University of Virginia Historical Collections at the Claude Moore Health Sciences Library

Case Studies

Cranial Fractures, Bladder Stones, and Spinal Dislocations

Surgical Examination of a Fractured Cranium

MSS from North Italy, circa 1300, Rome. Rolandus Parmensis, Chirurgia, I, 5-6, Surgical examination of a fractured cranium

MSS from North Italy, circa 1300, Rome. Biblioteca Casanatense, Rolandus Parmensis, Chirurgia, I, 5-6, Surgical examination of a fractured cranium

Broken heads were handled with care. Here the physician (magister), with hands on each side of the body, makes a careful examination, exploring the fracture with a finger. According to Rogerius (Chirurgia I, 4), “there is no better method of identifying a cranial fracture.” As indicated in the accompanying text, he will probably trephine, then cleanse the wound (note the cloth held by the assistant) and medicate (note the flask of medicine held by his assistant). A surgical ointment called apostolicon chirurgicum was much used in such cases. The text above the picture reads as follows:

Concerning cranial fracture in the shape of a fissure. Sometimes it chances that the cranium is fractured like a fissure and is split so that neither side seems higher than the other; also that it is uncertain whether the fracture extends inside the cranium. To find out, have the patient hold his mouth and nostrils shut, then blow vigorously; if any breath comes out of the cleft, you know that the cranium is fractured even into the cerebrum. Treat as follows. If the wound is narrow, enlarge it, and unless prevented by bleeding immediately trephine with an iron instrument, very cautiously on both sides of the fissure. Make as many holes as seems wise, then cut the cranium from one whole to another with a bistoury (spathumina), so that the incision extends to the edge of the fissure. Carefully remove pus oozing from above the cerebrum with a silk from a fine linen cloth introduced sideways between the cerebrum and cranium by means of a feather… [then medicate].

Celsan Operation for Bladder Stones

Manuscript from North Italy

Manuscript from North Italy circa 1300, Rome. Biblioteca Casanatense, Rolandus Parmensis, Chirurgia III, 34, Celsan operation for bladder stones

Throughout the ancient and medieval times bladder stones were removed by a method called “Celsan” because of Celsus’ detailed description in his De Medicina (VII, 26). According to him, and also Rogerius (Chirurgia III, 41-43), after the patient dieted for several days the stone was worked down into the urinary tract. Manuscripts of John Arderne’s fourteenth century Chirurgia contain marginal sketches showing the stone worked out into the penis whence it was excised. In the traditional procedure, however, the physician inserted a finger in the anus to work the stone downward to the outlet of the bladder while he pressed externally to assist in controlling the movement. This is described in the text which follows the miniature. Once the stone was worked to the outlet of the bladder, it was removed by surgery. The operation (as today) was performed from the rear. This is shown in the miniature, with the patient in the traditional position, legs jack-knifed, held firmly by assistants (discipuli) while the surgeon extracts the stone through a bloody incision. The text below the picture, along with the preceding section of text, describes the operation and also pre- and post-operational treatment as follows:

If there is a stone in the bladder, make sure of it as follows: have a strong person sit on a bench, his feet on a stool; the patient sits on his lap, legs bound to his neck with a bandage, or steadied on the shoulders of the assistants. The physician stands before the patient and inserts two fingers of his right hand into the anus, pressing with his left fist above the patient’s pubes. With his fingers engaging the bladder from above, let him work over all of it. If he finds a hard, firm pellet it is a stone in the bladder, which is soft and fleshy; thus you find that it impedes urination; if you want to extract the stone, precede it with a light diet and fasting for two days beforehand, On the third day, having done everything beforehand, as we said, to find whether there is a stone in the bladder, locate the stone, bring it to the neck of the bladder; there, at the entrance, with two fingers above the anus, incise lengthwise with an instrument and extract the stone… [medication, morning and night for nine days]. –Rogerius, Chirurgia, III, 36

Vertebra Reduction by Jolting on a Ladder

Manuscript from Byzantium

Manuscript from Byzantium, c. 1100, Florence. Laurentian Library, MS 74.7, folio 200, Apollonius, Dislocations, 2, in Greek, Reduction by jolting on a ladder

In spinal reductions the merited reputation of the ancient Greeks for progressive medical methods has an exception, the brutal method of reducing the spinal dislocation by tying the patient (or victim) to a ladder which has dropped to the ground vertically so as to jolt the displaced vertebrae into proper alignment. This procedure was described in the fifth century BCE Hippocratic treatise On Joints (Peri Arthron) ch. 44, copied and illustrated four centuries later by Apollonius in Dislocations ch. 2, to be copied and recopied into two other Greek manuscripts. According to the Hippocratic tradition, a “humpback,” considered almost incurable, might be treated by jolting the patient while tied to a ladder. This procedure can be seen in our miniature and followed in detail in the accompanying text.

Cases where the curvature is low on the spine are best treated with the head downward… Pad the ladder… Lay the patient on it, on his back, using soft but strong bandages, tie his ankles to the ladder; bind his legs together below and above the knees and bandage to the hips. Bandage him loosely at the flanks and chest; tie the arms and hands, extended along his sides, to the body, but not to the ladder. Then raise the ladder against a high tower or house. The ground should be solid and the assistants well trained so that they will let the ladder fall smoothly and in a vertical position…It is best to drop it from a mast by a pulley… Jolting is best done with such an apparatus, but it is disagreeable to discuss in detail. Cases where the curvature is high up on the spine are better treated with the feet downward…Bind the patient firmly to the ladder at his chest, but loosely at his neck, merely enough to keep it straight. Bring his head to the ladder at the forehead. Bind the rest of the body loosely here and there, only to keep it vertical… Fasten the legs together, but not to the ladder, so they hang in line with the back.

In modern times, until the nineteenth century, such procedures were used in medicine, and also in corporal punishment under the name strappado.