with regard to dentistry and the treatment of the teeth in Egypt that can be traced back to good authorities in Egyptology of a generation or more ago. But it is rather hard to confirm the accounts we have by actual specimens. Either none were found or for some reason those actually discovered are now not readily available for study. Among the Phoenicians, however, though we have good reasons to think that they learn their arts and crafts from the Egyptians, there is convincing evidence of a high development of dentistry. M. Ernest Rennan during an exploring expedition in Phoenicia found in the Old Necropolis at Sidon a set of teeth wired together two of which were artificial. It was a striking example of bridge work, very well done, and may now be seen in the Louvre. It would be more than a little surprising from what we know of the lack of inventiveness on the part of the Phoenicians and their tendency to acquire their arts by imitation if they had reached such a climax of invention by themselves. Since they adapted and adopted most of their arts and crafts from Egypt with which they were in close commercial relations, it has been argued with some plausibility that the Egyptians may have had many modes of dental prosthesis but removed all artificial teeth and dental appliances from the mouth of corpses before them. In preparation for the next world, because there was some religious objection to such human handiwork being left in place for the hereafter as they hoped for it, there is a well authenticated tradition of inanimate intercourse in a commercial way between the old Etruscans who inhabited the Italian hill country and the Phoenicians so that it is no surprise to find that the oldest of Etruscan tombs contains some fine examples of bridge work. An improvement has come over Phoenician work, however, and bands of gold, instead of wire, are used for holding artificial teeth in place. Guarini, whose history of dentistry is the standard work on the subject, on a commission from the Italian government carefully studied these specimens of Etruscan dental work in the Williams of Italy, and has made some interesting observations on them. In one specimen, which is especially notable, two incisor teeth are replaced by a single tooth from a calf. This was grooved in such a way as to make it seem like two separate teeth, Guarini suggests a very interesting and quite unexpected source for this. While examining the specimen, he wondered where the old Etruscan dentist had obtained a calf's tooth without a trace of wear on it. He came to the conclusion that he must have cut into the gums of a young calf before the permanent tooth was erupted in order to get this structure absolutely unworn for his purpose. A number of examples of bridge work have been found in the old Etruscan tombs. The dates of their construction are probably not later than 500 BC, and some of them are perhaps earlier than 700 BC. The Etruscans affected the old Romans in the matter of dentistry so that it is easy to understand the passage in the Laws of the Twelve Tables issued about 450 BC, while forbidding the burial of gold with corpses made a special exception for such gold as was fastened to the teeth. Gold was rare at Rome, and care was exercised not to allow any unnecessary decrease of the visible supply almost in the same way as governments now protect their gold reserves. It may seem like comparing little things with great, but the underlying principle is the same, hence this special law, and it's quite natural exception. In Pope Julius Museum in Rome there is a specimen of a gold cap made of two pieces of gold riveted together and also riveted to bands of metal which were fastened around the neighboring teeth in order to hold the cap in place. This is from later Republican times at Rome. At the end of the Republic and the beginning of the Empire there appear to have been many forms of dental appliances. Marshall says that the reason why one lady's teeth whose name he does not conceal are white and another's name also given were dark was that the first one brought hers and the second still had her own. In another satiric poem he describes an elderly woman as so much frightened that when she ran away her teeth fell out while her friends lost their false hair. Filings of many kinds were used, dentrophyses of nearly 9 were invented, and dentistry evidently reached a high state of development, though we have nowhere a special name for a dentist, and the work seems to have been done by physicians who took this as a specialty. While in the Middle Ages there was, owing to conditions, a loss of much of this knowledge of antiquity with regard to dentistry or an obscuration of it, it never disappeared completely and whenever men have written seriously about medicine, above all about surgery in relation to the face and the mouth, the teeth have come in for their share of scientific and practical consideration. Asius, the first important Christian writer on medicine and surgery, discusses as we have seen in the sketch of him, the nutrition of the teeth, their nerves quote, which came from the third pair and entered the teeth by a small hole existing at the end of the root end quote, and other interesting details of anatomy and physiology. He knows much about the hygiene of the teeth, discusses extraction, and the cure of the fistula, and other details. Paul of Aegean in the next century has much more and while they both quote mainly from older authors, there seems no doubt that they themselves have made not a few observations and had practical experience. It was from these men that the Arabian physicians and surgeons obtain their traditions of medicine and so it is not surprising to find that they discuss dental diseases and their treatment rationally and in considerable detail. Abul cases particularly has much that is of interest and interest. We have pictures of two score of dental instruments that were used by them. 