Part 23

"For the preservation of teeth--considered by him, quite rightly, a matter of great importance--Giovanni of Arcoli repeats the various counsels given on the subject by preceding writers, but he gives them as ten distinct canons or rules, creating in this way a kind of decalogue of dental hygiene. These rules are: (1) It is necessary to guard against the corruption of food and drink within the stomach; therefore, easily corruptible food--milk, salt fish, etc.--must not be partaken of, and after meals all excessive movement, running exercises, bathing, coitus, and other causes that impair the digestion, must also be avoided. (2) Everything must be avoided that may provoke vomiting. (3) Sweet and viscous food--such as dried figs, preserves made with honey, etc.--must not be partaken of. (4) Hard things must not be broken with the teeth. (5) All food, drink, and other substances that set the teeth on edge must be avoided. (6) Food that is too hot or too cold must be avoided, and especially the rapid succession of hot and cold, and vice versa. (7) Leeks must not be eaten, as such a food, by its own nature, is injurious to the teeth. (8) The teeth must be cleaned at once, after every meal, from the particles of food left in them; and for this purpose thin pieces of wood should be used, somewhat broad at the ends, but not sharp-pointed or edged; and preference should be given to small cypress twigs, to the wood of aloes, or pine, rosemary, or juniper and similar sorts of wood which are rather bitter and styptic; care must, however, be taken not to search too long in the dental interstices and not to injure the gums or shake the teeth. (9) After this it is necessary to rinse the mouth by using by preference a vinous decoction of sage, or one of cinnamon, mastich, gallia, moschata, cubeb, juniper seeds, root of cyperus, and rosemary leaves. (10) The teeth must be rubbed with suitable dentrifices before going to bed, or else in the morning before breakfast. Although Avicenna recommended various oils for this purpose, Giovanni of Arcoli appears very hostile to oleaginous frictions, because he considers them very injurious to the stomach. He observes, besides, that whilst moderate frictions of brief duration are helpful to the teeth, strengthen the gums, prevent the formation of tartar, and sweeten the breath, too rough or too prolonged rubbing is, on the contrary, harmful to the teeth, and makes them liable to many diseases."

All this is so modern in many ways that we might expect a detailed exact knowledge of the anatomy of the teeth and even something of their embryology from Arculanus. It must not be forgotten, however, that coming as he does before the Renaissance, the medical sciences in the true sense of the word are as yet unborn. Men are accumulating information for practical purposes but not for the classification and co-ordination that was to make possible the scientific development of their knowledge.

Giovanni of Arcoli's acquaintance with the anatomy of the teeth was rather sadly lacking. He does not know even with certainty the number of roots that the teeth have. This has been attributed to the fact that he obtained most of his information from books, and had not the time to verify descriptions that he had found. It has been argued from this that he was himself probably not a practical dentist, and turned to that specialty only as a portion of his work as a general surgeon, and that consequently he was not sufficiently interested to verify his statements. His chapters on dentistry would seem to bear out this conclusion to some extent, though the very fact that one who was himself not specially interested in dental surgery should have succeeded in gathering together so much that anticipates modern ideas in dentistry, is of itself a proof of how much knowledge of the subject there was available for a serious student of that time. The anatomy of the teeth continued to be rather vague until about the middle of the next century when Eustachius, whose investigations of the anatomy of the head have deservedly brought him fame and the attachment of his name to the Eustachian canal, wrote his "Libellus de Dentibus--Manual of the Teeth," which is quite full, accurate, and detailed. Very little has been added to the microscopic anatomy of the teeth since Eustachius' time. He had the advantage, of course, of being intimately in contact with the great group of Renaissance anatomists,--Vesalius, Columbus, Varolius, Fallopius, and the others, the great fathers of anatomy. Besides, his position as Papal Physician and Professor of Anatomy at the Papal Medical School at Rome gave him opportunities for original investigation, such as were not easily obtained elsewhere.

Arculanus can scarcely be blamed, therefore, for not having anticipated the Renaissance, and we must take him as merely the culmination of medieval knowledge with regard to anatomy and surgery. Medieval medical men did not have the time nor apparently the incentive to make formal medical science, though it must not be forgotten, as has been said, that they did use the knowledge they obtained by their own and others' observation to excellent advantage for the practical benefit of ailing humanity. The sciences related to medicine are conscious developments that follow the evolution of practical medicine, nor must it be forgotten that far from always serving as an auxiliary to applied medical science, often indeed in the history of medicine scientific pursuits have led men away into side issues from which they had to be brought back by some genius medical observer. As might be expected, then, it is with regard to the practical treatment and general consideration of ailments of the teeth that Giovanni of Arcoli is most interesting. In this some of his chapters contain a marvellous series of surprises.

