Digitized by the Internet Archive in 2010 with funding from Boston Library Consortium Member Libraries http://www.archive.org/details/oldtimemakersofmOOwals Old -Time Makers of Medicine BY THE SAME AUTHOR FORDHAM UNIVERSITY PRESS SERIES MAKERS OF MODERN MEDICINE Lives of the men to whom nineteenth century medical science 1 910. $2.00 net. owes most. Second Edition. New York, THE POPES AND SCIENCE The story of Papal patronage of the sciences and especially medicine. 45th thousand. New York, 1911. $2.00 net. MAKERS OF ELECTRICITY Lives of the men to whom important advances in electricity are due. In collaboration with Brother Potamian, F. S.C., Sc.D. (London), Professor of Physics at Manhattan College. New York, 1909. $2.00 net. EDUCATION, HOW OLD THE NEW Addresses in the history of education on various occasions. 3rd thousand. New York, 1911. $2.00 net. IN PREPARATION MAKERS OF ASTRONOMY PROBLEMS OLD AND NEW IN EDUCATION THE THIRTEENTH GREATEST OF CENTURIES Georgetown University edition. 5th thousand. 116 illustra- tions, nearly 600 pages. Catholic Summer School Press, New York, 191 1. Postpaid, $3.50. THE DOLPHIN PRESS SERIES CATHOLIC CHURCHMEN IN SCIENCE First and second series, each $1.00 net. IN COLLABORATION ESSAYS IN PASTORAL MEDICINE o'MALLEY AND WALSH A manual of information on medical subjects for the clergy, religious superiors, superintendents of hospitals, nurses and charity workers. Longmans, New York, 1911. $2.50 net. I Old-Time Makers of Medicine j THE STORY OF THE STUDENTS AND TEACHERS OF THE SCIENCES RELATED TO MEDICINE DURING THE MIDDLE AGES BY Vn/3 James J. Walsh, K.C.St.G., M.D. Ph.D., LL.D., Litt.D., Sc.D. DEAN AND PROFESSOR OF NERVOUS DISEASES AND OF THE HISTORY OF MEDICINE AT FORDHAM UNIVERSITY SCHOOL OF MEDICINE; PROFESSOR OF PHYSIOLOGICAL PSYCHOLOGY AT THE CATHEDRAL COLLEGE, NEW YORK NEW YORK FORDHAM UNIVERSITY PRESS 1911 Copyright 191 i JAMES J. WALSH fiW/ ----- 1^8170 THE QUINN & BODEN CO. PRESS RAHWAY, N. J. Co REVEREND DANIEL J. QUINN, S.J. The historical material here presented was gathered for my classes at Fordham University School of Medi- cine during your term as president of the University. It seems only fitting then, that when put into more permanent form it should appear under the patrpnage of your name and tell of my cordial appreciation of more than a quarter of a century of valued friendship. " When we have thoroughly mastered contem- porary science it is time to turn to past science; nothing fortifies the judgment more than this com- parative study; impartiality of mind is developed thereby, the uncertainties of any system become manifest. The authority of facts is there confirmed, and we discover in the whole picture a philosophic teaching which is in itself a lesson ; in other words, we learn to know, to understand, and to judge." — Littre: (Euvres d'Hippocrate, T. I, p. 477. a There is not a single development, even the most advanced of contemporary medicine, which is not to be found in embryo in the medicine of the olden time." — Littre: Introduction to the Works of Hip- pocrates. " How true it is that in reading this history one finds modern discoveries that are anything but dis- coveries, unless one supposes that they have been made twice." — Dujardin: Histoire de la Chirurgie, Paris, 1774 (quoted by Gurlt on the post title-page of his GeschicMe der Chirurgie, Berlin, 1898). PREFACE The material for this book was gathered partly for lectures on the history of medicine at Fordham University School of Medicine, and partly for articles on a number of subjects in the Catholic En- cyclopedia. Some of it was developed for a series of addresses at commencements of medical schools and before medical societies,fon the general topic how old the new is in surgery, medicine, dentistry, and pharmacy.! /The information thus presented aroused so much interest, the accomplishments of the physicians and surgeons of a period that is usu- ally thought quite sterile in medical science proved, indeed, so astonishing, that I was tempted to con- nect the details for a volume in the Fordham Uni- versity Press series. There is no pretence to any original investigation in the history of medicine, nor to any extended consultation of original documents. I have had most of the great books that are men- tioned in the course of this volume in my hands, and have given as much time to the study of them as could be afforded in the midst of a rather busy life, but I owe my information mainly to the distin- guished German and French scholars who have in recent years made deep and serious studies of these Old Makers of Medicine, and I have made my ac- knowledgments to them in the text as opportunity presented itself. There is just one feature of the book that may vi PREFACE commend it to present-day readers, and that is that jour medieval medical colleagues, when medicine em- braced most of science, faced the problems of medi- cine and surgery and the allied sciences that are now interesting us, in very much the same temper of mind as we do, and very often anticipated our solutions of them — much oftener, indeed, than most of us, unless we have paid special attention to history, have any idea of.i The volume does not constitute, then, a contribution to that theme that has interested the last few generations so much, — the supposed continuous progress of the race and its marvellous advance, — but rather emphasizes that puzzling question, how is it that men make im- portant discoveries and inventions, and then, after a time, forget about them so that they have to be made over again! \ This is as true in medical science and in medical practice as in every other depart- ment of human effort. It does not seem possible that mankind should ever lose sight of the progress in medicine and surgery that has been made in re- cent years, yet the history of the past would seem to indicate that, in spite of its unlikelihood, it might well come about. Whether this is the lesson of the book or not, I shall leave readers to judge, for it was not intentionally put into it. OUR lady's day in harvest, 1911. CONTENTS CHAPTER PAGE I. Introduction 1 II. Great Physicians in Early Christian Times 23 III. Great Jewish Physicians . . . .61 IV. Maimonides 90 V. Great Arabian Physicians . . . .109 VI. The Medical School at Salerno . ,141 VII. Const antine Africanus . . . .163 VIII. Medieval Women Physicians . . .177 IX. Mondino and the Medical School of Bologna 202 X. Great Surgeons of the Medieval Univer- sities 234 XL Guy de Chauliac 282 XII. Medieval Dentistry — Giovanni of Arcoli 313 XIII. CUSANUS AND THE FlRST SUGGESTION OF LAB- ORATORY Methods in Medicine . . 336 XIV. Basil Valentine, Last of the Alchemists, First of the Chemists . . . .349 APPENDICES I. St. Luke the Physician . . . .381 II. Science at the Medieval Universities . 400 III. Medieval Popularization of Science . .427 " Of making many books there is no end." — Eccles. xii, 12 (circa 1000 B.C.). " The little by-play between Socrates and Euthy- demus suggests an advanced condition of medical literature : ' Of course, you who have so many books are going in for being a doctor/ says Socrates, and then he adds, ' there are so many books on medi- cine, you know.' As Dyer remarks, whatever the quality of these books may have been, their number must have been great to give point to this chaff. ' ' — Aequanimitas, William Osler, M.D., F.E.S., Blakis- tons, Philadelphia, 1906. " Augescunt aliae gentes, aliae minuuntur; Inque brevi spatio mutantur saecla animantum, Et, quasi cursores vitai lampada tradunt." — OVID. One nation rises to supreme power in the world, while another declines, and, in a brief space of time, the sovereign people change, transmitting, like racers, the lamp of life to some other that is to suc- ceed them. " There is one Science of Medicine which is con- cerned with the inspection of health equally in all times, present, past and future." — PLATO. I INTRODUCTION Under the term Old-Time Medicine most people probably think at once of Greek medicine, since that developed in what we have called ancient history, and is farthest away from us in date. As a matter of fact, however, mnch more is known abont Greek medical writers than those of any other period ex- cept the last century or two. Our histories of medi- cine discuss Greek medicine at considerable length and practically all of the great makers of medicine in subsequent generations have been influenced by the Greeks. Greek physicians whose works have come down to us seem nearer to us than the medical writers of any but the last few centuries. As a con- sequence we know and appreciate very well as a rule how much Greek medicine accomplished, but in our admiration for the diligent observation and breadth of view of the Greeks, we are sometimes prone to think that most of the intervening generations down to comparatively recent times made very little progress and, indeed, scarcely retained what the Greeks had done. The Eomans certainly justify this assumption of non-accomplishment in medicine, but then in everything intellectual Rome was never much better than a weak copy of Greek thought. In science the Romans did nothing at all worth while talking about. All their medicine they borrowed 2 OLD-TIME MAKERS OF MEDICINE from the Greeks, adding nothing of their own. What food for thought there is in the fact, that in spite of all Rome's material greatness and wide empire, her world dominance and vaunted prosperity, we have not a single great original scientific thought from a Roman. Though so much nearer in time medieval medicine seems much farther away from us than is Greek medicine. Most of us are quite sure that the im- pression of distance is due to its almost total lack of significance. It is with the idea of showing that the medieval generations, as far as was possible in their conditions, not only preserved the old Greek medicine for us in spite of the most untoward cir- cumstances, but also tried to do whatever they could for its development, and actually did much more than is usually thought, that this story of " Old- Time Makers of Medicine " is written. It repre- sents a period — that of the Middle Ages — that is, or was until recently, probably more misunderstood than any other in human history. The purpose of the book is to show at least the important head- lands that lie along the stream of medical thought during the somewhat more than a thousand years from the fall of the Roman Empire under Augus- tulus (476) until the discovery of America. After that comes modern medicine, for with the sixteenth century the names and achievements of the workers in medicine are familiar — Paracelsus, Vesalius, Co- lumbus, Servetus, Csesalpinus, Eustachius, Varolius, Sylvius are men whose names are attached to great discoveries with which even those who are without any pretence to knowledge of medical history are INTRODUCTION 3 not unacquainted. In spite of nearly four centuries of distance in time these men seem very close to us. Their lives will be reserved for a subsequent volume, " Our Forefathers in Medicine.' ' It is usually the custom to contemn the Middle Ages for their lack of interest in culture, in educa- tion, in literature, in a word, in intellectual accom- plishment of any and every kind, but especially in science. There is no doubt about the occurrence of marked decadence in the intellectual life of the first half of this period. This has sometimes been at- tributed to what has been called