much attention and after being commented on by his pupil Rolando, the

work of both of them being subsequently annotated by the Four Masters,

this combined work became the basis of modern surgery. Roger was

probably born either in Palermo or Parma. There are traditions of his

having taught for a while at Paris and at the University of Montpellier,

though these are not substantiated. His book was printed at Venice in

1546, and has been lately reprinted by De Renzi in his Collectio

Salernitana.



Roland was a pupil of Roger's, and the two names that often occur in

medieval romance became associated in a great historic reality as a

consequence of Roland's commentary on his master's work, which was a

favorite text-book in surgery for a good while in the thirteenth century

at Salerno. Some space will be given to the consideration of their

surgical teaching after a few words with regard to some disciples who

made a second commentary, adding to the value of the original work.



This is the well-known commentary of the Four Masters, a text-book of

surgery written somewhat in the way that we now make text-books in

various departments of medicine, that is, by asking men who have made

specialties of certain subjects to write on that subject and then bind

them all together in a single volume. It represents but another striking

reminder that most of our methods are old, not new as we are likely to

imagine them. The Four Masters took the works of Roger and Rolando,

acknowledged their indebtedness much more completely than do our modern

writers on all occasions, I fear, and added their commentaries.



Gurlt says (Geschichte der Chirurgie, Vol. I, p. 703) that in spite

of the fact that there is some doubt about the names of the authors,

this volume constitutes one of the most important sources for the

history of surgery of the later Middle Ages and makes it very clear that

these writers drew their opinions from a rich experience. It is rather

easy to illustrate from the quotations given in Gurlt or from the

accounts of their teaching in Daremberg or De Renzi some features of

this experience that can scarcely fail to be surprising to modern

surgeons. For instance, what is to be found in this old text-book of

surgery with regard to fractures of the skull is likely to be very

interesting to surgeons at all times. One might be tempted to say that

fewer men would die every year in prison cells who ought to be in

hospitals, if the old-time teaching was taken to heart. For there are

rather emphatic directions not to conclude because the scalp is

unwounded that there can be no fracture of the skull. Where nothing can

be felt care must be exercised in getting the history of the case. For

instance, if a man is hit by a metal instrument shaped like the clapper

of a bell or by a heavy key, or by a rounded instrument made of

lead--this would remind one very much of the lead pipe of the modern

time, so fruitful of mistakes of diagnosis in head injuries--special

care must be taken to look for symptoms in spite of the lack of an

external penetrating wound. Where there is good reason to suspect a

fracture because of the severity of the injury, the scalp should be

incised and a fracture of the cranium looked for carefully. That is

carrying the exploratory incision pretty far. If a fracture is found the

surgeon should trephine so as to relieve the brain of any pressure of

blood that might be affecting it.



There are many warnings, however, of the danger of opening the skull and

of the necessity for definitely deciding beforehand that there is good

reason for so doing. How carefully their observations had been made and

how well they had taken advantage of their opportunities, which were, of

course, very frequent in those warlike times when firearms were unknown,

hand-to-hand conflict common, and blunt weapons were often used, can be

appreciated very well from some of the directions. For instance, they

knew of the possibility of fracture by contrecoup. They say that

quite frequently though the percussion comes in the anterior part of

the cranium, the cranium is fractured on the opposite part.[18] They

even seem to have known of accidents such as we now discuss in

connection with the laceration of the middle meningeal artery. They warn

surgeons of the possibilities of these cases. They tell the story of a

youth who had a very small wound made by a thrown stone and there seemed

no serious results or bad signs. He died the next day, however. His

cranium was opened and a large amount of black blood was found

coagulated about his dura mater.



There are many interesting things said with regard to depressed

fractures and the necessity for elevating the bone. If the depressed

portion is wedged then an opening should be made with the trephine and

an elevating instrument called a spatumen used to relieve the pressure.

Great care should be taken, however, in carrying out this procedure lest

the bone of the cranium itself, in being lifted, should injure the soft

structures within. The dura mater should be carefully protected from

injury as well as the pin. Care should especially be exercised at the

brow and the rear of the head and at the commissures (proram et pupim

et commissuras), since at these points the dura mater is likely to be

adherent. Perhaps the most striking expression, the word infect being

italicized by Gurlt, is: In elevating the cranium be solicitous lest

you should infect or injure the dura mater.



For wounds of the scalp sutures of silk are recommended because this

resists putrefaction and holds the wound edges together. Interrupted

sutures about a finger-breadth apart are recommended. The lower part of

the wound should be left open so that the cure may proceed properly.

