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Hugo of lucca and the school at bologna
[FromFerneIius’UniversaMedicina;Geneva, 1679.1
BOOKSHELF
BROWSING
HUGO OF LUCCA AND THE SCHOOL AT BOLOGNA INCUNABULA MEDICA IV FELIX CUNHA, SAN
W
FRANCISCO,
M.D.
CALIFORNIA
HEN, because of war with its Iater other, seeking exactly that same haven discrimination and persecution of of peace and soIace. One such briIIiant the defeated, it became necessary personaIity at SaIerno, seeking a new for the studious minded at SaIerno to seek haven where he couId work in his own refuge eIsewhere, there were open to them manner, is interesting since he furnished a three avenues of refuge. First of these was Iink in the chain of the dissemination of the University at MontpelIier in France, at medica knowIedge. ProbabIy because he that time in the process of growing, not was a IoyaI and patriotic ItaIian, and yet within reach of its great fame which perhaps because of the much shorter was to come Iater. SecondIy, there was the journey necessary from SaIerno, this indiUniversity at Paris, in about the same situ- vidua1 chose not Paris or MontpeIIier, but ation as MontpeIIier, yet a bit cIoser to its the third of the avaiIabIe possibihties, the zenith than the former. This Iater fame University at BoIogna. was to resuIt from the very conditions The part which it is possibIe for a singIe causing the ecIipse of SaIerno. SeveraI great mind or a great teacher to pIay in the briIIiant minds of the century came to the fieId of art and science has been repeatedIy Paris facuIty who wouId have gone to demonstrated throughout history. In the days of the earIy centuries, students flocked SaIerno otherwise. The studious inteIIectua1 mind, more from a11parts of the known worId to a great particuIarIy if of a phiIosophica1 bent, re- teacher or a great master. Where they quires for working a scene of peace and gathered in suffIcientIy Iarge numbers and tranquiIity that there may be opportunity the facuIty was of outstanding caIiber, a for deep specuIation with freedom from center of teaching grew, or a university, and it was in such manner that BoIogna such environmenta factors as discipIine, dictation, regimentation, persecution and began and grew. One particuIar individua1 who was to be strife. ApparentIy conditions have aItered IittIe from those days of 700 years ago, instrumenta in heIping its growth and since today in our own times we see an fame, was . Hugo, who, because he came exodus of just such personaIities from one from the ItaIian town of Lucca, was called part of the worId and a migration to an- Hugo of Lucca. As a surgeon he was not 172
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without training or experience, having been associated with those two great names of the tweIfth century, RoIand of Parma and Roger of SaIerno for many years. BoId daring surgeons were these Iatter and neither the teachings of Constantin, nor the schoo1 of SaIerno couId influence them. Their work was of such outstanding briIIiance and accompIishment, that they couId stand entireIy aIone and unaided without any reffected prestige from any university, even the famed SaIerno. Among their many contributions they described syphiIitic or venerea1 Iesions aImost 300 years before Columbus returned from America (another nai1 in the canard that syphilis had its origin among the Indians in America and was brought back into Europe by CoIumbus’ saiIors). They described the Iesions of cancer, particuIarIy superficia1 skin cancers, quite accurateIy. InternaI cancers more often they confused with syphiIis, yet that is done even today. The use of seaweed, the eating of it or decoctions of it in the treatment of sweIIings of the neck, such as in goiter or tubercuIous adenitis was advocated by both. In other words they “IugoIized” their goiter patients as we do today, except that manufacturing facilities not being avaiIabIe, they obtained their drugs in the crude stage and so used them. Laudatory biographies of both these briIIiant personaIities have been written by many students of medica history and are avaiIabIe to those who wish to read more about either of them. The consensus of opinion among students of medica history is that Hugo of Lucca surpassed even his teachers, because they foIIowed more or Iess bIindIy, dogmaticaIIy and unquestionabIy that which had been set down in manuscript by their iIIustrious predecessors, whereas he possessed a facuIty of questioning everything, of appIying a certain practicaIity to everything, every formuIa or procedure, simpIifying it, and discarding that which he found not true in actua1 practice. In the practice of medicine there have been from time to time such men. They fai1
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to foIIow in the groove of custom because their own judgment teIIs them not to. There have been and there wiI1 aIways be great practica1 teachers of medicine who devote their entire time to study and teaching and practice, Iike Hugo. Having Iittle time to write or express themseIves on paper, their passing from the scene is usuaIIy marked by a sparseness of avaiIabIe writings. Posterity suffers thereby, but these men are usuaIIy so practicaI-minded that the wide pubIication of one of their methods, which to their own thinking is of such utter simpIicity as to be aImost ridicuIous, is distastefu1, savors of persona1 aggrandizement, and they Iook upon it with disdain. So it was with Hugo. ExceedingIy smaI1 is the amount of his writings which can be authenticated, though he Iived and practiced unti1 he was about a hundred years oId. One fortunate circumstance Iessened the possibiIity that a11 his work wouId be Iost. He had severa sons, four of whom decided to make medicine their fieId. One, Theodorich, caIIed Theodorich Borgognoni, he was particuIarIy attached to and made him his intimate associate, assistant and confidant. Because of a feeIing that the teachings of his father shouId be made known to the scientific worId, Theodorich took it upon himseIf to gather together and pubIish severa tracts, the most famous of a11 being a “Cyrurgia.” Two hundred years or so Iater, in 1498 and 1499, these were gathered into print and pubIished in Latin in Venice and in French in Lyons. These two items today form very rare incunabuIa, diffIcuIt to obtain at aImost any price. Due to the constant interchange of ideas, practice, and writings of father and son, Hugo and Theodorich are usuaIIy spoken of together and their writings are considered jointIy. In order to understand why Hugo of Lucca is considered as one of the greatest of an examination into his contemporaries, some of his surgica1 ideas and procedures is of heIp.