the inhibitory effect of Christianity on worldly interests. Eeligion is said to have occupied people so much with thoughts of the other world that the beauties and wonders, as well as much of the significance, of the world around them were missed. Those who talk thus, however, forget entirely the circumstances which brought about the serious decadence of interest in culture and science at this time. The Eoman Empire had been the guardian of letters and education and science. While the Eomans were not original in themselves, at least they had shown intense interest in what was accomplished by the Greeks and their imitation had often risen to heights that made them worthy of consideration for themselves. They were liberal patrons of Greek art and of Greek literature, and did not neglect Greek science and Greek medi- cine. Galen's influence was due much more to the prominence secured by him as the result of his stay in Eome than would have been possible had he stayed in Asia. There are many other examples of Eoman patronage of literature and science that 4 OLD-TIME MAKERS OF MEDICINE might be mentioned. As we shall see, Eome drained Greece and Asia Minor of their best, and appropri- ated to herself the genius products of the Spanish Peninsula. Eome had a way of absorbing what was best in the provinces for herself. Just as soon as Rome was cut off from intimate relations with the provinces by the inwandering of barbarians, intellectual decadence began. The im- perial city itself had never been the source of great intellectual achievement, and the men whom we think of as important contributors to Rome's literature and philosophy were usually not born within the confines of the city. It is surprising to take a list of the names of the Latin writers whom we are ac- customed to set down simply as Romans and note their birthplaces. Rome herself gave birth to but a very small percentage of them. Virgil was born at Mantua, Cicero at Arpinum, Horace out on the Sabine farm, the Plinys out of the city, Terence in Africa, Persius up in Central Italy somewhere, Livy at Padua, Martial, Quintilian, the Senecas, and Lucan in Spain. When the government of the city ceased to be such as assured opportunity for those from outside who wanted to make their way, deca- dence came to Roman literature. Large cities have never in history been the fruitful mothers of men who did great things. Genius, and even talent, has always been born out of the cities in which it did its work. It is easy to understand, then, the deca- dence of the intellectual life that took place as the Empire degenerated. For the sake of all that it meant in the Roman Empire to look towards Rome at this time, however. INTRODUCTION 5 it seemed better to the early Christians to establish the centre of their jurisdiction there. Necessarily, then, in all that related to the purely intellectual life, they came under the influences that were at work at Eome at this time. During the first centuries they suffered besides from the persecutions directed against them by the Emperors at various times, and these effectually prevented any external manifesta- tions of the intellectual life on the part of Christians. It took much to overcome this serious handicap, but noteworthy progress was made in spite of obstacles, and by the time of Constantine many important of- ficials of the Empire, the educated thinking classes of Eome, had become Christians. After the conver- sion of the Emperor opportunities began to be af- forded, but political disturbances consequent upon barbarian influences still further weakened the old civilization until much of the intellectual life of it almost disappeared. Gradually the barbarians, finding the Roman Em- pire decadent, crept in on it, and though much more of the invasion was peaceful than we have been ac- customed to think, the Romans simply disappearing because family life had been destroyed, children had become infrequent, and divorce had become ex- tremely common, it was not long before they re- placed the Romans almost entirely. These new peo- ples had no heritage of culture, no interest in the intellectual life, no traditions of literature or science, and they had to be gradually lifted up out of their barbarism. This was the task that Chris- tianity had to perform. That it succeeded in ac- complishing it is one of the marvels of history. 6 OLD-TIME MAKERS OF MEDICINE The Church's first grave duty was the preserva- tion of the old records of literature and of science. Fortunately the monasteries accomplished this task, which would have been extremely perilous for the precious treasures involved but for the favorable conditions thus afforded. Libraries up to this time were situated mainly in cities, and were subject to all the vicissitudes of fire and war and other modes of destruction that came to cities in this disturbed period. Monasteries, however, were usually situ- ated in the country, were built very substantially and very simply, and the life in them formed the best possible safeguard against fire, which worked so much havoc in cities. As we shall see, however, not only were the old records preserved, but ex- cerpts from them were collated and discussed and applied by means of direct observation. This led the generations to realize more and more the value of the old Greek medicine and made them take further precautions for its preservation. The decadence of the early Middle Ages was due to the natural shifting of masses of population of this time, while the salvation of scientific and liter- ary traditions was due to the one stable element in all these centuries — the Church. Far from Chris- tianity inhibiting culture, it was the most important factor for its preservation, and it provided the best stimulus and incentive for its renewed development just as soon as the barbarous peoples were brought to a state of mind to appreciate it. Bearing this in mind, it is easier to understand the course of medical traditions through the Middle Ages, and especially in the earlier period, with re- INTRODUCTION 7 gard to which our documents are comparatively scanty, and during which the disturbed conditions made medical developments impossible, and any- thing more than the preservation of the old authors out of the question. The torch of medical illumina- tion lighted at the great Greek fires passes from people to people, never quenched, though often burn- ing low because of unfavorable conditions, but some- times with new fuel added to its flame by the con- tributions of genius. The early Christians took it up and kept it lighted, and, with the Jewish physi- cians, carried it through the troublous times of the end of the old order, and then passed it on for a while to the Arabs. Then, when favorable condi- tions had developed again, Christian schools and scholars gave it the opportunity to burn brightly for several centuries at the end of the Middle Ages. This medieval age is probably the most difficult period of medical history to understand properly, but it is worth while taking the trouble to follow out the thread of medical tradition from the Greeks to the Renaissance medical writers, who practically begin modern medicine for us. It is easy to understand that Christianity's in- fluence on medicine, instead of hampering, was most favorable. The Founder of Christianity Himself had gone about healing the sick, and care for the ailing became a prominent feature of Christian work. One of the Evangelists, St. Luke, was a physician. It was the custom a generation ago, and even later, when the Higher Criticism became pop- ular, to impugn the tradition as to St. Luke having been a physician, but this has all been undone, and 8 OLD-TIME MAKERS OF MEDICINE Harnack's recent book, " Luke the Physician, ' ' makes it very clear that not only the Third Gospel, but also the Acts, could only have been written by a man thoroughly familiar with the Greek medical terms of his time, and who had surely had the ad- vantage of a training in the medical sciences at Alexandria. This makes such an important link in medical traditions that a special chapter has been devoted to it in the Appendix. Very early in Christianity care for the ailing poor was taken up, and hospitals in our modern sense of the term became common in Christian com- munities. There had been military hospitals before this, and places where those who could afford to pay for service were kept during illness. Our mod- ern city hospital, however, is a Christian institution. Besides, deformed and ailing children were cared for and homes for foundlings were established. Be- fore Christianity the power even of life and death of the parents over their children was recognized, and deformed or ailing children, or those that for some reason were not wanted, were exposed until they died. Christianity put an end to this, and in two classes of institutions, the hospitals and the asylums, abundant opportunity for observation of illness was afforded. Just as soon as Christianity came to be free to establish its institutions publicly, hospitals became very common. The Emperor Julian, usually known as the Apostate, who hoped to re-establish the old Eoman Olympian religion, wrote to Oribasius, one of the great physicians of this time, who was also an important official of his household, that these Christians had established INTRODUCTION 9 everywhere hospitals in which not only their own people, but also those who were not Christians, were received and cared for, and that it would be idle to hope to counteract the influence of Christianity until corresponding institutions could be erected by the government. From the very beginning, or, at least, just as soon as reasonable freedom from persecution gave op- portunity for study, Christian interest in the med- ical sciences began to manifest itself. Nemesius, for instance, a Bishop of Edessa in Syria, wrote toward the end of the fourth century a little work in Greek on the nature of man, which is a striking illustration of this. Nemesius was what in modern times would be called a philosopher, that is, a spec- ulative thinker and writer, with regard to man's nature, rather than a physical scientist. He was convinced, however, that true philosophy ought to be based on a complete knowledge of man, body and soul, and that the anatomy of his body ought to be a fundamental principle. It is in this little volume that some enthusiastic students have found a de- scription that is to them at least much more than a hint of knowledge of the circulation of the blood. Hyrtl doubts that the passage in question should be made to signify as much as has been suggested, but the occurrence of any even distant reference to such a subject at this time shows that, far from there being neglect of physical scientific questions, men were thinking seriously about them. Just as soon as Christianity brought in a more peaceful state of affairs and had so influenced the mass of the people that its place in the intellectual 10 OLD-TIME MAKERS OF MEDICINE life could be felt, there comes a period of cultural development represented in philosophy by the Fathers of the Church, and during which we have a series of important contributors to medical litera- ture. The first of these was Aetius, whose career and works are treated more fully in the chapter on " Great Physicians in Early Christian Times.' ' He was followed by Alexander of Tralles, probably a Christian, for his brother was the architect of Santa