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 illa cavendum est medico a coitu et malis cibis aera corrumpentibus, ut sunt allia, cepe, et hujusmodi, et colloquio mulieris menstruosæ, et manus ejus debent esse mundæ, 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 farfetched explanation when one knows enough about the directions that were laid down in the surgical text-books of that time.

THE NORTH ITALIAN SURGEONS

After Roger and Rolando and the Four Masters, who owe the inspiration for their work to Salerno and the south of Italy, comes a group of north Italian surgeons: Bruno da Longoburgo, usually called simply Bruno; Theodoric and his father, Hugo of Lucca, and William of Salicet. Immediately following them come two names that belong, one almost feels, to a more modern period: Mondino, the author of the first text-book on dissection, and Lanfranc (the disciple of William of Salicet), who taught at Paris and "gave that primacy to French surgery which it maintained all the centuries down to the nineteenth " (Pagel). It might very well be thought that this group of Italian surgeons had very little in their writings that would be of any more than antiquarian interest for the modern time. It needs but a little knowledge of their writings as they have come down

to us to show how utterly false any such opinion is. To Hugo da Lucca and his son Theodoric we owe the introduction and the gradual bringing into practical use of various methods of anesthesia. They used opium and mandragora for this purpose and later employed an inhalant mixture, the composition of which is not absolutely known. They seem, however, to have been very successful in producing insensibility to pain for even rather serious and complicated and somewhat lengthy operations. Indeed it is to this that must be attributed most of their surprising success as surgeons at this early date.

We are so accustomed to think that anesthesia was discovered about the middle of the nineteenth century in America that we forget that literature is full of references in Tom Middleton's (seventeenth century) phrase to " the mercies of old surgeons who put their patients to sleep before they cut them." Anæsthetics were experimented with almost as zealously, during the latter half of the thirteenth century at least, as during the latter half of the nineteenth century. They were probably not as successful as we are, but they did succeed in producing insensibility to pain, otherwise they could never have operated to the extent they did. Moreover the traditions show that the Da Luccas particularly had invented a method that left very little to be desired in this matter of anæsthesia. A reference to the sketch of Guy de Chauliac in this volume will show how practical the method was in his time.

Nearly the same story as with regard to anæsthetics has to be repeated for what are deemed so surely modern developments,-asepsis and antisepsis. I

have already suggested that Roger seems to have known how extremely important it was to approach operations upon the skull with the most absolute cleanliness. There are many hints of the same kind in other writers which show that this was no mere accidental remark, but was a definite conclusion derived from experience and careful observation of results. We find much more with regard to this same subject in the writings of the group of northern Italian surgeons and especially in the group of those associated with William of Salicet. Professor Clifford Allbutt, Regius Professor of Medicine at the University of Cambridge, England, in his address before the St. Louis World's Fair Congress of Arts and Science in 1904, did not hesitate to declare that William discussed the causes for union by first intention and the modes by which it might be obtained. He, too, insisted on cleanliness as the most important factor in having good surgical results, and all of this group of men, in operating upon septic cases, used stronger wine as a dressing. This exerted, as will be readily understood, a very definite antiseptic quality.

Evidently some details of the teaching of this group of great surgeons in northern Italy in the second half of the thirteenth century will make clearer to us how much the rising universities of the time were accomplishing in medicine and surgery as well as in their other departments. The dates of the origin of some of these universities should perhaps be recalled so as to remind readers how closely related they are to this great group of surgical teachers. Salerno was founded very early, probably in

the tenth century; Bologna, Reggio, and Modena came into existence toward the end of the twelfth century; Vicenza, Padua, Naples, Vercelli, and Piacenza, as well as Arezzo, during the first half of the thirteenth century; Rome, Perugia, Trevizo, Pisa, Florence, Sienna, Lucca, Pavia, and Ferrara during the next century. The thirteenth century was the special flourishing period of the universities, and the medical departments, far from being behind, were leaders in accomplishment. (See my "The Thirteenth Greatest of Centuries," N. Y., 1908.)

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BRUNO DA LONGOBURGO

The first of this important group of north Italian surgeons who taught at these universities was Bruno of Longoburgo. While he was born in Calabria, and probably studied in Salerno, his work was done at Vicenza, Padua, and Verona. His text-book, the Chirurgia Magna," dedicated to his friend Andrew of Piacenza, was completed at Padua in January, 1252. Gurlt notes that he is the first of the Italian surgeons who quotes, besides the Greeks, the Arabian writers on surgery. Eclecticism had definitely come into vogue to replace exclusive devotion to the Greek authors, and men were taking what was good wherever they found it. Gurlt tells us that Bruno owed much of what he wrote to his own experience and observation. He begins his work by a definition of surgery, chirurgia, tracing it to the Greek and emphasizing that it means handwork. He then declares that it is the last instrument of medicine to be used only when the other two instruments,