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First, and perhaps most simpIe, were his ideas as to the etioIogy of headaches. He distinguished them as being either of brain origin or derived from a state of disturbed digestion. He stated, “Those found to be due to some cause within the skuI1 or in the brain itseIf, such as might be caused by the pressure of a tumor, wiI1 be found to be constant and continuous, without any relief whatsoever, even for an instant, while those arising from a disturbed state of digestion wiI1 be found to have intervaIs of compIete freedom, then very intense and severe intervaIs dependent entireIy upon the state of the stomach.” Because war and civi1 combat were the order of the day, the most common injuries were those occurring from bIudgeoning of the skuI1 by heavy weapons wieIded with great force and producing a11 types and degrees of skuI1 fracture. It was obviousIy necessary that the surgeon of the time be most experienced and skiIIed in the handIing of such a type of injury. The next most common type of injury was that caused by arrows. These wounds caIIed for no end of ingenuity on the part of the surgeon. The making of arrow heads invariabIy exhibited an unusua1 degree of maIicious invention. Some were made in such a manner that when they penetrated into the flesh they could not be withdrawn without extensive incision into and damage of the tissues for a considerabIe surrounding area. In such cases Hugo evolved a technique entireIy his own. He made no attempt to extract the arrow immediately upon penetration, endeavoring first to disinfect the wound with hot wine appIications. Then in a few days as the muscuIar rigidity reIaxed, it was easier to extract the arrow head, often without any additiona incisions whatever. Theodorich, in describing this method of his father’s reIates, “Once I saw two strong men make efforts to extract an arrow from the body of one who had been so injured. Despite their great strength they were unsuccessfu1 and the injured one was brought to my master, Hugo. By the appIication of his usuaI
of Lucca remedies in a few days the arrow withdrew aImost of itseIf.” When it is considered that every ingenious expedient that the brain of man couId devise was used to tip these arrow heads, such as dipping them for Iong periods in poisonous concoctions or smearing them with known poisons, anything that wouId increase the deadIiness of the weapon, then it is not hard to visuaIize that the probIem of wound infection and its handling was no minor one. Here aIso he had his own particuIar technique. AI1 wounds were dressed with wine, and he emphasized that it was important to use the best possibIe wine that couId be obtained. In the hands of an honest individua1 this admonition was probabIy very wise. It has been related that contemporaries and foIIowers of Hugo carried out this admonition with rather shady resuIts, setting aside the good wine for persona1 consumption and using for the wound any other that was at hand. Human behavior down through the centuries has probabIy been no better and no worse. Hugo described the penetrating wounds of the chest caused by arrows, the resultant empyemas, the compIications of rib fractures, the Iung abscess and Iung gangrene which often foIIowed. He reached a peak of surgica1 accomplishment by performing a compIete Iobectomy, aIthough invoIuntariIy. In describing this particuIar case, Master Hugo reIates : “There was a nobIeman Iiving in BoIogna, named DomiceIIus whom I was caIIed upon to treat. When I arrived within the waIIs of his house the stench of rotting ffesh was of such intensity that I thought it aImost unbearabIe. On approaching his bedside, I noted that his once huge frame had shrunken to an aImost unbeIievabIe degree, both from the nature of his wound and from the wracking of his body with pain. As I stood there, he coughed up quantities of the most fou1 smeIIing substance in which were great pieces of substance and when I examined his wound which was an enormous one of his chest,
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I couId see the putrefying substance of his Iung and I noted that that which he coughed up was exactIy the same as I couId see in his wound. As I proceeded to dress his wound according to my usua1 procedure I thrust my hand into the wound and on withdrawing it found that it contained such a huge portion of Iung substance that I became aIarmed. However, I was abIe by my method to hea this man compIeteIy even though a part of the lung was Iost.” In the treatment of wounds Hugo very often differed from the strongIy entrenched medica authorities, but he was very carefu1 aIways to mention wherein he differed and why. He casuaIIy mentioned that he was quite aware that GaIen or Avicenna recommended some other procedure or strongIy advised against the very steps he was using, but then he cited his reasons, and, as though to cIinch the matter, gave names and pIaces where he cured so and so by this very method. Nothing couId be more convincing. His son, Theodorich, who was working with him constantIy and absorbing as much of his father’s wisdom as he couId, speaks of the treatment of these wounds thusIy : “When a white pap-Iike fluid runs out of the wound, then things are not too well, and when a very thin serous-Iike fluid comes out then there is great danger, but one must not despair whoIIy because I personaIIy have heaIed such men foIIowing the treatment advocated by my father and I have seen a great many who showed the above mentioned signs heaIed by him.” The third type of traumatic injury most commonIy met with was that caused by the sword. These wounds varied from minor Iacerations to cuts of extreme degree. If one has noticed in the museums the varying type of weapon which came under the heading of sword, one can we11 visuaIize the extent of injury which couId be infficted by a husky expert wieIding such an instrument, particuIarIy those enormous two handed and doubIe edge bIades.
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Hugo describes the wound produced by just such a two handed affair wieIded by a giant of a man which caught his opponent across one side of the skuI1. Not onIy did it trephine him, but it accompIished a partia1 decerebration much the same as that achieved by our research men with great pains. The victim did not die, much to the astonishment of Hugo himseIf and the physicians of SaIerno. The Iatter had refused to undertake his treatment, forcing him to journey to BoIogna to Hugo. In Hugo’s treatment of this case he stressed the necessity for the utmost cleanIiness in and about the wound, the carefu1 shaving of the surrounding skuI1, the wisdom of avoiding the probing of such a wound needIessIy or too many times. The actua1 treatment was to 611 the cavity with a consecrated oil, “oIei consecrationi,” then to appIy a pressure tamponade, snug and firm but free from any unnecessary force. Theodorich, in describing this particuIar case states, “One ventricIe of the man’s head was totaIIy empty of brain substance, nevertheIess he was heaIed by my father Hugo who restored the brain substance by ffesh (this presumably means connective tissue) and as it was the ceIIuIe of memory I noted that he was very astonished that the man retained his memory as before.” This entire description one can accept with the proverbia1 grain of saIt. Theodorich stressed the fact that these types of wounds when treated by his father from the very beginning and dressed onIy by himseIf, invariabIy did weI1. This Ieaves, one presumes, a IoophoIe for Hugo, because his cases invariabIy came from a distance and had been treated in some form or another by other surgeons in other IocaIities. The Iack of success, when it did occur, couId thus very convenientIy be shifted back to the origina physician. The same type of aIibi is used today with not the sIightest deviation in method. As can we11 be imagined, Hugo’s success with such outstanding cases as the man with the gangrene of the Iung and the other with the Ioss of brain substance brought
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him a fame far beyond the geographica borders of his town and his country. His practice grew enormously and he was caIIed everywhere in consuhation.
of Lucca
JANUARY. I g.w
tions of Avicenna. It seems that Avicenna advocated attempting to sew the structures together whereas according to Hugo perfect approximation of the structures by
PROLOGVS
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Suftipc iginnprwr charilUmc0 urex@um,imo C padonc~iiipdlui. .ig utamplG. Qti opursrimiii,brrurcorporc, VII Specin chirurgi~,Grutrcfiatur Io%~ioW, & fitr. vcro medico valdenmporc fuiCGdomino HugoDkit~llim, chirurgia%duplex:auticuni:nu~in of nc , ncquevidcre, nrquc corn rchtndcrc, Cubice ntquc dikeread pknum potuitxpcrr~P mus curu ~o~m:n~mrllrficinmcmbtirmoU~~uc,vrincrr~ fuu:idro in 0arw iRa imwrfc&um mcum cxwo~ ne,ntrui~,vcnis,& limMwr.l\liafirin mrmbriodw ri;r~prri.nbq&mdql;orUcvnbopn6cnr;G~rls,vrinoliibur,& conGmilibm:qu+ Gcurdifferunc tnimrximc, qucmxprdi(tovi~rxlmioinnuUo in coauarimaqu~~m, fdilictcmolkk. h durinouimusdifcordare. Vcautemadlibrum IRumac cicGccrinomnlopmcioncchirurgicL Chirurgk cths h&or hrbearur uidGr chirwgia, vndedicr quzfirin mcmbricmolUbu~,,(tbdiuidin~plicinr: nccnon tur, qurks opmrorc8 tiaedcbcar, aut Prin carnccanffi, incifio,fcu ipforuminanrio,& i,lquotdiuiduurfprcicr,breufurun,aurlnciGonunntparur.Aur6rinurnira~pul ter dmombo. fintibus:ruc in h dicinw phkboromia . igimrcfi opcrrriomanualisin corpoGucfaio. Aur fit in ncruirfcciidi~krii. crtiicincilio Ch’lrurgla rc animalisrd %ratzr~ndcns:Vtl Gc, noi~Nr.Aur~riidG~ongG,&Nncpu~cruradidrur Chirur~acRvldmum inRrumcntii mcdidnz. Trk vcl f&w.In diaohnnmatc oi (II oanniculir, nomienimfu&uWmwwa mc&cint,qaibus median& x oat~rr~pn~ra. &i&irvtro ‘u+Gdn &mbrts bus, morborumcauGsvdccmc8~sfubucnirc,f~U duris,dupkx cR:aurcnim Bcin o l?lbus duris, 8r diciccrdiarta,pocio,&chirwgir. CixratR primumin *urrcftauratio IiutconfoliJaio ~acrctorum:autfirin ~ummNm:& cR mcliuqtcurt&rNr C&in c8nr~ olrbus dlrlo~.dsrlocoproprio.B~ppcllnrurcon10 rcgiminisrcurorum dicb. Si p0GLmushomincm iunccio diluncrorum. rurrr~cumdina:noncur~murcumcumaliquapouodvnufquifqw vdutrir,vakatfaautem 9 d6c. Er Dam&n AphoriLSi porrris hominrm cura clllusiu~nirc:diuid~musinqlrlruorprr r~p~rdi~nm,profpermlinucnicnr:hocaucZinRruticulrslibrumiRumordinrr~ p~rctpitulaparttrfinmenrum Gurrcgtmmai irurcontrrcaubm,&h. gulardininguLndo:iraum~n g,inprimrparrchuiu~ cirdig&ionun. Scam d urn rcgimcnfcu inRrumT libri non in fptcidi, f&b qua&m inandimusgc-
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nrralicac~ crIcEUC Diuiditur aurcrnlibtr ilkin qunruorparrt% In prima pnrceagirurvniurrhlirrrdr vulncribus, vlcc ribu~,defluxuhnguinir,& m~dicinisipforum,driu dicijr morrio,dc vulncribus ncr~orun~ , curl JpOhcmaria didi, atqu Infccunda pure ryuy
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FIG. I. Page from Hugo and Theodorich’s
There were apparentIy many deep sword wounds of the neck, often invoIving the great vesseIs, the direct seque1 of attempts to decapitate the opponent. Here Hugo’s therapy was unique and individuaIistic. According to his custom, he humbIy apologizes for his technique, stating that he knows he is contrary to the recommenda-
“Cyrurgia.”