Sophia, and by Paul of iEgina, with regard to whom we know only what is contained in his medical writings, but whose contemporaries were nearly all Christians. Their books are valuable to us, partly because they contain quotations from great Greek writers on medicine, not always otherwise available, but also because they were men who evidently knew the subject of medicine broadly and thoroughly, made observations for themselves, and controlled what they learned from the Greek forefathers in medicine by their own experience. Just at the be- ginning of the Middle Ages, then, under the foster- ing care of Christianity there is a period of consid- erable importance in the history of medical litera- ture. It is one of the best proofs that we have not only that Christianity did not hamper medical de- velopment, but that, directly and indirectly, by the place that it gave to the care of the ailing in life as well as the encouragement afforded to the intel- lectual life, it favored medical study and writing. A very interesting chapter in the story of the early Christian physician is to be found in what we know of the existence of women physicians in the fourth and fifth centuries. Theodosia, the mother INTRODUCTION 11 of St. Procopius the martyr, was, according to Carptzovius, looked upon as an excellent physician in Eome in the early part of the fourth century. She suffered martyrdom under Diocletian. There was also a Nicerata who practised at Constantinople un- der the Emperor Arcadius. It is said that to her St. John Chrysostom owed the cure of a serious ill- ness. From the very beginning Christian women acted as nurses, and deaconesses were put in charge of hospitals. Fabiola, at Eome, is the foundress of the first important hospital in that city. The story of these early Christian women physicians has been touched upon in the chapter on " Medieval Women Physicians, ' ' as an introduction to this interesting feature of Salernitan medical education. During the early Christian centuries much was owed to the genius and the devotion to medicine of distinguished Jewish physicians. Their sacred and rabbinical writers always concerned themselves closely with medicine, and both the Old Testament and the Talmud must be considered as containing chapters important for the medical history of the periods in which they were written. At all times the Jews have been distinguished for their knowl- edge of medicine, and all during the Middle Ages they are to be found prominent as physicians. They were among the teachers of the Arabs in the East and of the Moors in Spain. They were probably among the first professors at Salerno as well as at Montpellier. Many prominent rulers and ecclesi- astics selected Jewish physicians. Some of these made distinct contributions to medicine, and a num- ber of them deserve a place in any account of medi- 12 OLD-TIME MAKERS OF MEDICINE cine in the making during the Middle Ages. One of them, Maimonides, to whom a special chapter is de- voted, deserves a place among the great makers of medicine of all time, because of the influence that he exerted on his own and succeeding generations. Any story of the preservation and development of medical teaching and medical practice during the Middle Ages would be decidedly incomplete without due consideration of the work of Jewish physicians. Western medical literature followed Eoman lit- erature in other departments, and had only the Greek traditions at second hand. During the dis- turbance occasioned by the invasion of the barbari- ans there was little opportunity for such leisure as would enable men to devote themselves with tran- quillity to medical study and writing. Medical tradi- tions were mainly preserved in the monasteries. Cassiodorus, who, after having been Imperial Prime Minister, became a monk, recommended particularly the study of medicine to the monastic brethren. With the foundation of the Benedictines, medicine became one of the favorite studies of the monks, partly for the sake of the health of the brethren themselves, and partly in order that they might be helpful to the villages that so often gathered round their monasteries. There is a well-grounded tradi- tion that at Monte Cassino medical teaching was one of the features of the education provided there by the monks. It is generally conceded that the Bene- dictines had much to do with the foundation of Salerno. In the convents for women as well as the monasteries for men serious attention was given to medicine. Women studied medicine and were pro- INTRODUCTION 13 fessors in the medical department of Salerno. Other Italian universities followed the example thus set, and so there is abundant material for the chapter on " Medieval Women Physicians. ' ' The next phase of medical history in the medieval period brings us to the Arabs. Utterly uninterested in culture, education, or science before the time of Mohammed, with the growth of their political power and the foundation of their capitals, the Arab Caliphs took up the patronage of education. They were the rulers of the cities of Asia Minor in which Greek culture had taken so firm a hold, and captive Greece has always led its captors captive. With the leisure that came for study, Arabians took up the cultivation of the Greek philosophers, especially Aristotle, and soon turned their attention also to the Greek physicians Hippocrates and Galen. For some four hundred years then they were in the best posi- tion to carry on medical traditions. Their teachers were the Christian and Jewish physicians of the cities of Asia Minor, but soon they themselves be- came distinguished for their attainments, and for their medical writings. Interestingly enough, more of their distinguished men flourished in Spain than in Asia Minor. We have suggested an explanation for this in the fact that Spain had been one of the most cultured provinces of the Eoman Empire, pro- viding practically all the writers of the Silver Age of Latin literature, and evidently possessing a widely cultured people. It was into this province, not yet utterly decadent from the presence of the northern Goths, that the Moors came and readily built up a magnificent structure of culture and edu- 14 OLD-TIME MAKERS OF MEDICINE cation on what had been the highest development of Roman civilization. The influence of the Arabs on Western civiliza- tion, and especially on the development of science in Europe, has been much exaggerated by certain writers. Closely in touch with Greek thought and Greek literature during the eighth, ninth, and tenth centuries, it is easy to understand that the Arabian writers were far ahead of the Christian scholars of Europe of the same period, who were struggling up out of the practical chaos that had been created by the coming of the barbarians, and who, besides, had the chance for whatever Greek learning came to them only through the secondary channels of the Latin writers. Rome had been too occupied with politics and aggrandizement ever to become cul- tured. In spite of this heritage from the Greeks, decadence took place among the Arabs, and, as the centuries go on, what they do becomes more and more trivial, and their writing has less significance. Just the opposite happened in Europe. There, there was noteworthy progressive development until the magnificent climax of thirteenth century accomplish- ment was reached. It is often said that Europe owed much to the Arabs for this, but careful analysis of the factors in that progress shows that very lit- tle came from the Arabs that was good, while not a little that was unfortunate in its influence was bor- rowed from them with the translations of the Greek authors from that language, which constituted the main, indeed often the only, reason why Arabian writers were consulted. With the foundation of the medical school of INTRODUCTION 15 Salerno in the tenth century, the modern history of medical education may be said to begin, for it had many of the features that distinguish our modern university medical schools. Its professors often came from a distance and had travelled extensively for purposes of study; they attracted patients of high rank from nearly every part of Europe, and these were generous in their patronage of the school. Students came from all over, from Africa and Asia, as well as Europe, and when abuses of medical prac- tice began to creep in, a series of laws were made creating a standard of medical education and reg- ulating the practice of medicine, that are interesting anticipations of modern movements of the same kind. Finally a law was passed requiring three years of preliminary work in logic and philosophy before medicine might be taken up, and then four years at medicine, with a subsequent year of practice with a physician before a license to practise for one's self was issued. In addition to this there was a still more surprising feature in the handing over of the department of women's diseases to women pro- fessors, and the consequent opening up of licensure to practise medicine to a great many women in the southern part of Italy. The surprise that all this should have taken place in the south of Italy is lessened by recalling the fact that the lower end of the Italian peninsula had been early colonized by Greeks, that its name in later times was Magna Grsecia, and that the stimulus of Greek tradition has always been especially favorable to the develop- ment of scientific medicine. Salerno's influence on Bologna is not difficult to 16 OLD-TIME MAKEES OF MEDICINE trace, and the precious tradition of surgery par- ticularly, which was carried to the northern uni- versity, served to initiate a period of surgery last- ing nearly two centuries, during which we have some of the greatest contributions to this branch of med- ical science that were ever made. The development of the medical school at Bologna anticipated by but a short time that of a series of schools in the north Italian universities. Padua, Piacenza, Pisa, and Vicenza had medical schools in the later Middle Ages, the works of some of whose professors have attracted attention. It was from these north Italian medical schools that the tradition of close observation in medicine and of thoroughly scientific surgery found its way to Paris. Lanfranc was the carrier of surgery, and many French students who went to Italy came back with Italian methods. In the fourteenth century Guy de Chauliac made the grand tour in Italy, and then came back to write a text-book of surgery that is one of the monuments in this department of medical science. Before his time, Montpellier had attracted attention, but now it came to be looked upon as a recognized centre of great medical teaching. The absence of the Popes from Italy and the influence of their presence at Avignon made itself felt. While culture and edu- cation declined in Italy in the midst of political dis- turbances, they advanced materially at the south of France. For our generation undoubtedly the most interest- ing chapter in the history of medieval medicine is that which tells of the marvellous development of surgery that took place in the thirteenth and four- INTRODUCTION 17 teenth centuries. Considerable space has been de- voted to this, because it represents not only an important phase of the history of medicine, and recalls the names and careers of great makers of medicine, but also because it il- lustrates exquisitely the possibility of important discoveries in medicine being made, applied