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 of the dental arches. Orthodontia is sometimes said to be of much later origin and to begin many centuries after Abul cases time, yet no one who knows of his work can speak of Orthodontia as an invention after him. In this, however, as in most of the departments of medicine and surgery, the Arabs were merely imitators, though probably they expanded somewhat the practical knowledge that had come to them. When the great revival in surgery came in the 12th and 13th centuries, it is not surprising that there should also have been an important renewal of interest in dentistry. A detailed review of this would take us too far afield, but at least something may be said of two or three of the great representative surgical writers who touched on this specialty. About the middle of the 14th century, that Prince of Surgeons and model of surgical writers, Guy Descholiac, wrote his great textbook of surgery, Legrand surgery, an extremely interesting feature of this work is to be found in the chapters that treat of diseases of the teeth. These are not very comprehensive and are evidently not so much the result of his experience as the fruit of his reading, yet they contain many practical valuable ideas that are supposed to be ever so much later than the middle of the 14th century. His anatomy and physiology at least are not without many errors. His rules for the preservation of the teeth show that the ordinary causes of dental decay were well recognized even as early as this. Emphasis was laid on not taking foods too hot or too cold and above all not to follow either hot or cold food by something very different from it in temperature. The breaking of hard things with the teeth was recognized as one of the most frequent causes of such deterioration of the enamel as gives opportunity for the development of decay. The eating of sweets and especially the sticky sweets, preserves and the like, was recognized as an important source of carries. The teeth were supposed to be cleaned frequently and not to be cleaned too roughly for this would do more harm than should. We find these rules repeated by succeeding writers on general surgery who touch upon dentistry or at least the care of the teeth and they were not original with Gaide Sholiak but part of the tradition of surgery. As noted by Guarini in his History of Dentistry, the translation of which was published under the auspices of the National Dental Association of the United States of America, Sholiak recognized the dentist as specialist. Besides it should be added as is evident from his enumeration of the surgical instruments which he declares necessary for them. They were not as we might easily think in the modern time mere tooth polars but at least the best among them treated teeth as far as their limited knowledge and means at command enabled them to do so. And these means were much more elaborate than we have been led to think and much more detailed than we have reason to know that they were at certain subsequent periods. In fact though Gaide Sholiak frankly confesses that he touches on the subject of dentistry only in order to complete his presentation of the subject of surgery and not because he has anything of his own to say with regard to the subject. There is much that is of present day interest in his brief paragraphs. He observes that operations on the teeth are special and belong to the dentatories or dentists to whom doctors have given them over. He considers, however, that the operations in the mouth should be performed under the direction of a physician. It is in order to give physicians the general principles with which they may be able to judge the advisability or necessity for dental operations that his short chapters are written. 