Red powder was strewed over the wound and the leaf of a plant set above

it. In the lower angle of the wound a pledget of lint for drainage

purposes was inlaid. Hemorrhage was prevented by pressure, by the

binding on of burnt wool firmly, and by the ligature of veins and by

the cautery.



There are rather interesting discussions of the prognosis of wounds of

the head, especially such as may be determined from general symptoms in

this commentary of the Four Masters on Roger's and Rolando's treatises.

If an acute febrile condition develops, the wound is mortal. If the

patient loses the use of the hands and feet or if he loses his power of

direction, or his sensation, the wound is mortal. If a universal

paralysis comes on, the wound is mortal. For the treatment of all these

wounds careful precautions are suggested. Cold was supposed to be

particularly noxious to them. Operations on the head were not to be done

in cold weather and, above all, not in cold places. The air where such

operations were done must be warmed artificially. Hot plates should

surround the patient's head while the operation was being performed. If

this were not possible they were to be done by candlelight, the candle

being held as close as possible in a warm room. These precautions are

interesting as foreshadowing many ideas of much more modern time and

especially indicating how old is the idea that cold may be taken in

wounds. In popular medicine this still has its place. Whenever a wound

does badly in the winter time patients are sure that they have taken

cold. Such popular medical ideas are always derived from supposedly

scientific medicine, and until we learned about microbes physicians used

the same expressions. We have not got entirely away from them yet.



These old surgeons must have had many experiences with fractures at the

base of the skull. Hemorrhages from the mouth and nose, for instance,

and from the ears were considered bad signs. They were inclined to

suggest that openings into the skull should be discovered by efforts to

demonstrate a connection between the mouth and nares and the brain

cavity. For instance, in their commentary the Four Masters said: Let

the patient hold his mouth and nostrils tight shut and blow strongly.

If there was any lessening of the pressure or any appearance of air in

the wound in the scalp, then a connection between the mouth and nose was

diagnosticated. This is ingenious but eminently dangerous because of the

infectious material contained in the nasal and oral cavities, so likely

to be forced by such pressure into the skull. They were particularly

anxious to detect linear fractures. One of their methods of negative

diagnosis for fractures of the skull was that if the patient were able

to bring his teeth together strongly, or to crack a nut without pain,

then there was no fracture present. One of the commentators, however,

adds to this sed hoc aliquando fallit--but this sign sometimes

fails. Split or crack fractures were also diagnosticated by the method

suggested by Hippocrates of pouring some colored fluid over the skull

after the bone was exposed, when the linear fracture would show by

coloration. The Four Masters suggest a sort of red ink for this purpose.



While they have so much to say about fractures of the skull and insist,

over and over again, that though all depressed fractures need treatment

and many fissure fractures require trepanation, still great care must be

exercised in the selection of cases. They say, for instance, that

surgeons who in every serious wound of the head have recourse to the

trephine must be looked upon as fools and idiots (idioti et

stolidi). In the light of what we now know about the necessity for

absolute cleanliness,--asepsis as we have come to call it,--it is rather

startling to note the directions that are given to a surgeon to be

observed on the day when he is to do a trepanation. For obvious reasons

I prefer to quote it in the Latin: Et nota quod die ilia cavendum est

medico a coitu et malis cibis aera corrumpentibus, ut sunt allia, cepe,

et hujusmodi, et colloquio mulieris menstruosae, et manus ejus debent

esse mundae, etc. My quotation is from Gurlt, Vol. I, p. 707. The

directions are most interesting. The surgeon's hands must be clean, he

must avoid the taking of food that may corrupt the air, such as onions,

leeks, and the like; must avoid menstruating and other women, and in

general must keep himself in a state of absolute cleanliness.



To read a passage like this separated from its context and without

knowing anything about the wonderful powers of observation of the men

from whom it comes, it would be very easy to think that it is merely a

set of general directions which they had made on some general principle,

perhaps quite foolish in itself. We know, however, that these men had by

observation detected nearly every feature of importance in fractures of

the skull, their indications and contra-indications for operation and

their prognosis. They had anticipated nearly everything of importance

that has come to be insisted on even in our own time in the handling of

these difficult cases. It is not unlikely, therefore, that they had also

arrived at the recognition by observations on many patients that the

satisfactory after-course of these cases which were operated on by the

surgeon after due regard to such meticulous cleanliness as is suggested

in the paragraph I have quoted, made it very clear that these aseptic

precautions, as we would call them, were extremely important for the

outcome of the case and, therefore, were well worth the surgeon's

attention, though they must have required very careful precautions and

considerable self-denial. Indeed this whole subject, the virtual

anticipation of our nineteenth-century principles of aseptic surgery in

the thirteenth century, is not a dream nor a far-fetched explanation

when one knows enough about the directions that were laid down in the

surgical text-books of that time.