success- fully for years, and then being lost or completely forgotten, though contained in important medical books that were always available for study. The more we know of this great period in the history of surgery, the more is the surprise at how much was accomplished, and how many details of our modern surgery were anticipated. Most of us have had some inkling of the fact that anaesthesia is not new, and that at various times in the world's history men have invented methods of producing states of sensi- bility in which more or less painless operations were possible. Very few of us have realized, however, the perfection to which anaesthesia was developed, and the possibility this provided for the great surgeons of the later medieval centuries to do opera- tions in all the great cavities of the body, the skull, the thorax, and the abdomen, quite as they are done in our own time and apparently with no little degree of success. Of course, any such extensive surgical interven- tion even for serious affections would have been worse than useless under the septic conditions that would surely have prevailed if certain principles of antisepsis were not applied. Until comparatively recent years we have been quite confident in our as- surance that antisepsis and asepsis were entirely 18 OLD-TIME MAKERS OF MEDICINE modern developments of surgery. More knowledge, however, of the history of surgery has given a seri- ous set-back to this self-complacency, and now we know that the later medieval surgeons understood practical antisepsis very well, and applied it success- fully. They used strong wine as a dressing for their wounds, insisted on keeping them clean, and not allowing any extraneous material of any kind, ointments or the like, to be used on them. As a con- sequence they were able to secure excellent results in the healing of wounds, and they were inclined to boast of the fact that their incisions healed by first intention and that, indeed, the scar left after them was scarcely noticeable. We know that wine would make a good antiseptic dressing, but until we actu- ally read the reports of the results obtained by these old surgeons, we had no idea that it could be used to such excellent purpose. Antisepsis, like anaesthesia, was marvellously anticipated by the surgical fore- fathers of the medieval period. It has always seemed to me that the story of Medieval Dentistry presented an even better il- lustration of a great anticipatory development of surgery. This department represents only a small surgical specialty, but one which even at that period was given over to specialists, who were called denta- tores. Guy de Chauliac's review of the dentistry of his time and the state of the specialty, as pictured by John of Arcoli, is likely to be particularly inter- esting, because if there is any department of med- ical practice that we are sure is comparatively re- cent in origin, it is dentistry. Here, however, we find that practically all our dental manipulations, INTRODUCTION 19 the filling of teeth, artificial dentures, even ortho- dontia, were anticipated by the dentists of the Mid- dle Ages. "We have only the compressed account of it which is to be found in text-books of general surgery, and while in this they give mainly a her- itage from the past, yet even this suffices to give us a picture very surprising in its detailed anticipation of much that we have been inclined to think of as quite modern in invention and dis- covery. Medicine developed much more slowly than surgery, or, rather, lagged behind it, as it seems nearly always prone to do. Surgical problems are simple, and their solution belongs to a great extent to a handicraft. That is, after all, what chirurgy, the old form of our word surgery, means. Medical problems are more complex and involve both art and science, so that solutions of them are often merely temporary and lack finality. During the Middle Ages, however, and especially towards the end of them, the most important branches of medi- cine, diagnosis and therapeutics, took definite shape on the foundations that lie at the basis of our mod- ern medical science. We hear of percussion for ab- dominal conditions, and of the most careful study of the pulse and the respiration. There are charts for the varying color of the urine, and of the tints of the skin. With Nicholas of Cusa there came the definite suggestion of the need of exact methods of diagnosis. A mathematician himself, he wished to introduce mathematical methods into medical diagnosis, and suggested that the pulse should be counted in connection with the water clock, the 20 OLD-TIME MAKERS OF MEDICINE water that passed being weighed, in order to get very definite comparative values for the pulse rate under varying conditions, and also that the specific gravity of fluids from the body should be ascer- tained in order to get another definite datum in the knowledge of disease. It was long before these sug- gestions were to bear much fruit, but it is interest- ing to find them so clearly expressed. At the very end of the Middle Ages came the father of modern pharmaceutical chemistry, Basil Valentine. Already the spirit that was to mean so much for scientific investigation in the Eenaissance period was abroad. Valentine, however, owes little to anything except his own investigations, and they were surprisingly successful, considering the cir- cumstances of time and place. His practical sug- gestions so far as drugs were concerned did not prove to have enduring value, but then this has been a fate shared by many of the masters of medicine. There were many phases of medical practice, how- ever, that he insisted on in his works. He believed that the best agent for the cure of the disease was nature, and that the physician's main business must be to find out how nature worked, and then foster her efforts or endeavor to imitate them. He in- sisted, also that personal observation, both of pa- tients and drugs, was more important than book knowledge. Indeed, he has some rather strong ex- pressions with regard to the utter valuelessness of book information in subjects where actual experi- ence and observation are necessary. It gives a con- ceit of knowledge quite unjustified by what is really known. INTRODUCTION 21 What is interesting about all these men is that they faced the same problems in medicine that we have to, in much the same temper of mind that we do ourselves, and that, indeed, they succeeded in solving them almost as well as we have done, in spite of all that might be looked for from the accumula- tion of knowledge ever since. It was very fortunate for the after time that in the period now known as the Eenaissance, after the invention of printing, there were a number of seri- ous, unselfish scholars who devoted themselves to the publication in fine printed editions of the works of these old-time makers of medicine. If the neglect of them that characterized the eighteenth and early nineteenth centuries had been the rule at the end of the fifteenth and during the sixteenth century, we would almost surely have been without the possibil- ity of ever knowing that so many serious physicians lived and studied and wrote large important tomes during the Middle Ages. For our forefathers of a few generations ago had very little knowledge, and almost less interest, as to the Middle Ages, which they dismissed simply as the Dark Ages, quite sure that nothing worth while could possibly have come out of the Nazareth of that time. What they knew about the people who had lived during the thousand years before 1500 only seemed to them to prove the ignorance and the depths of superstition in which they were sunk. That medieval scholars should have written books not only well worth preservation, but containing anticipations of modern knowledge, and, though of course they could not have known that, even significant advances over their own sci- 22 OLD-TIME MAKERS OF MEDICINE entific conditions, would have seemed to them quite absurd. Fortunately for us, then, the editions of the early printed books, so many of them monuments of learn- ing and masterpieces of editorial work with regard to medieval masters of medicine, were lying in libraries waiting to be unearthed and restudied dur- ing the nineteenth century. German and French scholars, especially during the last generation, have recovered the knowledge of this thousand years of human activity, and we know now and can sym- pathetically study how the men of these times faced their problems, which were very much those of our own time, in almost precisely the same spirit as we do ours at the present time, and that their solutions of them are always interesting, often thorough and practical, and more frequently than we would like to think possible, resemble our own in many ways. For the possibility of this we are largely indebted originally to the scholars of the Eenaissance. With- out their work that of our investigators would have been quite unavailing. It is to be hoped, however, that our recovery of this period will not be followed by any further eclipse, though that seems to be almost the rule of human history, but that we shall continue to broaden our sympathetic knowledge of this wonderful medieval period, the study of which has had so many surprises in store for us. II GREAT PHYSICIANS IN EAELY CHRISTIAN TIMES What we know of the life of the Founder of Christianity and how much He did for the ailing poor would make us expect that the religion that He established would foster the care and the cure of suffering humanity. As we have outlined in the In- troduction, the first of the works of Christian service that was organized was the care of the sick. At first a portion of the bishop's house was given over to the shelter of the ailing, and a special order of as- sistants to the clergy, the deaconesses, took care of them. As Christians became more numerous, spe- cial hospitals were founded, and these became pub- lic institutions just as soon as freedom from perse- cution allowed the Christians the liberty to give overt expression to their feelings for the poor. While hospitals of limited capacity for such special purposes as the sheltering of slaves or of soldiers and health establishments of various kinds for the wealthy had been erected before Christianity, this was the first time that anyone who was ill, no mat- ter what the state of his pecuniary resources, could be sure to find shelter and care. The expression of the Emperor Julian the Apostate, that admission to these hospitals was not limited to Christians, is the 23 24 OLD-TIME MAKERS OF MEDICINE best possible evidence of the liberal charity that in- spired them. The ordinary passing student of the history of medicine or of hospital foundation and organization, can have no idea of the magnitude of some of these institutions, and their importance in the life of the time, unless it is especially pointed out. St. Basil, about the middle of the fourth century, erected what was spoken of as " a city for the sick," before the gates of Csesarea. Gregory of Nazianzen, his friend, says " that well built and furnished houses stood on both sides of streets symmetrically laid out about the church, and contained rooms for the sick, and the infirm of every variety were intrusted to the care of doctors and nurses.' ' There were sep- arate buildings for strangers, for the poor, and for the ailing, and comfortable dwellings for the physi- cians and nurses. An important