pressures and pads was a11 that was necessary. In the treatment of ordinary Iacerations or cuts he was considered a master. His approximation of edges was so perfect, that his son often stated, “My master Hugo heaIs and consoIidates a11wounds with wine hnd compresses, making a convenient and
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Cunha-Hugo
artistic dressing which he knows how to do so VeII, thus producing the most beautifu1 cicatrices without the use of either sutures or salves. No ragged or stringy cicatrix ever remained from the wound or abscess of a man he had treated himself. In conformity with this I have never seen a singIe broken or cut blood vessel which he was not abIe to cIose by the use of such a dressing.” ApparentIy the greater proportion of thece civi1 and war traumatisms were not superficial, but penetrated deepIy as Hugo describes. He stresses the painful symptoms which accompanied the encIosure of a cut nerve ending in a scar. However, he did not advocate the suturing of the cut ends of nerves even though they were easily visibIe and it couId be done very readiIy. He cIaimed that his method of treatment by pressure and approximation was efficacious in a11 wounds whether nerves or bIood vesseIs were invoIved or not. He recommended the most exact conjunction of the surrounding tissue, this approximation to be maintained by little “cushions” (compresses?) which acted aIso to keep the wound dry. “When it became absoIuteIy necessary the sides of a wound might be sewed without, however, touching the nerve itseIf. . . . The ends of a disunited nerve shaI1 be brought together by pressure upon the surrounding tissue onIy.” He recommended massage with a special oi1 of his own formula if the nerve ever did get entangIed in the scar and was painfu1. In his septic wounds, he threw overboard the theory which was then and Iater caIIed that of “IaudabIe pus,” and used IittIe cushions soaked in warm wine to cIean them, then dried them thoroughIy. Sometimes he used an “attractive smeIIing cIeansing desiccant appIied by a suitabIe dressing which the master could make very weI1.” Hugo constantIy admonished that wounds couId not be heaIed by either incantation or magic powders nor by cauterization with heated stones as was done in many pIaces. He apparentIy recognized “septicemia ” secondary to infected wounds, stating that
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when the virus escaped from the wound into the interior, then a warm decoction of roses and various other substances was to DeapoRematemamillarum,kvirgre. Defclirofi. De tumore. 2.2 ‘3 Depurtulisalbisqualiiiunba,qurapparbrub nafo:h fupcrpomis maxillarum, =4 De fcroffulis. a5 Dcglanduh’s;&~nodis. 26 De tefiudine. a7 De nodis fiue teRudinibus contingcntibusin ca pite:& dicuntur cornua. De nodis Iiue lupus qua: nafcuntur in palpcbris oculorum. ‘9 De bubone, 3* De bocio. 3’ De napta, in ma 3s Deinflatio’efiucpingucdincquxapparct millirquorundam hominum. De hydropifi. Deomnieminentiaetruptur~qu+Pccidirinfi~ phac vent& De herniaintelh’nali, Deherniaaouofa.ventofi.etcarnofa; Deapoltem~tibu~tefiiculorum. De verrucis,h porrisaccidentibusin virga,ueI in alia parte corporis,ct de clauis,ctformicir, De clauis hue callis. De cura t’ormicacum f&o, DC htmorrhoidibur DCfiRulisin ano. De ficu E&o in ano. 4 4 De lapide veke & renum, 4 5 De cauterfis & iuuamento ipforum : 6 quoma do fintin quiburdam aegritudirnbus ficiZda. 4 6 De con’ibufiioncignis, aqua, h olri:vclaliquo huiufmodi. 4 7 Defcabie,& pruritu. Deoutilisfaciei. De malo mortuo. Deimpetigine,&f&piginc. De gum rofacea. Depannaritio. De morphea. Dclenriginibu~~ panno,rugis,liuore,nigredine. De lepra. De tuberibus,
Lb 11
2. A list of varying subjects published by Hugo and Theodorich, evidence of their versatihty.
be given internaIIy. But the wound was to be continuousIy treated according to his method despite this escape of virus, and he remarked that if it had been treated correctIy the virus could not have escaped into the interior. That he was abIe, one can hardIy doubt. The description of his method of reduction of fractures by first immersing the patient in a hot bath thereby reIaxing a11 invoIved structures, then sIowIy and carefuIIy teas-
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ing or coaxing the fragments into aIignment, is briEant. In fractures of ribs he used gentIe massage and compression much in the manner in which we do artificia1 respiration, pressing inwardIy where necessary with one hand and massaging IightIy somewhere near with the other unti1 he had obtained that degree of approximation of fragments he desired. In similar manner he reduced disIocations. A description by his son of such a fracture reduction is as foIIows, “The master Sir Hugo, Ied the patient into a warm bath where he was instructed to Iie down. Dipping his hands into first turpentine, then honey and then pitch, Hugo Iaid his hands on the pIace where there was the weakness, pressed inwardIy then Iifted his hands suddenIy. This procedure was repeated quite often until the ribs were brought back into a norma position after which a dressing of pitch and tar was made to hoId this position.” In the matter of spIints for fractures, he did not recommend them or use them much. He preferred thickened dressings which couId be mouIded by hand rather than those made of “timbers” as he described them. Compound fractures he described in detai1. Their treatment was to consist of the appIication of both his methods. The first, reduction of the fracture itseIf, the second, his usua1 method of treatment of any and a11 wounds. That he was humane in his work can be judged by his descriptions of his “spongia soporifera ” to induce narcosis in those patients where pain couId not be avoided. AIthough there is much evidence that there were many varied procedures for producing some degree of narcosis and insensibiIity to pain by surgeons in much earIier times, Hugo stressed the use of inhalations of varied and secret drugs as anesthetics. The composition of his “ spongia somniferens ” was known only to him. By many it is presumed that this method of narcosis was originated by him. Whether this is true or not we do not know, but at any rate he popuIarized its use.