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, anointments, rubbings, fumigations, cauterizations, filings, fillings, and the various manual operations. He says that the dentitor must be provided with the appropriate instruments among which he names scrapers, rasps, straight and curved spatumina, elevators, simple and with two branches, toothed tenacula, and many different forms of probes and cannulas. He should also have small scalpels, tooth trappings, and files. Sholiak is particularly emphatic in his insistence on not permitting elementary materials to remain in 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 detailed. His favorite 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 the mouth with wine as a precaution against dental decay. A finest decoction of wild mint and of pepper he considered particularly beneficial, though he thought that dentrophyses, either powder or liquid, should also be used. He seems to recommend powder dentrophyses as more efficacious. His favorite 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 worthwhile giving his directions for it. He took equal parts of cuttlebone, small white seashells, pumice stone, burnt stags horn, niter, alum, rock salt, burnt roots of iris, aristolokia, and reeds. All of these substances should be carefully reduced to powder and then mixed. His favorite liquid dentrophys contained the following ingredients, half a pound each of sal ammonia 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 olympic and dissolved. The teeth should be rubbed with it, using a little scarlet cloth for the purpose. Just why this particular color 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 dentrophys used. Because of the presence of what we call tartar, and what he called the hardened limosity, or liminess, limosite and dorsi. When that condition is present, he suggests the use of rasps and spatumina and other instrumental means of removing the tartar. Evidently he did not believe in the removal of teeth, unless this was absolutely necessary, and no other method of treatment would avail to save the patient from continuous distress. He summarizes the authorities with regard to the extraction of teeth and the removal of dental fragments and roots. He evidently knew of the many methods suggested before his time of removing teeth without recourse to instrumental extraction. There were a number of applications to the gums that were claimed by older authors to remove the teeth without the need of metal instruments. We might expect that Sholiak would detect the fallacy with regard to these, and expose it. He says that while much is claimed for these methods, he has never seen them work in practice, and he distrusts them entirely. The most interesting phase of what Gaide Sholiak has to say with regard to dentistry is of course to be found in his paragraphs on the artificial replacement of the lost teeth and the subject of dental prosthesis generally. When teeth become loose he advises that they be fastened to the healthy ones with a gold chain. Guarini suggests that he evidently means a gold wire. If the teeth fall out, they may 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 Abul Qasis and Ali Abbas and Raziz. 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. On the whole, however, it must be confessed that we have here in the middle of the 14th century a rather surprising anticipation of the knowledge of a special department of medicine which is usually considered to be distinctly modern, and indeed as having only attracted attention seriously in comparatively recent times. After a guy de Sholiak, the next important contributor to dentistry is Giovanni of Arcoli, often better known by his Latin name, Johann Arculanus, who was a professor of medicine and surgery at Bologna, and afterwards at Padua, just before and after the middle of the 15th century, and who died in 1484. He is famous principally for being the first we know who mentions the filling of teeth with gold. It might possibly be suggested that, coming at this time, Arculanus should rather be reckoned as a maker of medicine in the Renaissance than as belonging to the Middle Ages and its influences. His education, however, was entirely completed before the earliest date at which the Renaissance movement is usually said to begin. That is, with the fall of Constantinople in 1452, and he was dead before the other date, that of the discovery of America in 1492, which the Germans have in recent years come to set down as the end of the Middle Ages. Besides, what he has to say about dentistry occurs in typical medieval form. It is found in a commentary on Rossi's, written just about the middle of the 15th century. In the later True Renaissance, such a commentary would have been on a Greek author. In his commentary, Arculanus touches on most of the features of medicine and surgery from the standpoint of his own experience as well as from what he knows of the writings of his predecessors and contemporaries. With the rest he has a series of chapters on diseases of the teeth. Guarini, in his History of Dentistry says that, quote, this subject dentistry is treated rather fully and with great accuracy, end quote. Even some short references to it will, I think, demonstrate this rather readily. Arculanus is particularly full in his directions for preservation of the teeth. We are rather prone to think that prophylaxis is comparatively a modern idea and that most of the principles of conservation of human tissues and the prevention of deterioration and disease are distinctly modern. It needs only a little consideration of Arculanus instruction in the matter of the teeth, however, to undo any such false impression. For obvious reasons, I prefer to quote Guarini's summation of this medieval student of dentistry's rules for dental hygiene, quote, for the preservation of teeth considered by him quite rightly a matter of great importance. Giovanni of Arcoli repeats the various counsels given on the subject by preceding writers. But he gives them as 10 distinct canons or rules, creating in this way a kind of catalog 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, saltfish, etc., must not be partaken of and after meals all excessive movement, running exercises, bathing, coyotes, and other causes that impair the digestion 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. Food that is too hot or too cold must be avoided, and especially the rapid succession of hot and cold and vice versa. 