portion of the in- stitution was set apart for the care of lepers, which constituted a prominent feature in Basil's work in which he himself took a special interest. Earlier in the same century Helena, the mother of the Em- peror Constantine, had built similar institutions around Jerusalem, and during this same century nearly everywhere we have evidence of organi- zation of hospitals and of care for the ailing poor. Not only were hospitals erected, but arrangements were made for the care of the ailing poor in their own homes and for the visitation of them, and for the bringing to places adapted for their care and treatment of such as were found on the street, or neglected in their homes. The Church evidently GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 25 considered itself bound to care for men's bodies as well as their souls, and many of the expressions in common use among Christians referred to this fact. Eeligion itself was spoken of as a medicine of the soul and the body. Christianity was denned as the religion of healing. The word salvation had a refer- ence to both body and soul. Baptism was spoken of as the bath of the soul, the holy Eucharist as the elixir of immortal life, and penance as the medi- cine of the soul. It is not surprising to find, then, that Harnack has found among the texts that il- lustrate the history of early Christian literature this one : " In every community there shall be at least one widow appointed to assist women who are stricken with illness, and this widow shall be trained in her duties, neat and careful in her ways, shall not be self-seeking, must not indulge too freely in wine in order that she may be able to take up her duties at night as well as by day, and shall con- sider it her duty to keep the Church officials in- formed of all that seems necessary." The saving of deformed and ailing infants or children whose parents did not care to have the trouble of rearing them, required the establishment by the Christians of another set of institutions, Foundling Asylums and Hospitals for Children. Until the coming of Christianity parents were sup- posed to have the right of life and death over their children, and no one questioned it. In every coun- try in the world until the coming of Christianity this had always been the case. Besides, there were in- stitutions for the care of the old. These are the classes of mankind who are especially liable to suf- 26 OLD-TIME MAKERS OF MEDICINE fer from disease, and the opportunity to study human ailments in such institutions could scarcely help but provide facilities for clinical observa- tion such as had not existed before. Unfor- tunately the work of Christianity was hampered, first by the Eoman persecutions, and then later by the invasion of the barbarians, who had to be edu- cated and lifted up to a higher plane of civilization before they could be brought to appreciate the value of medical science, much less contribute to its de- velopment. Harnack, whose writings in the higher criticism of Scripture have attracted so much attention in re- cent years, began his career in the study of Christian antiquities with a monograph on Medical Features of Early Christianity. 1 He mentions altogether some sixteen physicians who reached distinc- tion in the earliest days of Christianity. Some of these were priests, some of them bishops, as Theodotos of Laodicea; Eusebius, Bishop of Eome; Basilios, Bishop of Ancyra, and at least one, Hierakas, was the founder of a religious order. The first Christian physicians came mainly from Syria, as might be expected, for here the old Greek medical traditions were active. Among them must be enumerated Cosmas and Damian, physicians who were martyred in the persecution of Diocletian, and who have been chosen as the patrons of the medical profession. Justinian erected a famous church to them. It became the scene of pilgrimages. Organi- zations of various kinds since, as the College of St. 1 " Medicinisches aus der Aeltesten Kirchen Geschichte," Leipzig, 1892. GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 27 Come, and medical societies, have been named after them. Some idea of the interest of ecclesiastics in med- ical affairs may be gathered from a letter of Bishop Theodoret of Cyrus, directed to the prefect of the city, when he was about to leave the place. He wrote (see Puschmann, Vol. I., p. 494) : " When I took up the Bishopric of Cyrus I made every effort to bring in from all sides the arts that would be useful to the people. I succeeded in persuading skilled physicians to take up their residence here. Among these is a very pious priest, Peter, who practises medicine with great skill, and is well known for his care for the people. Now that I am about to leave the city, some of those who came at my invitation are preparing also to go. Peter seems resolved to do this. I appeal to your highness, therefore, in order to commend him to your special care. He handles patients with great skill and brings about many cures." Distinguished Christian writers and scholars, and the Fathers of the Church in the early centuries, evi- dently paid much attention to medicine. Tertullian speaks of medical science as the sister of philosophy, and has many references to the medical doctrines discussed in his time. Lactantius, in his work, " De Opificio Dei," has much to say with regard to the human body as representing the necessity for design in creation. His teleological arguments have much more force now than they would have had for peo- ple generally twenty years ago. We have come back to recognize the place of teleology. Clement of Alexandria was an early Christian temperance ad- 28 OLD-TIME MAKERS OF MEDICINE vocate, who argued that the use of wine was only justified when it did good as a medicine. The prob- lems of embryology and of diseases of childhood interested him as they did many other of the early Christian writers. AETIUS The first great Christian physician whose works meant much for his own time, and whose writings have become a classic in medicine, was Aetius Ami- denus, that is, Aetius of Amida, who was born in the town of that name in Mesopotamia, on the upper Tigris (now Diarbekir), and who flourished about the middle of the sixth century. His medical studies, as he has told us himself, were made at Alexandria. After having attracted attention by his medical learning and skill, he became physician to one of the emperors at Byzantium, very probably Justinian, (527-565). He seems to have been succeeded in the special post that was created for him at court by Alexander of Tralles, the second of the great Chris- tian physicians. There is no doubt that Aetius was a Christian, for he mentions Christian mysteries, and appeals to the name of the Saviour and the martyrs. He was evidently a man of wide reading, for he quotes from practically every important med- ical writer before his time. Indeed, he is most valuable for the history of medicine, because he gives us some idea of the mode of treatment of various subjects by predecessors whose fame we know, but none of whose works have come to us. His official career and the patronage of the Emperor, the GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 29 breadth of his scholarship, and the thoroughly prac- tical character of his teaching, show how medical science and medical art were being developed and encouraged at this time. Aetius' work that is preserved for us is known in medical literature as his sixteen books on medical practice. In most of the manuscript it is divided into four Tetrabibloi, or four book parts, each of which consists of four sections called Logoi in Greek, Sermones in Latin. This work embraces all the departments of medicine, and has a considerable portion devoted to surgery, but most of the im- portant operations and the chapters on fractures and dislocations are lacking. Aetius himself an- nounces that he had prepared a special work on surgery, but this is lost. Doubtless the important chapters that we have noted as lacking in his work would be found in this. He is much richer in pathology than most of the older writers, at least of the Christian era ; for instance, Gurlt says that he treats this feature of the subject much more ex- tensively even than Paulus ^Eginetus, but most of his work is devoted to therapeutics. At times those who read these old books from cer- tain modern standpoints are surprised to find such noteworthy differences between writers on medicine, who are separated sometimes only by a generation, and sometimes by not more than a century, in what regards the comparative amount of space given to pathology, etiology, and therapeutics. Just exactly the same differences exist in our own day, however. We all know that for those who want pathology and etiology the work of one of our great teachers is to 30 OLD-TIME MAKERS OF MEDICINE be consulted, while for therapeutics it is better to go to someone else. When we find such differences among the men of the olden time we are not so apt to look at them with sympathetic discrimina- tion, as we do with regard to our contemporaries. We may even set them down to ignorance rather than specialization of interest. These differences depend on the attitude of mind of the physician, and are largely the result of his own personal equation. They do not reflect in any way either on his judg- ment or on the special knowledge of his time, but are the index of his special receptivity and teaching habit. Aetius' first and second books are taken up en- tirely with drugs. The first book contains a list of drugs arranged according to the Greek alphabet. In the third book other remedial measures, dietetic, manipulative, and even operative, are suggested. In these are included venesection, the opening of an artery, cupping, leeches, and the like. The fourth and fifth books take up hygiene, special dietetics, and general pathology. In the sixth book what the Germans call special pathology and therapy begins with the diseases of the head. The first chapter treats of hydrocephalus. In this same book rabies is treated. What Aetius has consists mainly of quotations from previous authors, many of whom he had evidently read with great care. Concerning those " bitten by a rabid dog or those who fear water, ' ' Gurlt has quoted the following ex- pression, with regard to which most people will be quite ready to agree with him when he says that it contains a great deal of truth, usually thought to be GEE AT PHYSICIANS IN EARLY CHRISTIAN TIMES 31 of much later origin : ' ' When, therefore, any one has been bitten by a rabid dog the treatment of the wound must be undertaken just as soon as possible, even though the bite should be small and only super- ficial. One thing is certain, that none of those who are not rightly treated escape the fatal effect. The first thing to do is to make the wound larger, the mouth of it being divided and dilated by the scalpel. Then every portion of it and the surrounding tissues must be firmly pressed upon with the definite pur- pose of causing a large efflux of blood from the part. Then the wound should be deeply cauterized, etc. ,, There are special chapters devoted to eye and ear diseases, and to various affections of the face. Un- der this the question of tattooing and its removal comes in. It is surprising how much Aetius has with regard to such nasal affections as polyps and ulcers and bleedings from the nose. In this book, however, he treats only of