of Lucca
JANUARY,
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His therapeutic armamentarium is evidence of his versatiIity. He himseIf made “coIIyria,” prescribing them for many redness and inffammation of the eyes. A “ hoIy saIve” which was a “cure aI1” in the heaIing of wounds, was a secret formuIa. Another saIve contained mercury which he used in skin diseases and it is to him that credit must be given for the first description of the saIivation and gum changes produced by the proIonged use of mercury. Others of his salves contained arsenic and were used as cauterizing agents in fissures and wounds. These were caIIed “encaustrum ” and Iikewise were a secret composition of his own. He wrote of using a “coaguIum Ieporis” which historians reIate was not new to him or his time, having been used in earlier days. It consisted mereIy of the coagulated bIood of hares. If onIy these historians had recorded in what conditions he used this coaguIated rabbits’ bIood, particuIarIy if in hemorrhage, what an interesting point that wouId make. He did describe extensive bleeding from wounds, but no technique of treatment other than his usua1 method of closure. An anodyne powder is described by his son as being a part of the after treatment of a11 his severe cases, but its formuIa is not mentioned. It was caIIed onIy a “wound drink,” dissoIved in wine. Like any good surgeon he stressed the after care of his patients and paid particuIar attention to their diet. “Pigmenta,” his wound drinks were caIIed because they were designed to produce bIood and flesh. He was a very pious individua1 and instructed his patients to say a prayer whenever they partook of these drinks, which was severa times a day. He even designated certain prayers which shouId be said _. at the various hours. These wound drinks were mainIy highIy concentrated beef or chicken broths. As to meats, he decIared that capons, partridges, pheasants and smaI1 birds with fine beaks, were of exceptiona quaIity to produce blood and sinew. Meat of suckIing
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goats and of castrated spring cattIe was also very fine. Chicken eggs were to be eaten daiIy, cooked in any manner except sodden or fried. Paramount, however, was the instruction that the best wine obtainabIe, not requiring the addition of water, shouId be taken for regaining strength. That he took part in the civic Iife about him is evidenced by the fact that in I 2 14 he was appointed city physician to the town of Bologna. In 1218 he was persuaded to join the BoIognese contingent to the Crusade, returning in 1221 to take up once again his duties as city physician. In this post he is credited with drawing up the first IegaI sanitary measures and ruIes regarding water, waste disposa1, etc., as a modern heaIth officer wouId be expected to do. It is rather singuIar that a great name and presumabIy a great surgeon shouId have singIed out the name of Hugo of Lucca upon which to vent his viIification and abuse. Guy de ChavIiac swore to the high heavens that not onIy Hugo but aIso his son Theodorich, were no more than charlatans and quacks of the highest order, and accused them of pIagiarizing the oIder Greek masters, then cIaiming for themseIves that a11 they propounded was origina1. This anger and abuse was probably incited by the fact that Guy de ChaviIiac was the great exponent in his time of the theory of “IaudabIe pus,” whiIe Hugo and his son procIaimed vehementIy that there was no such thing. “It is not necessary, as many supposedIy great minds have taught and are teaching, that pus must be generated in wounds. To practice such a method is onIy to hinder nature and to prevent good approximation and heaIing of wounds.” Yet we find in the works of Guy de ChaviIiac, who accuses them of pIagiarism, the identica1 descriptions word for word as written by Theodorich at the direction of Hugo, and even the Zustrations to the chapters of his great opus, his surgery, are copies of those from the works of Hugo.
of Lucca
American
Journal
of Surgery
I79
A perusa1 of the Iife and work of the two individuaIs makes one ponder whether one shouted the Ioudest and had the best pubIicity whiIe the other went on unspectacuIarIy producing resuIts. At any rate, history seems to have given the verdict of popuIarity to Guy de ChavIiac, whether he deserved it or not. The SchooI of BoIogna itseIf, independent of its famed facuIty member, was instrumental in contributing a miIestone in the progress of medica science and it came about in an interesting manner. First, in speaking of these medieva1 universities certain things must be kept in mind in order that a better picture may be obtained. In BoIogna as at SaIerno, Monte Cassino, and other centers, the actua1 popuIarity and success of the institution was dependent entirely upon the fame and Iearning of its faculty. It was because of the quaIity of scoIarship that students flocked from EngIand, Germany, France, and other countries to any one particuIar center. At the very peak or height of its amuence the schoo1 of BoIogna had a registration of 10,000, speaking voIumes for its facuIty. Its fame rested upon its schoo1 of medicine and surgery and its schoo1 of Iaw. One day in the streets of BoIogna a man dropped dead from no apparent cause. The medica facuIty being unabIe to give any satisfactory expIanation other than that it was probabIy due to some disease of the heart, the Iaw facuIty insisted that a postmortem examination of the heart shouId be made and this was done. It is rather certain that human dissection was practiced in oId Grecian and Roman times, but it was done secretIy and no actua1 record ever was made. There is an old medica manuscript in the BodIeian Library which contains a drawing of a dissection scene, using a human body. This manuscript is presumed to have been written about the year 1300 A.D. The Church had formaIIy prohibited human dissection because it had become the practice of the Crusaders to cut up the bodies of those who died and hoi1 the pieces in order
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to separate the Aesh from the bones, since it was more feasibIe to repatriate the bones of those who died in distant countries. The bones might then be buried in the home parish. Transportation facilities had to be considered. It was easier to transport a few bones than a whoIe body, but the Church forbade this practice. When the Iaw facuIty considered this case of sudden and unexpIained death, they demanded at Ieast a post-mortem examination of the heart. By so doing they broke the fetters of custom which had entwined medica anatomy for ages and unknowingIy Iaid the foundation for the schoo1 of briIIiant anatomists who were to foIIow and who were to base their descriptions and drawings upon the study of actua1 human bones and flesh. This was definiteIy a miIestone in medica progress, and to the University of BoIogna must be given the credit first for the estabIishment of post-mortems in the study of disease, and second, for the briIIiant strides in anatomy which took pIace from that time on. As to the writings and works which Hugo Ieft to posterity, as stated previousIy, there is some degree of uncertainty as to whether much has disappeared or whether he reaIIy wrote IittIe. He Iived to a very oId age, reckoned by biographers to have been in the vicinity of one hundred years. He had four sons, a11of whom were physicians, but onIy one, Theodorich, attained any degree of fame. To him Hugo entrusted a11of his secret formuIae and methods of therapy, and it is recorded that he did not impose the oath of secrecy upon this son as was the custom of the times. This custom originated with earIier physicians and surgeons in order to protect the formuIae and methods they used for the benefit of their famiIies when they died, that they might continue to derive remuneration from them. If there was a son who eIected to become a physician a11 information was
of Lucca given to him and he was sworn to secrecy. If there was no son and an assistant had proved of sufficient IoyaIty and merit, then the information was his on the same basis. It is probabIe that Hugo wrote IittIe, Ieaving this part of his work to his son. A “ Cyrurgia ” was pubIished in Venice in 1497, and is presumed to consist of the combined manuscripts of Theodorich and Hugo. It is this work which Guy de ChavIiac Iater incorporated into his own. Later editions of it were pubIished in Venice, in ‘$99 and 1500. Two treatises which were definiteIy known to exist in manuscript from, a “De SubIimatione Arsenici,” and a “De AIuminibus et SaIibus” are presumabIy Iost. Copies in Spanish and ItaIian exist of a work entitIed “Practica Equorum” deaIing with veterinary medicine. It is supposed that the materia1 in this is entireIy Theodorich’s. OnIy the “ Cyrurgia” remains to Hugo’s memory. He compiIed it before the middIe of the thirteenth century and dedicated it to the bishop of VaIencia. This fact may account for its Iater Spanish transIation. From this Spanish transIation, one was made into Hebrew. A smaI1 manuscript deaIing with the manufacture of wines and with their use in disease was known to have existed but its whereabouts today is unknown. If found, it wouId probabIy be the first treatise on wine, antedating Andre De ViIIanouas’ “De Vinis ” by some years. Hugo shouId be cIassed among that Iarge group of physicians and surgeons who have stood UnfIinchingIy by principIes in which they believed. His pIace in medica history is secure because of his intenseIy practica1 aptitude, his abiIity as a surgeon, as a teacher of medicine, and as the rea1 founder of what couId be caIIed the ItaIian schoo1 of surgery which had originated with him at BoIogna in the middIe of the thirteenth century.
BOOKSHELF
BROWSING
HUGO OF LUCCA AND THE SCHOOL AT BOLOGNA INCUNABULA MEDICA IV FELIX CUNHA, SAN
W
FRANCISCO,
M.D.