7. Leaks 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, the wood of aloes, or pine, rosemary, or juniper and similar sorts of wood which are rather bitter and stiff dick. 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, by using by preference a venous decoction of sage, or one of cinnamon, mastich, gallia, moscata, cubab, juniper seeds, root of cypress, and rosemary leaves. 10. The teeth must be rubbed with suitable dentrophuses 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 while 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. End of Part 1 of 2 Chapter 12 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 12 Medieval Dentistry Giovanni of Arcoli Part 2 of 2 All this is so modern in many ways that we might expect the detailed exact anatomy of the teeth and even something of their embryology from Arculanus. It must not be forgotten, however, that coming as he does before the Renaissance the medical sciences and the true sense of the word are as yet unborn. Men are accumulating information for practical purposes, but not for the classification and coordination that was to make possible the development of their knowledge. Giovanni of Arcoli's acquaintance with the anatomy of the teeth was rather sadly lacking. He does not know even with certainty the number of roots that the teeth have. This has been attributed to the fact that he obtained most of his information from books and had not the time to verify descriptions that he had found. It has been argued from this that he was himself probably not a practical dentist and turned to that specialty only as a portion of his work as a general surgeon and that consequently he was not sufficiently interested to verify his statements. His chapters on dentistry would seem to bear out this conclusion to some extent, though the very fact that one who was himself not specially interested in dental surgery should have succeeded in gathering together so much that anticipates modern ideas in dentistry is of itself a proof of how much knowledge of the subject there was available for a serious student of that time. The anatomy of the teeth continued to be rather vague until about the middle of the next century when Eustatius, whose investigations of the anatomy of the head have deservedly brought him fame and the attachment of his name to the Eustatian canal wrote his libellis de dentibus manual of the teeth which is quite full, accurate and detailed. Very little has been added to the microscopic anatomy of the teeth since Eustatius' time. He had the advantage, of course, of being infinitely in contact with the great group of Renaissance anatomists, Vesalius, Columbus, Verolius, Phelopius, and the others, the great fathers of anatomy. Besides, his position as papal physician and professor of anatomy at the Papal Medical School at Rome gave him opportunities for original investigation, such as were not easily obtained elsewhere. Arculanus can scarcely be blamed, therefore, for not having anticipated the Renaissance. And we must take him as merely the culmination of medieval knowledge with regard to anatomy and surgery. Medieval medical men did not have the time, nor apparently the incentive to make formal medical science, though it must not be forgotten, as it has been said, that they did use the knowledge they obtained by their own and others' observation to excellent advantage for the practical benefit of ailing humanity. The sciences related to medicine are conscious developments that follow the evolution of practical medicine, nor must it be forgotten that far from always serving as an auxiliary science, often indeed in the history of medicine scientific pursuits have led men away into side issues from which they had to be brought back by some genius medical observer. As might be expected, then, it is with regard to the practical treatment and general consideration of ailments of the teeth that Giovanni of Arcoli is most interesting. Some of his chapters contain a marvelous series of surprises. Arculanus was probably born toward the end of the 14th century. The date of his death is variously placed as either 1460 or 1484 with the probability in favor of the former. From 1412 to 1427 he was professor at Bologna, where in accordance with the non-specializing tendencies of the time he did not occupy a single chair but several in succession. He seems first to have taught logic, then moral philosophy, and finally medicine. His reputation in medicine drew many students to the university