their medicinal treatment. What he has to say about affections of the teeth is so interesting that it deserves a paragraph or two by itself. He had much to say with regard to the nervous supply of the mucous membranes of the gums, tongue, and mouth, and taught that the teeth re- ceived nerves through the small hole existing at the end of every root. For children cutting teeth he advised the chewing of hard objects, and thought that the chewing of rather hard materials was good also for the teeth of adults. For fistulas leading to the roots of teeth he suggests various irritant treatments, and, if they do not succeed, recommends the removal of the teeth. He seems to have known 32 OLD-TIME MAKERS OF MEDICINE much about affections of the gums and recognizes a benignant and malignant epulis. He thought that one form of epulis was due to inflammation of a chronic character, and suggests that if remedies do not succeed it should be removed. His work is of interest mainly as showing that even at this time, when the desire for information of this kind is usu- ally supposed to have been in abeyance, physicians were gathering information about all sorts even of the minor ailments of mankind, gathering what had been written about them, commenting on it, adding their own observations, and in general trying to solve the problems as well as they could. Aetius seems to have had a pretty good idea of diphtheria. He speaks of it in connection with other throat manifestations under the heading of " crusty and pestilent ulcers of the tonsils." He divides the anginas generally into four kinds. The first consists of inflammation of the fauces with the classic symptoms, the second presents no inflamma- tion of the mouth nor of the fauces, but is compli- cated by a sense of suffocation — apparently our croup. The third consists of external and internal inflammation of the mouth and throat, extending towards the chin. The fourth is an affection rather of the neck, due to an inflammation of the vertebrae —retropharyngeal abscess — that may be followed by luxation and is complicated by great difficulty of respiration. All of these have as a common symp- tom difficulty of swallowing. This is greater in one variety than in another at different times. In cer- tain affections even " drinks when taken are re- turned through the nose." GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 33 Hypertrophy of the tonsils — Aetius speaks of them as glands — is to be treated by various astringent remedies, bnt if these fail the structures should be excised. His description of the excision is rather clear and detailed. The patient should be put in a good full light, and the mouth should be held open and each gland pulled forward by a hook and excised. The operator should be careful, how- ever, only to excise those portions that are beyond the natural size, for if any of the natural substance of the gland is cut into, or if the incision is made beyond the projecting portion of the tonsil, there is grave danger of serious hemorrhage. After ex- cision a mixture of water and vinegar should be kept in the mouth for some time. This should be admin- istered cold in order to prevent the flow of blood. After this very cold water should be taken. In this same book, Chapter L, he treats of for- eign bodies in the respiratory and upper digestive tracts. If there is anything in the larynx or the bronchial tubes the attempt must be made to secure its ejection by the production of coughing or sneez- ing. If the foreign body can be seen it should be grasped with a pincers and removed. If it is in the esophagus, Aetius suggests that the patient should be made to swallow a sponge dipped in grease, or a piece of fat meat, to either of which a string has been attached, in order that the foreign body may be caught and drawn out. If it seems preferable to carry the body on into the stomach, the swallowing of large mouthfuls of fresh bread or other such material is recommended. With regard to goitre, Aetius has some interest- 34 OLD-TIME MAKERS OF MEDICINE ing details. He says that " all tumors occurring in the throat region are called bronchoceles, for every tumor among the ancients was called a cele, and, though the name is common to them, they differ very much from one another." Some of them are fatty, some of them are pultaceous, some of them are cancerous, and some of them he calls honey tumors, because of a honey-like humor they contain. " Sometimes they are due to a local dilatation of the blood vessels, and this is most frequently connected with parturition, apparently being due to the draw- ing of the breath being prevented or repressed dur- ing the most violent pains of the patient. Such local dilatation at this point of the veins is incurable, but there are also hard tumors like scirrhus and malignant tumors, and those of great size. With the exception of these last, all the tumors of this region are easily cured, yielding either to surgery or to remedies. Surgery must be adapted to the special tumor, whether it be honey-like or fatty, or pultaceous." The prognosis of goitrous tumors is much better than might be expected, but evidently Aetius saw a number of the functional disturbances and enlargements of the thyroid gland, which are so variable in character as apparently to be quite amenable to treatment. Aetius ' treatment of the subject of varicosities is quite complete in its suggestions. " The term varices," he says, " is applied to dilated veins, which occur sometimes in connection with the testes and sometimes in the limbs. Operations on testicular varices patients do not readily consent to ; those on the limbs may be cured in several ways. GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 35 First, simple section of the skin lying above the dilated vessel is made, and with the hook it is sep- arated from the neighboring tissues and tied. After this the dilated portion is removed and pressure applied by means of a bandage. The patient is ordered to remain quiet, but with the legs higher than the head. Some people prefer treatment by means of the cautery.' ' Gurlt, in his " History of Surgery," calls attention to the fact that two of our modern methods of treating varicose veins are thus discussed in Aetius, that by ligation and that by the cautery. The cautery was applied over a space the breadth of a finger at several points along the dilated veins. Aetius' chapters on obstetrics and gynaecology are of special interest, because, while we are prone to think that gynaecology particularly is a compara- tively modern development of surgery, this surgical authority of the early Middle Ages treats it rather exhaustively. His sixteenth book is for the most part (one hundred and eleven chapters of it) de- voted to these two subjects. He has a number of interesting details in the first thirty-six chapters with regard to conception, pregnancy, labor, and lactation, which show how practical were the views of the physicians of the time. Gurlt has given us some details of his chapters on diseases of the breast. Aetius differentiates phagedenic and rodent ulcers and cancer. All the ordinary forms of phagedenic ulcer yield to treatment, while malignant growths are rendered worse by them. Where ulcers are old, he suggests the removal of their thickened edges by the cautery, for this hastens cure and 36 OLD-TIME MAKERS OF MEDICINE prevents N hemorrhage. With regard to cancer, he quotes from Archigenes and Leonides. He says that these tumors are very frequent in women, and quite rare in men. Even at this time cancer had been observed and recognized in the male breast. He emphasizes the fact that cancerous nodules be- come prominent and become attached to surround- ing tissues. There are two forms, those with ulcer, and those without. He describes the enlargement of the veins that follows, the actual varicosities, and the dusky or livid redness of the parts which seem to be soft, but are really very hard. He says that they are often complicated by very painful con- ditions, and that they cause enlargement of the glands and of the arms. The pain may spread to the clavicle and the scapula, and he seems to think that it is the pain that causes the enlargement of the glands at a distance. His description of ulcerative cancer of the breast is very striking. He says that it erodes without cause, penetrating ever deeper and deeper, and can- not be stopped until it emits a secretion worse than the poison of wild beasts, copious and abominable to the smell. With these other symptoms pains are present. This form of cancer is especially made worse by drugs and by all manner of manipulation. The paragraph from Leonides quoted by Aetius gives a description of operation for cancer of the breast, in which he insists particularly on the ex- tensive removal of tissue and the free use of the cautery. " The cautery is used at first in order to prevent bleeding, but also because it helps to destroy the remains of diseased tissues. When the burning GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 37 is deep, prognosis is much better. Even in cases where indurated tumors of the breast occur that might be removed without danger of bleeding, it is better to use the cautery freely, though the amputa- tion of such a portion down to the healthy parts may suffice." Aetius quotes this with approval. Others before Aetius had suggested the connec- tion between hypertrophy of the clitoris and cer- tain exaggerated manifestations of the sexual in- stinct, and the development of vicious sexual habits. As might be expected from this first great Christian physician and surgeon, he emphasizes this etiology for certain cases, and outlines an operation for it. This operation had been suggested before, but Aetius goes into it in detail and describes just how the operation should be done, so as to secure complete amputation of the enlarged organ, yet without in- jury. He warns of the danger of removing more than just the structure itself, because this may give rise to ugly and bothersome scars. After the opera- tion a sponge wet with astringent wine should be ap- plied, or cold water, especially if there is much tendency to bleeding, and afterwards a sponge with manna or frankincense scattered over it should be bound on. He treats of other pathological condi- tions of the female genitalia, varicose veins, growths of various kinds, hypertrophy of the portio vaginalis uteri, an operation for which is described, and of various tumors. He describes epithelioma very clearly, enumerates its most frequent locations in their order, lays down its bad prognosis, and hence the necessity for early operation with entire re- moval of the new growth whenever possible. He 38 OLD-TIME MAKERS OF MEDICINE feared hemorrhage very much, however, and warns with regard to it, and evidently had had some very unfortunate experiences in the treatment of these conditions. Aetius seems to have had as thoroughly scientific an interest in certain phases of chemistry apart from medicine as any educated physician of the modern time might have. Mr. A. P. Laurie, in his " Materials of the Printer's Craft/ ' * calls attention to the fact that the earliest reference to the use of drying oil for varnish is made by the physician Aetius. Aetius, or Aetios, to use for the nonce the Greek spelling of his name, which sometimes occurs in medical literature, and should be known, has been the subject of very varied estimation at different