While the old textbooks had emphasized the necessity for not allowing the circulation in the head to be disturbed by the cold, and insisted on the taking of special precautions in this matter, Bruno insists that wounds must be more carefully looked to in summer than in winter, because " putrefaction is greater in warm than in cold weather "— putref actio est major in sestate quam in hyeme. He is particularly insistent on the necessity of drainage. In wounds of the extremities the limb must always be so placed as to encourage drainage.
To secure it the wound may be enlarged; if necessary, even a counter-opening must be made to provide drainage. In order to secure proper union care must be exercised to bring the wound edges accurately together, and not allow hair or oil or dressings to come between them. In large wounds he considers stitching indispensable, and the preferable suture material in his experience is silk or linen. He discusses healing by first and second intention, and declares that with proper care the healing of a great many wounds by first intention can be secured. All his treatment of wounds is dry. Water he considered always did harm, and it is quite easy to understand that his experience taught him this, for the water generally available for surgeons in camps and battlefields and in emergency surgery was likely to do much more harm than good.
Some of the details of his technique of abdominal wounds will be particularly interesting to modern surgeons.
If there was difficulty in bringing about the reposition of the intestines, they were first to be pressed back with a sponge soaked in warm wine. Other manipulations are suggested, and if necessary the wound must be enlarged. If the omentum finds its way out of the wound, all of it that is black or green must be cut off. In cases where the intestines are wounded they are to be sewed with a small needle and a silk thread, and care is to be exercised in bringing about complete closure of the wound. This much will give a good idea of Bruno's thoroughness. Altogether, Gurlt, in his " History of Surgery," gives about fifteen large octavo pages of rather small type to a brief compendium of Bruno's teachings.
One or two other remarks of Bruno are rather interesting in the light of modern development in medicine. For instance, he suggests the possibility of being able to feel a stone in the bladder by means of bimanual palpation. He teaches that mothers may often be able to cure hernias, both umbilical and inguinal, in children by promptly taking up the treatment of them as soon as noticed, bringing the edges of the hernial opening together by bandages, and then preventing the reopening of the hernia, by prohibiting wrestling and loud crying and violent motion. He has seen overgrowth of the mamma in men, and declares that it is due to nothing else but fat, as a rule. He suggests if it should hang down and be in the way on account of its size, it should be extirpated. He seems to have known considerable about the lipomas, and advises that they need only be removed in case they become bothersomely large. The removal is easy, and any bleeding that takes place may be stopped by means of the cautery. He divides rectal fistulse into penetrating and nonpenetrating, and suggests salves for the non-penetrating and the actual cautery for those that penetrate. He warns against the possibility of producing incontinence by the incision of deep fistulse, for this would leave the patient in a worse state than before.
The most interesting feature of the work of the North Italian surgeons of the later Middle Ages is their discovery and development of the two special advances of our modern surgery in which we are inclined to take most pride. These are, union by first intention, and anaesthesia. It is of course very startling to think that surgeons of seven centuries ago should have made advances in these important phases of surgery — which were afterwards to be forgotten; but human history is not a story of constant progress, but of ups and downs, and the mystery of human history is the decadence that almost inevitably follows any period of supremely great accomplishment by mankind. The later Middle Age enjoyed a particularly great period of efflorescence and achievement in surgery, and this, quite as with literature and other phases of human accomplishment, was followed by distinct descent of interest in surgical theory, and decadence in surgical practice, until the Renaissance came to provide another climax of surgical development. It would be perilous to say, however, that the acme of the curve of Renaissance surgical progress was higher than its predecessor, though once more there is the surprise to find that this high point was followed by another descent, until the curve ascended again in our time.
What we have said already with regard to the requirement of cleanliness in operating upon the skull, insisted upon by the Salernitan School, will suggest that some of the practical value of asepsis had come home to these old-time surgeons. The North Italian surgeons went, however, much farther in their anticipations of asepsis. They insisted that if a surgeon made a wound through an unbroken surface and did not secure union by first intention, it was usually his own fault.
It is to them we owe the expression " union by first intention "—unio per primam intentionem— which means nothing to us except through its Latin equivalent. They boasted of getting linear cicatrices which could scarcely be seen, and evidently their practice fostered the best of surgical technique and was founded on excellent principles. The North Italian surgeons replaced the use of ointments by wine, and evidently realized its cleansing —that is, antiseptic—quality. What is often not realized is, that the very old traditional treatment of wounds by the pouring of wine and oil into them represented a mild antiseptic and a soothing protective dressing. The wine inhibited the growth of ordinary germs, the oil protected the wound from dust and dirt. They were not ideal materials for the purpose, but they were much better when discreetly used than many surgical dressings of much more modern times founded on elaborate theories.