and his fame spread all over Italy. The rival university of Padua then secured him and he seems to have been for some 20 years there. Later apparently, he accepted a professor's chair at Ferrara, where the Diestes were trying to bring their university into prominence. It was at Ferrara that he died. He was a man of wide reading, of extensive experience, both of men in medicine, and one of the scholars of his time. His works are, as we have said, mainly excerpts from earlier writers, and particularly the Arabians, but they contain enough of hints, drawn from his own observation and experience to make his work of great value. While, as Gert remarks in his history of surgery, Arculanus Name is one of those scarcely known. He is usually considered just one of many obscure writers at the end of the Middle Ages. His writings deserve a better fair. They contain much that is interesting, and a great deal that must have been of the highest practical value to his contemporaries. They attracted wide attention in his own, and immediately succeeding generations. The proof of this is that they exist in a large number of manuscript copies just as soon as printing was introduced. His books appeared in edition after edition. His Practica was printed in no less than seven editions in Venice. Three of them appeared before the end of the 15th century, which places them among the incunabula of printing. Probably nothing in the history of human intellectual interest is more striking than the excellent judgment displayed by the editors who selected the works to be printed at this time. Very few of them were trivial or insignificant. Fewer still were idle speculations, and most of them were almost of classic import for literature and science. Four editions of this work were printed in Venice in the 16th century, one of them as late as 1660, when the work done by such men as Vesalius, Columbus, Eustatius, and Phelopius would seem to have made Arculanus out of date. The dates of the various editions are Venice 1483, 1493, 1497, 1504, 1542, 1557, 1660. Besides, there was an edition printed at Vesal in 1540. Arculanus is said to have reintroduced the use of the Seton, that is the method of producing intense counter irritation by the introduction of some foreign body into an incision in the skin. We owe to him too, according to Pagel in the chapters on medieval medicine in Pushman's Handbook of the History of Medicine, an excellent description of alcoholic insanity. His directions for the treatment of conditions in the mouth and nose apart from the teeth are quite as explicit and practical, and in many ways quite as great an anticipation of some of our modern notions as what he has to say with regard to the teeth. For instance, in the treatment of polyps, he says that they should be incised and cauterised. 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. The incision should be cut off with a fine scissors or with a narrow file just small enough to permit its ingress into the nostrils or with a scalpel without cutting edges on the sides but only at its extremity and this cutting edge should be broad and well sharpened. If there is danger of hemorrhage or if there is fear of it the instruments with trig should be fired ig nature, that is heated at least to 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 Pledge of Cotton dipped in the green ointment described by Rossies should be placed in the nose. This Pledge it 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 aquafortis, 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 girl's history of surgery. In some cases he had seen the polyp was so difficult to get at or was situated so far back in the nose that it could not be reached by means of a tenaculum or scissors or even the special knife devised for that purpose. For these patients Arculanus describes an operation that is to be found in the older writers on surgery Paul of Agena Agenetus Avicenna and some of the other Arabian surgeons. For this three horsetail 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 error of a man who has tried it and has not been satisfied that this operation is quite uncertain and seems to depend a great deal on chance and much reliance must not be placed on it. Arculanus suggests a substitute method by which latent polyps or occult polyps as he calls them may be removed. There is scarcely an important disease for which Arculanus has not some interesting suggestions and the more one reads of him the more is one surprised to find how many things that we might think of as coming into the purview of medicine long after his time or at least as having been neglected from the time of the Greeks almost down to our own time are here treated explicitly, definitely and with excellent practical suggestions. He has a good deal to say with regard to the treatment of Angina, which he calls Sennach or Sennachia or Chinaca or Angina. Paracinac is a synonymous term but refers to a milder Sennach. He distinguished four forms of it. In one called canine Angina, because the patient's tongue hangs out of his mouth somewhat the same as from an overheated dog in the summertime. While at the same time the mouth