times. About the time of the Eenaissance he was one of the first of the early writers on medicine ac- corded the honor of printing, and then was reprinted many times, so that his estimation was very high. "With the reawakening of clinical medicine in the seventeenth century his reputation waxed again, and Boerhaave declared that the works of Aetius had as much importance for physicians as had the Pan- dects of Justinian for lawyers. This high estima- tion had survived almost from the time of the Eenaissance, when Cornelius went so far as to say: " Believe me, that whoever is deeply desirous of studying things medical, if he would have the whole of Galen abbreviated and the whole of Oribasius ex- tended, and the whole of Paulus (of ^Egina) ampli- fied, if he would have all the special remedies of the x Foulis, London and Edinburgh, 1910. GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 39 old physicians as well in pharmacy as in surgery boiled down to a summa for all affections, he will find it in Aetius." Naturally enough, this exag- gerated estimation was followed by a reaction, in which Aetius came to be valued at much less than he deserved. After all is taken into account in the vicissitudes of his fame, it is clear, however, that he is one of the most important links in the chain of medical tradition, and himself worthy to be classed among makers of medicine for his personal observa- tions and efforts to pass on the teachings of the old to succeeding generations. ALEXANDER OF TRALLES An even more striking example than the life and work of Aetius as evidence for the encouragement and patronage of medicine in early Christian times, is to be found in the career of Alexander of Tralles, whose writings have been the subject of most care- ful attention in the Eenaissance period and in our own, and who must be considered one of the great independent thinkers in medicine. While it is usu- ally assumed that whatever there was of medical writing during the Middle Ages was mere copying and compilation, here at least is a man who could not only judiciously select, but who could critically estimate the value of medical opinions and pro- cedure, and weighing them by his own experience and observation, turn out work that was valuable for all succeeding generations. The modern Ger- man school of medical historians have agreed in declaring him an independent thinker and physician, 40 OLD-TIME MAKERS OF MEDICINE who represents a distinct link in medical tradition. He came of a distinguished family, in which the following of medicine as a profession might be looked upon as hereditary. His father was a physi- cian, and it is probable that there were physicians in preceding generations, and one of his brothers, Dioscoros, was also a successful physician. Alto- gether four of his brothers reached such distinction in their life work that their names have come down to us through nearly fifteen hundred years. The eldest of them was Anthemios, the builder of the great church of Santa Sophia in Constantinople. As this is one of the world's great churches, and still stands for the admiration of men a millennium and a half after its completion, it is easy to under- stand that Anthemios' reputation is well founded. A second brother was Metrodoros, a distinguished grammarian and teacher, especially of the youthful nobility of Byzantium, as it was then called, or Con- stantinople, as we have come to call it. A third brother was a prominent jurist, also in Constan- tinople. The fourth brother, Dioscoros, like Alex- ander, a physician, remained in his birthplace, Tralles, and acquired there a great practice. It was with his father at Tralles that Alexander received his early medical training. The father of a friend and colleague, Cosmas, who later dedicated a book to Alexander, was also his teacher, while he was in his native city. As a young man, Alexander undertook extensive travels, which led him into Italy, Gaul, Spain, and Africa, everywhere gather- ing medical knowledge and medical experience. Then he settled down at Rome, probably in an official GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 41 position, and practised medicine successfully until a very old age. He was probably eighty years of age when, some time during the first decade of the seventh century, he died. Puschmann, who has made a special study of Alexander's life and work, suggests that since some of his books have the form of academic lectures he was probably a teacher of medicine at Rome. As might be expected from what we know of the rela- tions of the rest of the family to the nobility of the time, it is easy to understand, especially in connec- tion with hints in Alexander's favorite modes of therapeutics, that costliness of remedies made no difference to his patients, that he must have had the treatment of some of the wealthiest families in Rome. His principal work is a Treatise on the Pathology and Therapeutics of Internal Diseases, in twelve books. The first eleven books were evidently material gathered for lectures or teaching of some kind. The twelfth book, in which considerable use of Aetius' writings is made, was written, according to Puschmann, toward the end of Alexander's life, and was meant to contain supplementary matter, comprising especially his views gathered from ob- servation as to the pathology of internal diseases. A shorter treatise of Alexander is with regard to intestinal parasites. There are many printed edi- tions of these books, and many manuscript copies are in existence. Alexander was often quoted dur- ing the Middle Ages, and in recent years, with the growth of our knowledge of medical history, he has come to be a favorite subject of study. 42 OLD-TIME MAKERS OF MEDICINE Alexander's first book of pathology and thera- peutics treats of head and brain diseases. For bald- ness, the first symptom of which is falling out of the hair, he counsels cutting the hair short, washing the scalp vigorously, and the rubbing in of sulphur ointments. For grey hair he suggests certain hair dyes, as nutgalls, red wine, and so forth. For dandruff, which he described as the excessive forma- tion of small flake-like scales, he recommends rub- bing with wine, with certain salves, and washing with salt water. He gives a good deal of attention to diseases of t the nervous system. He has a rather interesting chapter on headache. The affection occurs in con- nection with fevers, after excess in drinking,, and as a consequence of injury to the skull. Besides, it V develops as a result of disturbances of the natural processes in the head, the stomach, the liver, and the spleen. Headache, as the first symptom of in- flammation of the brain, is often the forerunner of convulsions, delirium, and sudden death. Chronic or recurrent headache occurs in connection with plethora, diseases of the brain, biliousness, digestive disturbances, insomnia, and continued worry. Hemicrania has its origin in the brain, because of the presence of toxic materials, and specially their transformation into gaseous substances. It also occurs in connection with abdominal affections. This latter remark particularly is directed to the cases which occur in women. For apoplexy and the consequent paralysis, Alex- ander considered venesection the best remedy. Massage, rubbings, baths, and warm applications GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 43 are recommended for the paralytic conditions. He had evidently had considerable experience with epilepsy. It develops either from injuries of the head or from disturbances of the stomach, or oc- casionally other parts of the body. When it occurs in nursing infants, nourishment is the best remedy, and he gives detailed directions for the selection of a wet nurse, and very careful directions as to her mode of life. He emphasizes very much the neces- sity for careful attention to the gastro-intestinal tract in many cases of epilepsyj Planned diet and regular bowels are very helpful. He rejects treat- ment of the condition by surgery of the head, either by trephining or by incisions, or cauterization. Keg- ular exercise, baths, sexual abstinence are the foundation of any successful treatment. It is prob- able that we have returned to Alexander's treat- ment of epilepsy much more nearly than is generally thought. There are those who still think that rem- edies of various kinds do good, but in the large epileptic colonies regular exercise, bland diet, reg- ulation of the bowels, and avoidance of excesses of all kinds, with occupation of mind, constitute the mainstay of their treatment. Alexander has much to say with regard to phre- nitis, a febrile condition complicated by delirium, which, following Galen, he considers an affection of the brain. It is evidently the brain fever of the generations preceding the last, an important element of which was made up of the infectious meningitises. Alexander suggests its treatment by opiates after preliminary venesection, rubbings, lukewarm baths, and stimulating drinks. Every disturbance of the 44 OLD-TIME MAKERS OF MEDICINE patient must be avoided, and visitors must be for- bidden. The patient's room should rather be light than dark. His teaching crops up constantly in the centuries after his time, until the end of the nine- teenth century, and while we now understand the causes of the condition better, we can do little more for it than he did. Alexander divided mental diseases into two, the maniacal and melancholic. Mania was, however, really a further development of melancholia, and represented a high grade of insanity. Under melan- choly he groups not only what we denominate by that term, but also all depressed conditions, and the paranoias, as also many cases of imbecility. The cause of mental diseases was to be found in the blood. He counselled the use of venesection, of lax- atives and purgatives, of baths and stimulant rem- edies. He insisted very much, however, on mental influence in the disease, on change of place and air, visits to the theatre, and every possible form of mental diversion, as among the best remedial measures. After his book on diseases of the head, his most important section is on diseases of the respiratory system. In this he treats first of angina, and recom- mends as gargles at the beginning light astringents ; later stronger astringents, as alum and soda dis- solved in warm water, should be employed. Warm compresses, venesection from the sublingual veins, and from the jugular, and purgatives in severe cases, are the further remedies. He treats of cough as a symptom due to hot or cold, dry or wet dys- crasias. Opium preparations carefully used are the GEE AT PHYSICIANS IN EARLY CHRISTIAN TIMES 45 best remedies. The breathing in of steam impreg- nated with various ethereal resins, was also recom- mended. He gives a rather interestingly modern treatment of consumption. He recommends an abundance of milk with a strong nutritious diet, as digestible as possible. A good auxiliary to this treatment was change of air, a sea voyage, and a stay at a water- ing-place. Asses' and mares' milk are much better for these patients than cows ' and goats ' milk. There is not enough difference in the composition of these various milks to make their special consumption of import,| but it is probable that the suggestive in- fluence of the taking of an unusual milk had a very favorable effect upon patients, and this effect was renewed frequently, so that much good was ultimately accomplished. 