Arculanus was probably born towards the end of the fourteenth century. The date of his death is variously placed as either 1460 or 1484, with the probability in favor of the former. From 1412 to 1427 he was professor at Bologna, where in accordance with the non-specializing tendencies of the time he did not occupy a single chair but several in succession. He seems first to have taught Logic, then Moral Philosophy, and finally Medicine. His reputation in medicine drew many students to the university, and his fame spread all over Italy. The rival University of Padua then secured him, and he seems to have been for some twenty years there. Later apparently he accepted a professor's chair at Ferrara, where the D'Estes were trying to bring their university into prominence. It was at Ferrara that he died. He was a man of wide reading, of extensive experience, both of men and medicine, and one of the scholars of his time. His works are, as we have said, mainly excerpts from earlier writers and particularly the Arabians, but they contain enough of hints drawn from his own observation and experience to make his work of great value.

While, as Gurlt remarks in his "History of Surgery," Arculanus' name is one of those scarcely known--he is usually considered just one of many obscure writers of the end of the Middle Ages--his writings deserve a better fate. They contain much that is interesting and a great deal that must have been of the highest practical value to his contemporaries. They attracted wide attention in his own and immediately succeeding generations. The proof of this is that they exist in a large number of manuscript copies. Just as soon as printing was introduced his books appeared in edition after edition. His "Practica" was printed in no less than seven editions in Venice. Three of them appeared before the end of the fifteenth century, which places them among the _incunabula_ of printing.

Probably nothing in the history of human intellectual interest is more striking than the excellent judgment displayed by the editors who selected the works to be printed at this time. Very few of them were trivial or insignificant. Fewer still were idle speculations, and most of them were almost of classical import for literature and science. Four editions of this work were printed in Venice in the sixteenth century, one of them as late as 1560, when the work done by such men as Vesalius, Columbus, Eustachius, and Fallopius would seem to have made Arculanus out of date. The dates of the various editions are Venice, 1483, 1493, 1497, 1504, 1542, 1557, and 1560. Besides there was an edition printed at Basel in 1540.

Arculanus is said to have re-introduced the use of the seton, that is the method of producing intense counter-irritation by the introduction of some foreign body into an incision in the skin. We owe to him, too, according to Pagel in the chapters on medieval medicine in Puschmann's "Handbook of the History of Medicine," an excellent description of alcoholic insanity.

His directions for the treatment of conditions in the mouth and nose apart from the teeth are quite as explicit and practical, and in many ways quite as great an anticipation of some of our modern notions as what he has to say with regard to the teeth. For instance, in the treatment of polyps he says that they should be incised and cauterized. Soft polyps should be drawn out with a toothed tenaculum as far as can be without risk of breaking them off. The incision should be made at the root so that nothing or just as little as possible of the pathological structure be allowed to remain. It should be cut off with a fine scissors, or with a narrow file just small enough to permit its ingress into the nostrils, or with a scalpel without cutting edges on the sides, but only at its extremity, and this cutting edge should be broad and well sharpened. If there is danger of hemorrhage, or if there is fear of it, the instruments with which dissection is made should be fired (_igniantur_), that is, heated at least to a dull redness. Afterwards the stump, if any remains, should be touched with a hot iron or else with cauterizing agents so that as far as possible it should be obliterated.

After the operation a pledget of cotton dipped in the green ointment described by Rhazes should be placed in the nose. This pledget should have a string fastened to it, hanging from the nose in order that it may be easily removed. At times it may be necessary to touch the root of the polyp with a stylet on which cotton has been placed that has been dipped in _aqua fortis_ (nitric acid). It is important that this cauterizing fluid should be rather strong so that after a certain number of touches a rather firm eschar is produced. In all these manipulations in the nose Arculanus recommends that the nose should be held well open by means of a nasal speculum. Pictures of all these instruments occur in his extant works, and indeed this constitutes one of their most interesting and valuable features. They are to be seen in Gurlt's "History of Surgery."