CALIFORNIA
HEN, because of war with its Iater other, seeking exactly that same haven discrimination and persecution of of peace and soIace. One such briIIiant the defeated, it became necessary personaIity at SaIerno, seeking a new for the studious minded at SaIerno to seek haven where he couId work in his own refuge eIsewhere, there were open to them manner, is interesting since he furnished a three avenues of refuge. First of these was Iink in the chain of the dissemination of the University at MontpelIier in France, at medica knowIedge. ProbabIy because he that time in the process of growing, not was a IoyaI and patriotic ItaIian, and yet within reach of its great fame which perhaps because of the much shorter was to come Iater. SecondIy, there was the journey necessary from SaIerno, this indiUniversity at Paris, in about the same situ- vidua1 chose not Paris or MontpeIIier, but ation as MontpeIIier, yet a bit cIoser to its the third of the avaiIabIe possibihties, the zenith than the former. This Iater fame University at BoIogna. was to resuIt from the very conditions The part which it is possibIe for a singIe causing the ecIipse of SaIerno. SeveraI great mind or a great teacher to pIay in the briIIiant minds of the century came to the fieId of art and science has been repeatedIy Paris facuIty who wouId have gone to demonstrated throughout history. In the days of the earIy centuries, students flocked SaIerno otherwise. The studious inteIIectua1 mind, more from a11parts of the known worId to a great particuIarIy if of a phiIosophica1 bent, re- teacher or a great master. Where they quires for working a scene of peace and gathered in suffIcientIy Iarge numbers and tranquiIity that there may be opportunity the facuIty was of outstanding caIiber, a for deep specuIation with freedom from center of teaching grew, or a university, and it was in such manner that BoIogna such environmenta factors as discipIine, dictation, regimentation, persecution and began and grew. One particuIar individua1 who was to be strife. ApparentIy conditions have aItered IittIe from those days of 700 years ago, instrumenta in heIping its growth and since today in our own times we see an fame, was . Hugo, who, because he came exodus of just such personaIities from one from the ItaIian town of Lucca, was called part of the worId and a migration to an- Hugo of Lucca. As a surgeon he was not 172
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without training or experience, having been associated with those two great names of the tweIfth century, RoIand of Parma and Roger of SaIerno for many years. BoId daring surgeons were these Iatter and neither the teachings of Constantin, nor the schoo1 of SaIerno couId influence them. Their work was of such outstanding briIIiance and accompIishment, that they couId stand entireIy aIone and unaided without any reffected prestige from any university, even the famed SaIerno. Among their many contributions they described syphiIitic or venerea1 Iesions aImost 300 years before Columbus returned from America (another nai1 in the canard that syphilis had its origin among the Indians in America and was brought back into Europe by CoIumbus’ saiIors). They described the Iesions of cancer, particuIarIy superficia1 skin cancers, quite accurateIy. InternaI cancers more often they confused with syphiIis, yet that is done even today. The use of seaweed, the eating of it or decoctions of it in the treatment of sweIIings of the neck, such as in goiter or tubercuIous adenitis was advocated by both. In other words they “IugoIized” their goiter patients as we do today, except that manufacturing facilities not being avaiIabIe, they obtained their drugs in the crude stage and so used them. Laudatory biographies of both these briIIiant personaIities have been written by many students of medica history and are avaiIabIe to those who wish to read more about either of them. The consensus of opinion among students of medica history is that Hugo of Lucca surpassed even his teachers, because they foIIowed more or Iess bIindIy, dogmaticaIIy and unquestionabIy that which had been set down in manuscript by their iIIustrious predecessors, whereas he possessed a facuIty of questioning everything, of appIying a certain practicaIity to everything, every formuIa or procedure, simpIifying it, and discarding that which he found not true in actua1 practice. In the practice of medicine there have been from time to time such men. They fai1
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American Journal 01 Surgery
‘73
to foIIow in the groove of custom because their own judgment teIIs them not to. There have been and there wiI1 aIways be great practica1 teachers of medicine who devote their entire time to study and teaching and practice, Iike Hugo. Having Iittle time to write or express themseIves on paper, their passing from the scene is usuaIIy marked by a sparseness of avaiIabIe writings. Posterity suffers thereby, but these men are usuaIIy so practicaI-minded that the wide pubIication of one of their methods, which to their own thinking is of such utter simpIicity as to be aImost ridicuIous, is distastefu1, savors of persona1 aggrandizement, and they Iook upon it with disdain. So it was with Hugo. ExceedingIy smaI1 is the amount of his writings which can be authenticated, though he Iived and practiced unti1 he was about a hundred years oId. One fortunate circumstance Iessened the possibiIity that a11 his work wouId be Iost. He had severa sons, four of whom decided to make medicine their fieId. One, Theodorich, caIIed Theodorich Borgognoni, he was particuIarIy attached to and made him his intimate associate, assistant and confidant. Because of a feeIing that the teachings of his father shouId be made known to the scientific worId, Theodorich took it upon himseIf to gather together and pubIish severa tracts, the most famous of a11 being a “Cyrurgia.” Two hundred years or so Iater, in 1498 and 1499, these were gathered into print and pubIished in Latin in Venice and in French in Lyons. These two items today form very rare incunabuIa, diffIcuIt to obtain at aImost any price. Due to the constant interchange of ideas, practice, and writings of father and son, Hugo and Theodorich are usuaIIy spoken of together and their writings are considered jointIy. In order to understand why Hugo of Lucca is considered as one of the greatest of an examination into his contemporaries, some of his surgica1 ideas and procedures is of heIp.
I74
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Journal
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First, and perhaps most simpIe, were his ideas as to the etioIogy of headaches. He distinguished them as being either of brain origin or derived from a state of disturbed digestion. He stated, “Those found to be due to some cause within the skuI1 or in the brain itseIf, such as might be caused by the pressure of a tumor, wiI1 be found to be constant and continuous, without any relief whatsoever, even for an instant, while those arising from a disturbed state of digestion wiI1 be found to have intervaIs of compIete freedom, then very intense and severe intervaIs dependent entireIy upon the state of the stomach.” Because war and civi1 combat were the order of the day, the most common injuries were those occurring from bIudgeoning of the skuI1 by heavy weapons wieIded with great force and producing a11 types and degrees of skuI1 fracture. It was obviousIy necessary that the surgeon of the time be most experienced and skiIIed in the handIing of such a type of injury. The next most common type of injury was that caused by arrows. These wounds caIIed for no end of ingenuity on the part of the surgeon. The making of arrow heads invariabIy exhibited an unusua1 degree of maIicious invention. Some were made in such a manner that when they penetrated into the flesh they could not be withdrawn without extensive incision into and damage of the tissues for a considerabIe surrounding area. In such cases Hugo evolved a technique entireIy his own. He made no attempt to extract the arrow immediately upon penetration, endeavoring first to disinfect the wound with hot wine appIications. Then in a few days as the muscuIar rigidity reIaxed, it was easier to extract the arrow head, often without any additiona incisions whatever. Theodorich, in describing this method of his father’s reIates, “Once I saw two strong men make efforts to extract an arrow from the body of one who had been so injured. Despite their great strength they were unsuccessfu1 and the injured one was brought to my master, Hugo. By the appIication of his usuaI
of Lucca remedies in a few days the arrow withdrew aImost of itseIf.” When it is considered that every ingenious expedient that the brain of man couId devise was used to tip these arrow heads, such as dipping them for Iong periods in poisonous concoctions or smearing them with known poisons, anything that wouId increase the deadIiness of the weapon, then it is not hard to visuaIize that the probIem of wound infection and its handling was no minor one. Here aIso he had his own particuIar technique. AI1 wounds were dressed with wine, and he emphasized that it was important to use the best possibIe wine that couId be obtained. In the hands of an honest individua1 this admonition was probabIy very wise. It has been related that contemporaries and foIIowers of Hugo carried out this admonition with rather shady resuIts, setting aside the good wine for persona1 consumption and using for the wound any other that was at hand. Human behavior down through the centuries has probabIy been no better and no worse. Hugo described the penetrating wounds of the chest caused by arrows, the resultant empyemas, the compIications of rib fractures, the Iung abscess and Iung gangrene which often foIIowed. He reached a peak of surgica1 accomplishment by performing a compIete Iobectomy, aIthough invoIuntariIy. In describing this particuIar case, Master Hugo reIates : “There was a nobIeman Iiving in BoIogna, named DomiceIIus whom I was caIIed upon to treat. When I arrived within the waIIs of his house the stench of rotting ffesh was of such intensity that I thought it aImost unbearabIe. On approaching his bedside, I noted that his once huge frame had shrunken to an aImost unbeIievabIe degree, both from the nature of his wound and from the wracking of his body with pain. As I stood there, he coughed up quantities of the most fou1 smeIIing substance in which were great pieces of substance and when I examined his wound which was an enormous one of his chest,
NEW SERIES VOL. XLVII,
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I
Cunha-Hugo
I couId see the putrefying substance of his Iung and I noted that that which he coughed up was exactIy the same as I couId see in his wound. As I proceeded to dress his wound according to my usua1 procedure I thrust my hand into the wound and on withdrawing it found that it contained such a huge portion of Iung substance that I became aIarmed. However, I was abIe by my method to hea this man compIeteIy even though a part of the lung was Iost.” In the treatment of wounds Hugo very often differed from the strongIy entrenched medica authorities, but he was very carefu1 aIways to mention wherein he differed and why. He casuaIIy mentioned that he was quite aware that GaIen or Avicenna recommended some other procedure or strongIy advised against the very steps he was using, but then he cited his reasons, and, as though to cIinch the matter, gave names and pIaces where he cured so and so by this very method. Nothing couId be more convincing. His son, Theodorich, who was working with him constantIy and absorbing as much of his father’s wisdom as he couId, speaks of the treatment of these wounds thusIy : “When a white pap-Iike fluid runs out of the wound, then things are not too well, and when a very thin serous-Iike fluid comes out then there is great danger, but one must not despair whoIIy because I personaIIy have heaIed such men foIIowing the treatment advocated by my father and I have seen a great many who showed the above mentioned signs heaIed by him.” The third type of traumatic injury most commonIy met with was that caused by the sword. These wounds varied from minor Iacerations to cuts of extreme degree. If one has noticed in the museums the varying type of weapon which came under the heading of sword, one can we11 visuaIize the extent of injury which couId be infficted by a husky expert wieIding such an instrument, particuIarIy those enormous two handed and doubIe edge bIades.
