There are many interesting things said with regard to depressed fractures and the necessity for elevating the bone. If the depressed portion is wedged, then an opening should be made with the trephine, and an elevating instrument called a spatumen used to relieve the pressure. Great care should be taken, however, in carrying out this procedure, lest the bone of the cranium itself, in being lifted, should injure the soft structures within. The dura mater should be carefully protected from injury as well as the pia. Care should especially be exercised at the brow, and the rear of the head, and at the commissures (proram et pupim et commissuras), since at these points the dura mater is likely to be adherent. Perhaps the most striking expression, the word " infect " being italicized by Gurlt, is: " In elevating the cranium, be solicitous lest you should infect or injure the dura mater".
While these old-time surgeons insisted on the necessity for treating all depressed fractures, and even suggested that many fissure fractures required trephining, they deprecated meddlesome surgery of the cranium, unless there was evident necessity, quite as much as we do now. Surgeons who in every serious wound of the head have recourse to the trephine must, they said, be looked upon as fools and idiots (idioti et stolidi). When operations were done on the head, cold particularly was to be avoided. The operations were not to be done in cold weather, and above all not in cold places. The air of the operating-room must be warmed artificially. Hot plates should surround the patient's head while the operation was being performed. If this were not possible they were to be done by candlelight, the candle being held as close as possible in a warm room. They had many experiences with fractures at the base of the skull. Haemorrhages from the mouth and nose and from the ears were considered a bad sign. They even suggested, for diagnostic purposes, what seems to us the rather dangerous procedure that the patient should hold his mouth and nostrils tight shut and blow strongly. One of their methods of negative diagnosis for fractures of the skull was that, if the patient were able to bring his teeth together strongly, or to crack a nut without pain, then there was no fracture present. One of the commentators, however, adds to this, as well he might, sed hoc aliquando fallit— " but this sign sometimes fails." Split or crack fractures were also diagnosticated by the methods suggested by Hippocrates of pouring some coloured fluid over the skull after the bone was exposed, when a linear fracture would show by coloration. The Four Masters suggest a sort of red ink for this purpose.
One might well expect that, with trephining as frequent as this textbook of the Four Masters more than hints, the death-rate of these medieval surgeons must have been very high in head cases. We can scarcely understand such intervention in the conditions of operation assumed to exist in the Middle Ages without almost inevitable infection and consequent death. They seem to have come to an empiric recognition of the advantage of absolute cleanliness in such operations. Indeed, in the light of our modern asepsis and its development during our own generation, it is rather startling to note the anticipation of what is most recent in the directions that are given to a surgeon to be observed on the day when he is to do a trephining. I give it in the original Latin as it may be found in Gurlt (vol. L, p. 707): " Et nota quod die ilia cavendum est medico a coitu et malis cibis sera corrumpentibus, ut sunt allia, cepe, et hujusmodi, et colloquio mulieris menstruosss, et mantis ejus debent esse mundse, etc." The directions are most interesting. The surgeon's hands must be clean; he must avoid coitus and the taking of food that may corrupt the air, such as onions, leeks, and the like; must avoid menstruating women ; and in general must keep himself in a state of absolute cleanliness.
After the South Italian surgeons, some of whom taught at Bologna, a group of North Italian surgeons, most of whom probably were either direct or indirect pupils of the Salernitan School, must be considered. This includes such distinguished names in the history of surgery as Bruno da Longoburgo, usually called simply Bruno; Theo-doric and his father Hugh of Lucca; William of Salicet; Lanfranc, the disciple of William who taught at Paris, and gave that primacy to French surgery which was maintained all the centuries down to the nineteenth (p. 1); and Mondino, the author of the first manual on dissection, which continued for two centuries to be used by practically everyone who anywhere did dissection throughout Europe. Practically all of these men did their* best work between 1250 and 1300. Bruno of Longoburgo taught at Padua and Vicenza, and his textbook, the " Chirurgia Magna," was completed in Padua in January, 1252. Gurlt notes that " He is the first of the Italian surgeons who besides the Greeks quotes also the Arabian writers on surgery." Eclecticism had definitely come into vogue to replace exclusive devotion to the Greek authors, and men were taking what was good wherever they found it.
Bruno begins his work by a definition of surgery, chirurgia, tracing it to the Greek and emphasizing that it means handwork. He then declares that it is the last instrument of medicine to be used, only when the other two instruments, diet and potions, have failed. He insists that surgeons must learn by seeing surgical operations, and watching them long and diligently. They must be neither rash nor over-bold, and should be extremely cautious about operating. While he says that he does not object to a surgeon taking a glass of wine, the followers of this specialty must not drink to such an extent as to disturb their command over themselves, and they must not be habitual drinkers. While all that is necessary for their art cannot be learned out of books, they must not despise books, however, for many things can be learned readily from books, even about the most difficult parts of surgery. Three things the surgeon has to do— " to bring together separated parts, to separate those that have become abnormally united, and to extirpate what is superfluous".