In some cases he had seen the polyp was so difficult to get at or was situated so far back in the nose that it could not be reached by means of a tenaculum or scissors, or even the special knife devised for that purpose. For these patients Arculanus describes an operation that is to be found in the older writers on surgery, Paul of AEgina (AEginetus), Avicenna, and some of the other Arabian surgeons. For this three horse-tail hairs are twisted together and knotted in three or four places, and one end is passed through the nostrils and out through the mouth. The ends of this are then pulled on backward and forward after the fashion of a saw. Arculanus remarks evidently with the air of a man who has tried it and not been satisfied that this operation is quite uncertain, and seems to depend a great deal on chance, and much reliance must not be placed on it. Arculanus suggests a substitute method by which latent polyps or occult polyps as he calls them may be removed.

There is scarcely an important disease for which Arculanus has not some interesting suggestions, and the more one reads of him the more is one surprised to find how many things that we might think of as coming into the purview of medicine long after his time or at least as having been neglected from the time of the Greeks almost down to our own time are here treated explicitly, definitely, and with excellent practical suggestions. He has a good deal to say with regard to the treatment of angina, which he calls synanche, or synanchia, or cynanche, or angina. Parasynanche is a synonymous term, but refers to a milder synanche. He distinguished four forms of it. In one called canine angina, because the patient's tongue hangs out of his mouth, somewhat the same as from an overheated dog in the summer time, while at the same time the mouth is held open and he draws his breath pantingly, Arculanus suggests an unfavorable prognosis, and would seem to refer to those cases of Ludwig's angina in which there is involvement of the tongue and in which our prognosis continues to be of the very worst even to our own day. At times the angina causes such swelling in the throat that the breathing is interfered with completely. For this Arculanus' master, Rhazes, advised tracheotomy. Arculanus himself, however, apparently hesitated about that.

It is not surprising, then, to find that Arculanus is very explicit in his treatment of affections of the uvula. He divides its affections into _apostema, ulcus, putredo sive corrosio, et casus_. _Apostema_ was abscess, _ulcus_ any rather deep erosion, _putredo_ a gangrenous condition, and _casus_ the fall of the uvula. This is the notorious falling of the soft palate which has always been in popular medical literature at least. Arculanus describes it as a preternatural elongation of the uvula which sometimes goes to such an extent as to make it resemble the tail of a mouse. For shorter elongations he suggests the cautery; for longer, excision followed by the cautery so that the greater portion of the extending part may be cut off. If people fear the knife he suggests following Rhazes, the application of an astringent powder directly to the part by blowing through a tube. His directions for the removal of the uvula are very definite. Seat the patient upon a stool in a bright light while an assistant holds the head; after the tongue has been firmly depressed by means of a speculum let the assistant hold this speculum in place. With the left hand then insert an instrument, a stilus, by which the uvula is pulled forward, and then remove the end of it by means of a heated knife or some other process of cauterization. The mouth should afterwards be washed out with fresh milk.

The application of a cauterizing solution by means of a cotton swab wrapped round the end of a sound may be of service in patients who refuse the actual cautery. To be successful the application must be firmly made and must be frequently repeated.

After this it is not surprising to find that Arculanus has very practical chapters on all the other ordinary surgical affections. Empyema is treated very thoroughly, liver abscess, ascites, which he warns must be emptied slowly, ileus especially when it reaches stercoraceous vomiting, and the various difficulties of urination, he divides them into dysuria, ischuria, and stranguria, are all discussed in quite modern fashion. He gives seven causes for difficulty of urination. One, some injury of the bladder; two, some lesion of the urethra; three, some pathological condition in the power to make the bladder contract; four, some injury of the muscle of the neck of the bladder; five, some pathological condition of the urine; six, some kidney trouble, and seven, some pathological condition of the general system. He takes up each one of these and discusses the various phases, causes, disposition, and predispositions that bring them about. One thing these men of the Middle Ages could do, they reasoned logically, they ordered what they had to say well, and they wrote it out straightforwardly.

That Arculanus' work with regard to dentistry was no mere chance and not solely theoretic can be understood very well from his predecessors, and that it formed a link in a continuous tradition which was well preserved we may judge from what is to be found in the writings of his great successor, Giovanni or John de Vigo, who is considered one of the great surgeons of the early Renaissance, and to whom we owe what is probably the earliest treatise on "Gun-shot Wounds." John of Vigo was a Papal physician and surgeon, generally considered one of the most distinguished members of the medical profession of his time. Two features of his writing on dental diseases deserve mention. He insists that abscesses of the gums shall be treated as other abscesses by being encouraged to come to maturity and then being opened. If they do not close promptly, an irritant Egyptian ointment containing verdigris and alum among other things should be applied to them. In the cure of old fistulous tracts near the teeth he employs not only this Egyptian ointment but also arsenic and corrosive sublimate. What he has to say with regard to the filling of the teeth is, however, most important. He says it with extreme brevity, but with the manner of a man thoroughly accustomed to doing it. "By means of a drill or file the putrefied or corroded part of the tooth should be completely removed. The cavity left should then be filled with gold leaf." It is evident that the members of the Papal court, the Cardinals and the Pope himself, had the advantage of rather good dentistry at John de Vigo's hands even as early as the beginning of the sixteenth century.

