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]

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]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.

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] 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.