Quinancia was to be treated by gargles, applications, venesection from the sublingual vein, and these methods were to be used at first also in the other forms of the affection.

In the same chapter Roger treats of goiter and suggests various applications, but considers also in the severe forms the necessity for extirpation. He warns against any attempt to remove large goiters, but suggests that a temporary ligature of the goiter might be made and then a subsequent radical removal. Evidently a favorite palliative mode of treatment of his was cauterization with the hot iron and sometimes even penetration of the goiter in that way.

While Roger is the first of the western surgeons who wrote a treatise on this subject, he was very soon followed by Roland, a pupil whose work contains very little of importance that was not covered by his master, but who adds some personal comments which serve to show that men were thinking seriously about a great many surgical problems and solving them very well.

These two were followed in a few years by the "Textbook of the Four Masters," since famous in the history of medicine and surgery. Manifestly within the first century, probably indeed within the first fifty years of western surgical writing, it was recognized that a group of men could make a more complete textbook than a single man. It is usually thought that the "Four Masters" were Archimatteo, Petroncello, Plateario, and Ferrario. Of these only Plateario, or Platearius, is known apart from this book, for he was the son or the grandson of Platearius and Trotula, Platearius having been the Professor of Medicine and Trotula the Professor of Women's Diseases and the head of that department in the medical school of the University of Salerno, and for several generations their sons and grandsons continued to be prom

inent in the teaching staff of that school.

The next important writer on surgery in Italy, after Roland and Roger and the "Four Masters," was Bruno of Longoburgo, who was born down in Calabria-the heel of the Italian boot, as the name of his birthplace attached to his Christian name indicates-and who was probably a student at Salerno. In the Latin literature of the time, for of course all wrote in Latin, his name was Brunus and it is usually under this name that he is quoted. Though he studied in the south of Italy he practiced and taught in Verona and Padua. His book “Chirurgia Magna" was finished at Padua, as he himself declares toward the end of it, in January, 1252. His volume is noteworthy, mainly for the reason that he was the first of these mediæval surgeons of the West to quote not only the Greeks, but the Arabs. Arabian influence was an afterthought and a subsidiary factor, and not the origin of this mediæval surgery, as it is often declared to be by those who theorize without weighing the facts of chronology.

Bruno, to use his Italian name, has much to say of the treatment of various intranasal pathological conditions which disturb breathing. He describes several varieties of nasal polyps and differentiates one of them as a "malignant tumor." This was of darker color, of slight sensibility and was very hard. He advised against operation upon it and suggested that it should not be touched, as surgical intervention merely hastened its growth and made the patient

worse.

With regard to the removal of polyps he quotes Abulcasim, or Albucasis, the Moorish physician, special medical attendant of the Khalif el-Hakim III (961–976). Albulcasim, who flourished in the second half of the tenth century, wrote a very comprehensive medical and surgical work under the title "Altasrif" or "Tesrif," in some thirty books. This Moorish physician, who

is quoted by Bruno, suggests the removal of polyps by drawing them down with a hook, severing the connecting portion with a knife, and then shaving off any projection that may remain. The cautery was used to prevent recurrence and to assure the freedom of the nose for breathing. Bruno suggests that the root of the polyp should be cauterized with a hot iron or with some cauterizing material. He adds that sometimes the use of a cauterizing substance is quite sufficient to destroy a polyp and prevent its recurrence.

Bruno next discusses obstructions of the nasal passages which may occur from overgrowths in the back part of the nose, in the nose and throat space. For the treatment of these he quotes Paul of Ægina, the most famous medical writer of the late Greek time, of whose career we know so little, however, that differing authorities place him anywhere from the fourth to the seventh century A.D. Paul suggested that a ligature with knots at intervals should be passed through a tube into the nose and then brought out through the mouth and by to-and-fro motion employed to cut off projecting growths at the back of the nose. After this, cauterizing materials were to be used to prevent recurrence. Bruno seems to have been quite satisfied that he could make the nose patulous in this way and greatly relieve the patient and prevent the development of complications.

It may seem surprising that a surgeon in the middle of the thirteenth century should have so much surgical sense, but when it is recalled that Bruno was the originator of the expression "union by first intention," it will be easier to comprehend. That expression, so familiar in the modern times, has of course no significance in modern any language except what is lent to it by the old mediæval Latin, unio per primam intentionem. Bruno knew exactly what he was talking about when he used it, for he had seen wounds heal without pus and he

knew that this was the ideal way for healing to occur. His great contemporary, Theodoric, whose textbook appeared some ten years later, declared quite explicitly:

"It is not necessary, as Roger and Roland have taught and as many of their disciples are still teaching and as all modern surgeons profess, that pus should be generated in wounds. No error can be greater than this. Such a practice is indeed to hinder nature, to prolong the disease, and to prevent the conglutination and consolidation of the wound."

Theodoric himself copies Bruno with regard to operations within the nose, and has something special to say with regard to nasal repair after injuries. Every possible portion should be saved and if a part of the nose hang down this should be replaced and very carefully sewed on again. A pledget of silk soaked in warm wine of proper thickness and length should be inserted into the nostrils in order to maintain the parts in their proper places just as far as possible. If the patient's breathing, disturbed by this procedure, threatens in any way to interfere with the success of the operation, then the pledget of silk should have a goose quill run through it in order to facilitate breathing. The older medical and surgical authorities, especially Paul of Ægina and Hippocrates, had suggested a tube made of lead, but Theodoric found a quill much more cleanly and less bothersome.