John de Vigo, however, is not medieval. He lived on into the sixteenth century and was influenced deeply by the Renaissance. He counts among the makers of modern medicine and surgery, as his authorship of the treatise on gun-shot wounds makes clear. He comes in a period that will be treated of in a later volume of this series on "Our Forefathers in Medicine."

XIII

CUSANUS AND THE FIRST SUGGESTION OF LABORATORY METHODS IN MEDICINE

As illustrating how, as we know more about the details of medical history, the beginnings of medical science and medical practice are pushed back farther and farther, a discussion in the _Berliner klinische Wochenschrift_ a dozen years ago is of interest. Professor Ernest von Leyden, in sketching the history of the taking of the pulse as an important aid in diagnostics, said that John Floyer was usually referred to as the man who introduced the practice of determining the pulse rate by means of the watch. His work was done about the beginning of the eighteenth century. Professor von Leyden suggested, however, that William Harvey, the English physiologist, to whom is usually attributed the discovery of the circulation of the blood, had emphasized the value of the pulse in medical diagnosis, and also suggested the use of the watch in counting the pulse. Professor Carl Binz, of the University of Bonn, commenting on these remarks of Professor von Leyden, called attention to the fact that more than a century before the birth of either of these men, even the earlier, to whom the careful measurement of the pulse rate is thus attributed as a discovery, a distinguished German churchman, who died shortly after the middle of the fifteenth century, had suggested a method of accurate estimation of the pulse that deserves a place in medical history.

This suggestion is so much in accord with modern demands for greater accuracy in diagnosis that it seems not inappropriate to talk of it as the first definite attempt at laboratory methods in the department of medicine. The maker of the suggestion, curiously enough, was not a practising physician, but a mathematician and scholar, Cardinal Nicholas of Cusa, who is known in history as Cusanus from the Latin name of the town Cues on the Moselle River, some twenty-five miles south of Treves, where he was born. His family name, Nicholas Krebs, has been entirely lost sight of in the name derived from his native town, which is the only reason why most of the world knows anything about that town. Cardinal Cusanus suggested that in various forms of disease and at various times of life, as in childhood, boyhood, manhood, and old age, the pulse was very different. It would be extremely valuable to have some method of accurately estimating, measuring, and recording these differences for medical purposes. At that time watches had not yet been invented, and it would have been very difficult to have estimated the time by the clocks, for almost the only clocks in existence were those in the towers of the cathedrals and of the public buildings. The first watches, Nuremberg eggs, as they were called, were not made by Peter Henlein until well on into the next century. The only method of measuring time with any accuracy in private houses was the clepsydra or water-clock, which measured the time intervals by the flow of a definite amount of water. Cardinal Cusanus suggested then that the water-clock should be employed for estimating the pulse frequency. His idea was that the amount of water which flowed while a hundred beats of the pulse were counted, should be weighed, and this weight compared with that of the average weight of water which flowed while a hundred beats of the normal pulse of a number of individuals of the same age and constitution were being counted.

This was a very single and a very ingenious suggestion. We have no means of knowing now whether it was adopted to any extent or not. It may seem rather surprising that a cardinal should have been the one to make such a suggestion. Cusanus, however, was very much interested in mathematics and in the natural sciences, and we have many wonderful suggestions from his pen. He was the first, for instance, to suggest, more than a century before Copernicus, that the earth was not the centre of the universe, and that it would not be absolutely at rest or, as he said, devoid of all motion. His words are: "_Terra igitur, quae centrum esse nequit, motu omni carere non potest_." He described very clearly how the earth moved round its own axis, and then he added, what cannot fail to be a surprising declaration for those in the modern times who think such an idea of much later origin, that he considered that the earth itself cannot be fixed, but moves as do the other stars in the heavens. The expression is so astonishing at that time in the world's history that it seems worth the while to give it in its original form, so that it may be seen clearly that it is not any subsequent far-fetched interpretation of his opinion, but the actual words themselves, that convey this idea. He said: "_Consideravi quod terra ista non potest esse fixa, sed movetur ut aliae stellae._"