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American
Journal
of Surgery
‘75
Hugo describes the wound produced by just such a two handed affair wieIded by a giant of a man which caught his opponent across one side of the skuI1. Not onIy did it trephine him, but it accompIished a partia1 decerebration much the same as that achieved by our research men with great pains. The victim did not die, much to the astonishment of Hugo himseIf and the physicians of SaIerno. The Iatter had refused to undertake his treatment, forcing him to journey to BoIogna to Hugo. In Hugo’s treatment of this case he stressed the necessity for the utmost cleanIiness in and about the wound, the carefu1 shaving of the surrounding skuI1, the wisdom of avoiding the probing of such a wound needIessIy or too many times. The actua1 treatment was to 611 the cavity with a consecrated oil, “oIei consecrationi,” then to appIy a pressure tamponade, snug and firm but free from any unnecessary force. Theodorich, in describing this particuIar case states, “One ventricIe of the man’s head was totaIIy empty of brain substance, nevertheIess he was heaIed by my father Hugo who restored the brain substance by ffesh (this presumably means connective tissue) and as it was the ceIIuIe of memory I noted that he was very astonished that the man retained his memory as before.” This entire description one can accept with the proverbia1 grain of saIt. Theodorich stressed the fact that these types of wounds when treated by his father from the very beginning and dressed onIy by himseIf, invariabIy did weI1. This Ieaves, one presumes, a IoophoIe for Hugo, because his cases invariabIy came from a distance and had been treated in some form or another by other surgeons in other IocaIities. The Iack of success, when it did occur, couId thus very convenientIy be shifted back to the origina physician. The same type of aIibi is used today with not the sIightest deviation in method. As can we11 be imagined, Hugo’s success with such outstanding cases as the man with the gangrene of the Iung and the other with the Ioss of brain substance brought
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him a fame far beyond the geographica borders of his town and his country. His practice grew enormously and he was caIIed everywhere in consuhation.
of Lucca
JANUARY. I g.w
tions of Avicenna. It seems that Avicenna advocated attempting to sew the structures together whereas according to Hugo perfect approximation of the structures by
PROLOGVS
qucnm mulh opa-awi occwruIIt, qvr non PO’ WIUPI d&ciliprouidai: oporut mcdicum ingrniofum dli Ikm*Cenim m&urn c%ncn&in medicoingcniummrunle,dicirenim.Ine;mium mrdl* ci~~nlcadiu~futtm,&nuut~mrr~enrcm.cori
Suftipc iginnprwr charilUmc0 urex@um,imo C padonc~iiipdlui. .ig utamplG. Qti opursrimiii,brrurcorporc, VII Specin chirurgi~,Grutrcfiatur Io%~ioW, & fitr. vcro medico valdenmporc fuiCGdomino HugoDkit~llim, chirurgia%duplex:auticuni:nu~in of nc , ncquevidcre, nrquc corn rchtndcrc, Cubice ntquc dikeread pknum potuitxpcrr~P mus curu ~o~m:n~mrllrficinmcmbtirmoU~~uc,vrincrr~ fuu:idro in 0arw iRa imwrfc&um mcum cxwo~ ne,ntrui~,vcnis,& limMwr.l\liafirin mrmbriodw ri;r~prri.nbq&mdql;orUcvnbopn6cnr;G~rls,vrinoliibur,& conGmilibm:qu+ Gcurdifferunc tnimrximc, qucmxprdi(tovi~rxlmioinnuUo in coauarimaqu~~m, fdilictcmolkk. h durinouimusdifcordare. Vcautemadlibrum IRumac cicGccrinomnlopmcioncchirurgicL Chirurgk cths h&or hrbearur uidGr chirwgia, vndedicr quzfirin mcmbricmolUbu~,,(tbdiuidin~plicinr: nccnon tur, qurks opmrorc8 tiaedcbcar, aut Prin carnccanffi, incifio,fcu ipforuminanrio,& i,lquotdiuiduurfprcicr,breufurun,aurlnciGonunntparur.Aur6rinurnira~pul ter dmombo. fintibus:ruc in h dicinw phkboromia . igimrcfi opcrrriomanualisin corpoGucfaio. Aur fit in ncruirfcciidi~krii. crtiicincilio Ch’lrurgla rc animalisrd %ratzr~ndcns:Vtl Gc, noi~Nr.Aur~riidG~ongG,&Nncpu~cruradidrur Chirur~acRvldmum inRrumcntii mcdidnz. Trk vcl f&w.In diaohnnmatc oi (II oanniculir, nomienimfu&uWmwwa mc&cint,qaibus median& x oat~rr~pn~ra. &i&irvtro ‘u+Gdn &mbrts bus, morborumcauGsvdccmc8~sfubucnirc,f~U duris,dupkx cR:aurcnim Bcin o l?lbus duris, 8r diciccrdiarta,pocio,&chirwgir. CixratR primumin *urrcftauratio IiutconfoliJaio ~acrctorum:autfirin ~ummNm:& cR mcliuqtcurt&rNr C&in c8nr~ olrbus dlrlo~.dsrlocoproprio.B~ppcllnrurcon10 rcgiminisrcurorum dicb. Si p0GLmushomincm iunccio diluncrorum. rurrr~cumdina:noncur~murcumcumaliquapouodvnufquifqw vdutrir,vakatfaautem 9 d6c. Er Dam&n AphoriLSi porrris hominrm cura clllusiu~nirc:diuid~musinqlrlruorprr r~p~rdi~nm,profpermlinucnicnr:hocaucZinRruticulrslibrumiRumordinrr~ p~rctpitulaparttrfinmenrum Gurrcgtmmai irurcontrrcaubm,&h. gulardininguLndo:iraum~n g,inprimrparrchuiu~ cirdig&ionun. Scam d urn rcgimcnfcu inRrumT libri non in fptcidi, f&b qua&m inandimusgc-
prrdicco
rt.Etrcrundurnronmrimc~mmt~nbrcuum
P
qqlit
quzrurifintio, WI
pulfandbur :
Vt
tumcRporio:JcquaidcmCJ.Sicumpotioncinfirc
mirarem poUumurr~mourrc,rdchirurgiamrrcurrcndu’mmnon& Sirurrmpcr duoprrdi&rcgimi mituinfirumcnta remouninon 0tcric:rcmouta. 1 tw brnrficm rcrrijrcgiminis:vidc ccrchtrmgur. ~~uraurcmchirur~aach~quod e%manus:ct
nrralicac~ crIcEUC Diuiditur aurcrnlibtr ilkin qunruorparrt% In prima pnrceagirurvniurrhlirrrdr vulncribus, vlcc ribu~,defluxuhnguinir,& m~dicinisipforum,driu dicijr morrio,dc vulncribus ncr~orun~ , curl JpOhcmaria didi, atqu Infccunda pure ryuy
rprrmi
FIG. I. Page from Hugo and Theodorich’s
There were apparentIy many deep sword wounds of the neck, often invoIving the great vesseIs, the direct seque1 of attempts to decapitate the opponent. Here Hugo’s therapy was unique and individuaIistic. According to his custom, he humbIy apologizes for his technique, stating that he knows he is contrary to the recommenda-
“Cyrurgia.”