Theodoric has a good deal to say about the possibilities of repair of disfiguring wounds of the face and is a distinct pioneer in plastic surgery. His use of strong wine as the only dressing, his insistence on the absence of manipulation and his advice not to remove the dry dressing, as it was calledbecause after a time the strong wine evap

How curious this use of the word "modern" seems just after the middle of the thirteenth century.

orated, leaving the dressings perfectly drygave him abundant opportunity for securing such healing as would provide the best results. He did not hesitate to say, when a surgeon made an incision in a hitherto unbroken part, that if pus developed in it that complication was due to the surgeon's error-his manipulations were at fault. For this reason he advised against sewing up wounds of the scalp, though he gives a number of details of the procedure that should be employed to bring the parts carefully together and, by proper bandaging and pressure, to keep them together.

Strange as it may seem, Theodoric was a bishop as well as a surgeon and had been a member of the Dominican Order. His textbook of surgery published in the Venetian Collection of surgical works in 1498 makes that fact very clear. He is the first surgical writer who definitely mentions the use of an anæsthetic during operations. He says that its introduction was due to his father Ugo, or Hugh, of Lucca, as he is called, who is known to have been a great surgeon, but who wrote nothing, and whose fame is preserved only through his son's writings. Ugo of Lucca, or Hugh Borgognoni, to use the family name that he and his three physician sons employed, had been a surgeon to the crusaders about 1218 and was present at the siege of Damietta. After his return he was made the City Physician of Bologna, to whom not only matters of health but also of medico-legal significance were referred. His appointment and the statutes granting him powers are the first documents in the history of legal medicine in modern times.

Theodoric wrote of his father's experiences and those of his brothers as well as his own. Many of these details of surgical technique had been carefully treasured as secrets up to this time and transmitted as family heritages, as among the Asclepiadean families in the olden time. Theodoric broke this tradition and published them for the

benefit of humanity in his own and subsequent generations. Among other things, he gave us, particularly, as we have said, the method of producing narcosis, evidently carefully worked out so as to make it possible that extensive surgical work might be done on a patient without his feeling it, or but to a slight degree, and yet without any serious risk of his not awaking at the end of the operation.

Theodoric's description of the mode of obtaining anesthesia practiced by his father is as follows:

"Having made a mixture of the wine extracts of opium, hemlock, mandragora, unripe mulberries and wild lettuce, a sponge should be boiled in this fluid until all is boiled away, and then whenever anesthesia is wanted this sponge should be placed in warm water for an hour and applied to the nostrils until the patient sleeps, when the surgical operation should be performed. At its end another sponge dipped in vinegar should be frequently applied to the nostrils, or some of the juice of the root of hay should be injected into the nostrils, when the patient will soon awaken."

A mode of anesthesia resembling this in many respects is described by Guy de Chauliac after the middle of the fourteenth century, so that there seems to be no doubt that for several centuries operations in Europe were done under the influence of an anesthetic and that the practice was reasonably successful. It is easy to understand that it was neither so safe nor so sure as our practice in the matter. The surprise is that it should have existed, and for so long, and then have been entirely forgotten, so that the very idea of an anesthetic came as a surprise to the mid-nineteenth century. As a matter of fact the English poet Middleton mentions "the pities of old surgeons"

P

ERHAPS it is not the only way, but one of the ways of judging of the excellence of a work of science or literature is to take note of the discussion the author has elicited in less talented readers and the stimulation of the faculties thereby evidenced. In the conceit and braggadocio of Falstaff, aside from his being the butt of jokes, we perceive he is conscious of the quality of his mind when he says he is not only witty himself, but is the cause of wit in others.

There is no standard of truth whereby the accuracy of theory and practice of one age can be judged by another, though there are underlying general principles which persist as much perhaps by their vagueness and lack of limitation and inclusiveness as by their validity, but, for the most part, time withers most specific facts as they were apprehended two thousand or more years ago. When, however, a discourse, an oration, a poem, a philosophical treatise, or a narrative continues for generation after generation, century after century, for ages, to excite the comment of readers, as do, for instance, those of Homer, Herodotus, Hippocrates, Horace, Virgil, we are safe in recognizing in that objective evidence the proof of an inherent excellence which perhaps our own faculties do not reveal to us. Subjective testimony is of little interest to us. We care not if the intellectual creature at our side adores Ibsen-we might hate him; or if the man in the street reads Kipling to-day-to-morrow he may likely never give him a thought. It need not

disturb us if Plato is thought by the young lady at the library to have written something on astronomy or if the man who preaches in our church thinks Aristotle was a monk. We ourselves may be unable to get up any enthusiasm for either. But when we learn that all these men have by their words tapped the ocean of thought in every era of civilization since they lived and at their magic touch abundant streams of mental activity have gone forth to enrich the world, when we once realize what an ever living power they still exercise over the best minds which humanity produces, then what Dotty says about Ibsen or what Bill Broker thinks of Kipling, that the Reverend Mr. Stiggins is mistaken about Aristotle, or that we ourselves fall asleep or our minds wander when we read the "Phaedrus" of Plato or the "Poetics" of Aristotle, is of no consequence. It is a subjectivity which has nothing in the least to do with the quality of the writer's works; that we must judge of from what we come to know of the phenomena which the history of thought furnishes us.

The acknowledgment of this as a reality is common enough, so common as to have become perfunctory and of course occasionally a little ostentatious, but it is seldom the subject of analysis. Why is it, then, that these master artists continue to be the wellsprings of thought and the origin, usually unrecognized, of inspiration? Certainly not because of the facts they display. These are denied or discredited in a short time; but through every vicissitude of