is held open and he draws his breath pantingly Arculanus suggests an unfavorable prognosis and would seem to refer to those cases of lutewigs angina in which there is involvement of the tongue and in which our prognosis of the very worst even to our own day. At times the angina causes such swelling in the throat that the breathing is interfered with completely. For this Arculanus master, Roses advised tracheotomy Arculanus himself however apparently hesitated about that. It is not surprising then to find that Arculanus is very explicit in his treatment of affections of the uveola. He divides its affections into apostema ulcis putridosivecorosio edcausis apostema was abscess ulcis any rather deep erosion putrido a gangrenous condition and cases the fall of the uveola. This is the notorious falling of the soft palate which has always been in popular medical literature at least. Arculanus describes it as a preternatural elongation of the uveola which sometimes goes to such an extent as to make it resemble the tail of a mouse. For shorter elongations he suggests the caudary for longer excision followed by the caudary so that the greater portion of the extending part may be cut off. If people fear the knife he suggests following Rossies the application of an astringent powder directly to the part by blowing through a tube. His directions for the removal of the uveola are very definite. Seat the patient upon a stool in a bright light while an assistant holds the head. After the tongue has been removed by means of a speculum let the assistant hold the speculum in place. With the left hand then insert an instrument, a stylus by which the uveola is pulled forward and then remove the end of it by means of a heated knife or some other process of caudarization. The mouth should afterwards be washed out with fresh milk. The application of a caudarizing by means of a cotton swab wrapped around the end of a sound may be of service in patients who refuse the actual caudary. To be successful the application must be firmly made and must be frequently repeated. After this it is not surprising to find that Arculinus has very practical chapters on all the other ordinary surgical affections. Arculinus is treated very thoroughly liver, abscess, ascites, which he warns must be emptied slowly. Ilius, especially when it reaches stercoraceous vomiting and the various difficulties of urination he divides them into dysuria, ischuria, and stranguria are all discussed in quite modern fashion. He gives seven causes of healthy and urination. One, some injury of the bladder. Two, some lesion of the urethra. Three, some pathological condition in the power to make the bladder contract. Four, some injury of the muscle of the neck of the bladder. Five, some pathological condition of the urine. Six, some kidney trouble. And seven, pathological condition of the general system. He takes up each one of these and discusses the various phases, causes, disposition, and predispositions that bring them about. One thing these men of the middle ages could do. They reasoned logically, they ordered what they had to say well, and they wrote it out straightforwardly. That Arculinus work with regard to dentistry was no mere chance, and not solely theoretic, can be understood very well from his predecessors, and that it formed a link in continuous tradition, which was well preserved. We may judge from what is to be found in the writings of his great successor, Giovanni or John de Vigo, who is considered one of the great surgeons of the early Renaissance, the one we owe what is probably the earliest treatise on gunshot wounds. John de Vigo was a papal physician and surgeon, generally considered one of the most distinguished members of the medical profession of his time. Two features of his writing on dental diseases deserve mention. He insists that abscesses of the gums shall be treated as other abscesses being encouraged to come to maturity and then being open. If they do not close promptly, an irritant Egyptian ointment containing verdigris and alum, among other things, should be applied to them. In the cure of old fistulous tracts near the teeth, he employs not only this Egyptian ointment, but also arsenic and corrosive sublimate. What he has to say with regard to the filling of the teeth is, however, most important. He says with extreme brevity, but with the manner of a man thoroughly accustomed to doing it. Quote, by means of a drill or file, the putrified or corroded part of the tooth should be completely removed. The cavity left should then be filled with gold leaf. End quote. It is evident that the members of the papal court, the cardinals and the pope himself, had the advantage of rather good dentistry at John DeVigo's hands, even as early as the beginning of the 16th century. John DeVigo, however, is not medieval. He lived on into the 16th century and was influenced deeply by the Renaissance. He counts among the makers of modern medicine and surgery as his authorship of the treatise on gunshot wounds makes clear. He comes in a period that will be treated of in a later volume of this series on our forefathers in medicine. End of Part 2 of 2. End of Chapter 12.