pressures and pads was a11 that was necessary. In the treatment of ordinary Iacerations or cuts he was considered a master. His approximation of edges was so perfect, that his son often stated, “My master Hugo heaIs and consoIidates a11wounds with wine hnd compresses, making a convenient and
New SERVESVOL. XLVII. No. I
Cunha-Hugo
artistic dressing which he knows how to do so VeII, thus producing the most beautifu1 cicatrices without the use of either sutures or salves. No ragged or stringy cicatrix ever remained from the wound or abscess of a man he had treated himself. In conformity with this I have never seen a singIe broken or cut blood vessel which he was not abIe to cIose by the use of such a dressing.” ApparentIy the greater proportion of thece civi1 and war traumatisms were not superficial, but penetrated deepIy as Hugo describes. He stresses the painful symptoms which accompanied the encIosure of a cut nerve ending in a scar. However, he did not advocate the suturing of the cut ends of nerves even though they were easily visibIe and it couId be done very readiIy. He cIaimed that his method of treatment by pressure and approximation was efficacious in a11 wounds whether nerves or bIood vesseIs were invoIved or not. He recommended the most exact conjunction of the surrounding tissue, this approximation to be maintained by little “cushions” (compresses?) which acted aIso to keep the wound dry. “When it became absoIuteIy necessary the sides of a wound might be sewed without, however, touching the nerve itseIf. . . . The ends of a disunited nerve shaI1 be brought together by pressure upon the surrounding tissue onIy.” He recommended massage with a special oi1 of his own formula if the nerve ever did get entangIed in the scar and was painfu1. In his septic wounds, he threw overboard the theory which was then and Iater caIIed that of “IaudabIe pus,” and used IittIe cushions soaked in warm wine to cIean them, then dried them thoroughIy. Sometimes he used an “attractive smeIIing cIeansing desiccant appIied by a suitabIe dressing which the master could make very weI1.” Hugo constantIy admonished that wounds couId not be heaIed by either incantation or magic powders nor by cauterization with heated stones as was done in many pIaces. He apparentIy recognized “septicemia ” secondary to infected wounds, stating that
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American Journal of Surgery
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when the virus escaped from the wound into the interior, then a warm decoction of roses and various other substances was to DeapoRematemamillarum,kvirgre. Defclirofi. De tumore. 2.2 ‘3 Depurtulisalbisqualiiiunba,qurapparbrub nafo:h fupcrpomis maxillarum, =4 De fcroffulis. a5 Dcglanduh’s;&~nodis. 26 De tefiudine. a7 De nodis fiue teRudinibus contingcntibusin ca pite:& dicuntur cornua. De nodis Iiue lupus qua: nafcuntur in palpcbris oculorum. ‘9 De bubone, 3* De bocio. 3’ De napta, in ma 3s Deinflatio’efiucpingucdincquxapparct millirquorundam hominum. De hydropifi. Deomnieminentiaetruptur~qu+Pccidirinfi~ phac vent& De herniaintelh’nali, Deherniaaouofa.ventofi.etcarnofa; Deapoltem~tibu~tefiiculorum. De verrucis,h porrisaccidentibusin virga,ueI in alia parte corporis,ct de clauis,ctformicir, De clauis hue callis. De cura t’ormicacum f&o, DC htmorrhoidibur DCfiRulisin ano. De ficu E&o in ano. 4 4 De lapide veke & renum, 4 5 De cauterfis & iuuamento ipforum : 6 quoma do fintin quiburdam aegritudirnbus ficiZda. 4 6 De con’ibufiioncignis, aqua, h olri:vclaliquo huiufmodi. 4 7 Defcabie,& pruritu. Deoutilisfaciei. De malo mortuo. Deimpetigine,&f&piginc. De gum rofacea. Depannaritio. De morphea. Dclenriginibu~~ panno,rugis,liuore,nigredine. De lepra. De tuberibus,
Lb 11
2. A list of varying subjects published by Hugo and Theodorich, evidence of their versatihty.
be given internaIIy. But the wound was to be continuousIy treated according to his method despite this escape of virus, and he remarked that if it had been treated correctIy the virus could not have escaped into the interior. That he was abIe, one can hardIy doubt. The description of his method of reduction of fractures by first immersing the patient in a hot bath thereby reIaxing a11 invoIved structures, then sIowIy and carefuIIy teas-
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ing or coaxing the fragments into aIignment, is briEant. In fractures of ribs he used gentIe massage and compression much in the manner in which we do artificia1 respiration, pressing inwardIy where necessary with one hand and massaging IightIy somewhere near with the other unti1 he had obtained that degree of approximation of fragments he desired. In similar manner he reduced disIocations. A description by his son of such a fracture reduction is as foIIows, “The master Sir Hugo, Ied the patient into a warm bath where he was instructed to Iie down. Dipping his hands into first turpentine, then honey and then pitch, Hugo Iaid his hands on the pIace where there was the weakness, pressed inwardIy then Iifted his hands suddenIy. This procedure was repeated quite often until the ribs were brought back into a norma position after which a dressing of pitch and tar was made to hoId this position.” In the matter of spIints for fractures, he did not recommend them or use them much. He preferred thickened dressings which couId be mouIded by hand rather than those made of “timbers” as he described them. Compound fractures he described in detai1. Their treatment was to consist of the appIication of both his methods. The first, reduction of the fracture itseIf, the second, his usua1 method of treatment of any and a11 wounds. That he was humane in his work can be judged by his descriptions of his “spongia soporifera ” to induce narcosis in those patients where pain couId not be avoided. AIthough there is much evidence that there were many varied procedures for producing some degree of narcosis and insensibiIity to pain by surgeons in much earIier times, Hugo stressed the use of inhalations of varied and secret drugs as anesthetics. The composition of his “ spongia somniferens ” was known only to him. By many it is presumed that this method of narcosis was originated by him. Whether this is true or not we do not know, but at any rate he popuIarized its use.
of Lucca
JANUARY,
,yqo
His therapeutic armamentarium is evidence of his versatiIity. He himseIf made “coIIyria,” prescribing them for many redness and inffammation of the eyes. A “ hoIy saIve” which was a “cure aI1” in the heaIing of wounds, was a secret formuIa. Another saIve contained mercury which he used in skin diseases and it is to him that credit must be given for the first description of the saIivation and gum changes produced by the proIonged use of mercury. Others of his salves contained arsenic and were used as cauterizing agents in fissures and wounds. These were caIIed “encaustrum ” and Iikewise were a secret composition of his own. He wrote of using a “coaguIum Ieporis” which historians reIate was not new to him or his time, having been used in earlier days. It consisted mereIy of the coagulated bIood of hares. If onIy these historians had recorded in what conditions he used this coaguIated rabbits’ bIood, particuIarIy if in hemorrhage, what an interesting point that wouId make. He did describe extensive bleeding from wounds, but no technique of treatment other than his usua1 method of closure. An anodyne powder is described by his son as being a part of the after treatment of a11 his severe cases, but its formuIa is not mentioned. It was caIIed onIy a “wound drink,” dissoIved in wine. Like any good surgeon he stressed the after care of his patients and paid particuIar attention to their diet. “Pigmenta,” his wound drinks were caIIed because they were designed to produce bIood and flesh. He was a very pious individua1 and instructed his patients to say a prayer whenever they partook of these drinks, which was severa times a day. He even designated certain prayers which shouId be said _. at the various hours. These wound drinks were mainIy highIy concentrated beef or chicken broths. As to meats, he decIared that capons, partridges, pheasants and smaI1 birds with fine beaks, were of exceptiona quaIity to produce blood and sinew. Meat of suckIing
NEW SERIESVor XLVII, No. I
Cunha-Hugo
goats and of castrated spring cattIe was also very fine. Chicken eggs were to be eaten daiIy, cooked in any manner except sodden or fried. Paramount, however, was the instruction that the best wine obtainabIe, not requiring the addition of water, shouId be taken for regaining strength. That he took part in the civic Iife about him is evidenced by the fact that in I 2 14 he was appointed city physician to the town of Bologna. In 1218 he was persuaded to join the BoIognese contingent to the Crusade, returning in 1221 to take up once again his duties as city physician. In this post he is credited with drawing up the first IegaI sanitary measures and ruIes regarding water, waste disposa1, etc., as a modern heaIth officer wouId be expected to do. It is rather singuIar that a great name and presumabIy a great surgeon shouId have singIed out the name of Hugo of Lucca upon which to vent his viIification and abuse. Guy de ChavIiac swore to the high heavens that not onIy Hugo but aIso his son Theodorich, were no more than charlatans and quacks of the highest order, and accused them of pIagiarizing the oIder Greek masters, then cIaiming for themseIves that a11 they propounded was origina1. This anger and abuse was probably incited by the fact that Guy de ChaviIiac was the great exponent in his time of the theory of “IaudabIe pus,” whiIe Hugo and his son procIaimed vehementIy that there was no such thing. “It is not necessary, as many supposedIy great minds have taught and are teaching, that pus must be generated in wounds. To practice such a method is onIy to hinder nature and to prevent good approximation and heaIing of wounds.” Yet we find in the works of Guy de ChaviIiac, who accuses them of pIagiarism, the identica1 descriptions word for word as written by Theodorich at the direction of Hugo, and even the Zustrations to the chapters of his great opus, his surgery, are copies of those from the works of Hugo.
of Lucca
American
Journal
of Surgery
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A perusa1 of the Iife and work of the two individuaIs makes one ponder whether one shouted the Ioudest and had the best pubIicity whiIe the other went on unspectacuIarIy producing resuIts. At any rate, history seems to have given the verdict of popuIarity to Guy de ChavIiac, whether he deserved it or not. The SchooI of BoIogna itseIf, independent of its famed facuIty member, was instrumental in contributing a miIestone in the progress of medica science and it came about in an interesting manner. First, in speaking of these medieva1 universities certain things must be kept in mind in order that a better picture may be obtained. In BoIogna as at SaIerno, Monte Cassino, and other centers, the actua1 popuIarity and success of the institution was dependent entirely upon the fame and Iearning of its faculty. It was because of the quaIity of scoIarship that students flocked from EngIand, Germany, France, and other countries to any one particuIar center. At the very peak or height of its amuence the schoo1 of BoIogna had a registration of 10,000, speaking voIumes for its facuIty. Its fame rested upon its schoo1 of medicine and surgery and its schoo1 of Iaw. One day in the streets of BoIogna a man dropped dead from no apparent cause. The medica facuIty being unabIe to give any satisfactory expIanation other than that it was probabIy due to some disease of the heart, the Iaw facuIty insisted that a postmortem examination of the heart shouId be made and this was done. It is rather certain that human dissection was practiced in oId Grecian and Roman times, but it was done secretIy and no actua1 record ever was made. There is an old medica manuscript in the BodIeian Library which contains a drawing of a dissection scene, using a human body. This manuscript is presumed to have been written about the year 1300 A.D. The Church had formaIIy prohibited human dissection because it had become the practice of the Crusaders to cut up the bodies of those who died and hoi1 the pieces in order
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to separate the Aesh from the bones, since it was more feasibIe to repatriate the bones of those who died in distant countries. The bones might then be buried in the home parish. Transportation facilities had to be considered. It was easier to transport a few bones than a whoIe body, but the Church forbade this practice. When the Iaw facuIty considered this case of sudden and unexpIained death, they demanded at Ieast a post-mortem examination of the heart. By so doing they broke the fetters of custom which had entwined medica anatomy for ages and unknowingIy Iaid the foundation for the schoo1 of briIIiant anatomists who were to foIIow and who were to base their descriptions and drawings upon the study of actua1 human bones and flesh. This was definiteIy a miIestone in medica progress, and to the University of BoIogna must be given the credit first for the estabIishment of post-mortems in the study of disease, and second, for the briIIiant strides in anatomy which took pIace from that time on. As to the writings and works which Hugo Ieft to posterity, as stated previousIy, there is some degree of uncertainty as to whether much has disappeared or whether he reaIIy wrote IittIe. He Iived to a very oId age, reckoned by biographers to have been in the vicinity of one hundred years. He had four sons, a11of whom were physicians, but onIy one, Theodorich, attained any degree of fame. To him Hugo entrusted a11of his secret formuIae and methods of therapy, and it is recorded that he did not impose the oath of secrecy upon this son as was the custom of the times. This custom originated with earIier physicians and surgeons in order to protect the formuIae and methods they used for the benefit of their famiIies when they died, that they might continue to derive remuneration from them. If there was a son who eIected to become a physician a11 information was
of Lucca given to him and he was sworn to secrecy. If there was no son and an assistant had proved of sufficient IoyaIty and merit, then the information was his on the same basis. It is probabIe that Hugo wrote IittIe, Ieaving this part of his work to his son. A “ Cyrurgia ” was pubIished in Venice in 1497, and is presumed to consist of the combined manuscripts of Theodorich and Hugo. It is this work which Guy de ChavIiac Iater incorporated into his own. Later editions of it were pubIished in Venice, in ‘$99 and 1500. Two treatises which were definiteIy known to exist in manuscript from, a “De SubIimatione Arsenici,” and a “De AIuminibus et SaIibus” are presumabIy Iost. Copies in Spanish and ItaIian exist of a work entitIed “Practica Equorum” deaIing with veterinary medicine. It is supposed that the materia1 in this is entireIy Theodorich’s. OnIy the “ Cyrurgia” remains to Hugo’s memory. He compiIed it before the middIe of the thirteenth century and dedicated it to the bishop of VaIencia. This fact may account for its Iater Spanish transIation. From this Spanish transIation, one was made into Hebrew. A smaI1 manuscript deaIing with the manufacture of wines and with their use in disease was known to have existed but its whereabouts today is unknown. If found, it wouId probabIy be the first treatise on wine, antedating Andre De ViIIanouas’ “De Vinis ” by some years. Hugo shouId be cIassed among that Iarge group of physicians and surgeons who have stood UnfIinchingIy by principIes in which they believed. His pIace in medica history is secure because of his intenseIy practica1 aptitude, his abiIity as a surgeon, as a teacher of medicine, and as the rea1 founder of what couId be caIIed the ItaIian schoo1 of surgery which had originated with him at BoIogna in the middIe of the thirteenth century.