1 For hemoptysis, espe- cially when it was acute" and due as Alexander thought to the rupture of a blood vessel in the lungs, he recommended the opening of a vein at the elbow or the ankle— in order to divert the blood from the place of rupture to the healthy parts of the circula- tion. He insisted that the patients must rest, that they should take acid and astringent drinks, that cold compresses should be placed upon the chest (our ice bags), and that they should take only a liquid diet at most lukewarm, or, better, if agree- able to them, cold. When the bleeding stopped, a milk cure was very useful for the restoration of these^patients to strength. It is not surprising, then, to find that Alexander suggests a thoroughly rational treatment for pleurisy. He recognizes this as an inflammation 46 OLD-TIME MAKERS OF MEDICINE of the membrane covering the ribs, and its symp- toms are severe pain, disturbance of breathing, and coughing. In certain cases there is severe fever, and Alexander knows of purulent pleurisy, and the fact that when pus is present the side on which it is is warmer than the other. Pleurisy can be, he says, rather easily confounded with certain liver affections, but there is a peculiar hardness of the pulse characteristic of pleurisy, and there is no ex- pectoration in liver cases, though it also may be ab- sent in many cases of pleurisy. Sufferers from liver disease usually have a paler color than pleuritics. His treatment consists in venesection, purgatives, and, when pus is formed, local incision. He recommends the laying on of sponges dipped in warm water, and the internal use of honey lem- onade. Opium should not be used unless the patient suffers from sleeplessness. Some of the general principles of therapeutics that Alexander lays down are very interesting, even from our modern standpoint. Trust should not be placed in any single method of treatment. Every available means of bringing relief to the patient should be tried. " The duty of the physician is to cool what is hot, to warm what is cold, to dry what is moist, and to moisten what is dry. He should look upon the patient as a besieged city, and try to rescue him with every means that art and science places at his command. The physician should be an inventor, and think out new ways and means by which the cure of the patient's affection and the relief of his symptoms may be brought about. ' ■ The most important factor in his therapeutics is diet. GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 47 Watering-places and various forms of mineral waters, as well as warm baths and sea baths, are constantly recommended by him. He took strong ground against the use of many drugs, and the rage for operating. The prophylaxis of disease is in Alexander's opinion the important part of the physician's duty. His treatment of fever shows the application of his principle: cold baths, cold com- presses, and a cooling diet, were his favorite rem- edies. He encouraged diaphoresis nearly always, and gave wine and stimulating drugs only when the patient was very weak. He differentiates two kinds of quartan fever. One of these he attributes to an affection of the spleen, because he had noticed that the spleen was enlarged during it, and that, after purgation, the enlarged spleen decreased in size. Alexander was a strong opponent of drastic rem- edies of all kinds. He did not believe in strong purgatives, nor in profuse and sudden blood-let- tings. He opposed arteriotomy for this reason, and refused to employ extensive cauterization. His diagnosis is thorough and careful. He insisted par- ticularly on inspection and palpation of the whole body; on careful examination of the urine, of the feces, and the sputum; on study of the pulse and the breathing. He thought that a great deal might be learned from the patient's history. The general constitution is also of importance. His therapeutics is, above all, individual. Remedies must be admin- istered with careful reference to the constitution, the age, the sex, and the condition of the patient's strength. Special attention must always be paid to nature's efforts to cure, and these must be en- 48 OLD-TIME MAKERS OF MEDICINE couraged as far as possible. Alexander had no sympathy at all with the idea that remedies must work against nature. His position in this matter places him among the dozen men whose name and writings have given them an enduring place in the favor of the profession at all times, when we were not being carried away by some therapeutic fad or imagining that some new theory solved the whole problem of the causation and cure of disease. Gurlt, in his " History of Surgery," has ab- stracted from Alexander particularly certain phases of what the Germans call external pathology and therapeutics. For instance, Alexander's treatment of troubles connected with the ear is very interest- ing. Gurlt declares that this chapter alone provides striking evidence for Alexander's practical experi- ence and power of observation, as well as for his knowledge of the literature of medicine. He con- siders that only a short abstract is needed to show that. For water that has found its way into the external ear, Alexander suggests a mode of treatment that is still popularly used. The patient should stand upon the leg corresponding to the side on which there is water in his ear, and then, with head leaning to that side, should hop or kick out with the other leg. The water may be drawn out by means of suction through a reed. In order to get foreign bodies out of the external auditory canal, an ear spoon or other small instrument should be wrapped in wool and dipped in turpentine, or some other sticky material. Occasionally he has seen sneezing, especially if the mouth and nose are covered with a cloth, and the GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 49 head leant toward the affected side, bring about a dislodgrnent of the foreign body. If these means do not succeed, gentle injections of warm oil or wash- ing out of the canal with honey water should be tried. Foreign bodies may also be removed by means of suction. Insects or worms that find their way into the ear may be killed by injections of acid and oil, or other substances. Gurlt also calls attention to Alexander's careful differentiation of certain very dangerous forms of inflammation of the throat from others which are rather readily treated. He says, " Inflammation of the throat may, under certain circumstances, belong to the severest diseases. The patients succumb to it as a consequence of suffocation, just as if they were choked or hanged. For this reason, perhaps, the affection bears the name synanche, which means constriction." He then points out various other forms of inflammation of the throat, acute and chronic, suggesting various names and the differ- ential diagnostic signs. One of the most surprising chapters of Alexan- der's knowledge of pathology and therapeutics is to be found in his treatment of the subject of in- testinal worms, which is contained in a letter sent by him to his friend, Theodore, whose child was suf- fering from them. He describes the oxyuris ver- micularis with knowledge manifestly derived from personal observation. He dwells on the itching in the region of the anus, caused by the oxyuris, and the fact that they probably find their way into the upper part of the digestive tract because of the soiling of the hands. He knew that the tapeworms 50 OLD-TIME MAKERS OF MEDICINE often reached great length, — he has seen one over sixteen feet long, — and also that they had a life cycle, so that they existed in two different forms. He de- scribes the roundworms as existing in the intestines, bnt occasionally wandering into the stomach to be vomited. His vermifuges were the flowers and the seeds of the pomegranate, the seeds of the helio- trope, castor-oil, and certain herbs that are still used, by country people, at least, as worm medicines. For roundworms he recommended especially a de- coction of artemisia maritima, coriander seeds, and decoctions of thyme. Our return to ihympl for in- testinal parasites is interesting. For the oxyuris he prescribed clysters of ethereal oils. We have not advanced much in our treatment of intestinal worms in the fifteen hundred years since Alexan- der's time. PAUL or ^IGINA Another extremely important writer in these early medieval times, whose opportunities for study in medicine and for the practice of it, were afforded him by Christian schools and Christian hospitals, was Paul of JEgina, He was born on the island of .ZEgina, hence the name .iE'ginetus, by which he is commonly known. There used to be considerable doubt as to just when Paul lived, and dates for his career were placed as widely apart as the fifth and the seventh centuries. We know that he was edu- cated at the University of Alexandria. As that in- stitution was broken up at the time of the capture of the city by the Arabs, he cannot have been there GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 51 later than during the first half of the seventh cen- tury. An Arabian writer, Abul Farag, in " The Story of the Reign of the Emperor Heraclius," who died 641, says that " among the celebrated physi- cians who flourished at this time was Paulus iEginetus." In his works Paul quotes from Alex- ander of Tralles, so that there seems to be no doubt now that his life must be placed in the seventh century. The most important portion of Paul's work for the modern time is contained in his sixth book on surgery. In this his personal observations are especially accumulated. Gurlt has reviewed it at considerable length, devoting altogether nearly thirty pages to it, and it well deserves this lengthy abstract. Paul quotes a great many of the writers on surgery before his time, and then adds the re- sults of his own observation and experience. In it one finds careful detailed descriptions of many operations that are usually supposed to be modern. Very probably the description quoted by Gurlt of the method of treating fishbones that have become caught in the throat will give the best idea of how thoroughly practical Paul is in his directions. He says : " It will often happen in eating that fish- bones or other objects may be swallowed and get caught in some part of the throat. If they can be seen they should be removed with the forceps de- signed for that purpose. Where they are deeper, some recommend that the patient should swallow large mouthfuls of bread or other such food. Others recommend that a clean soft sponge of small circum- ference to which a string is attached be swallowed, 52 OLD-TIME MAKERS OF MEDICINE and then drawn out by means of the string. This should be repeated until the bone or other object gets caught in the sponge and is drawn out. If the patient is seen immediately after eating, and the swallowed object is not visible, vomiting should be brought on by means of a finger in the throat or irritation with the feather, and then not infrequently the swallowed object will be brought up with the vomit. ' ' In the chapter immediately following this, XXXIII, there is a description of the method of opening the larynx or the trachea, with the indica- tions for this operation. The surgeon will know that he has opened the trachea when the air streams out of the wound with some force, and the voice is lost. As soon as the danger of suffocation is over, the edges of the wound should be freshened and the skin surfaces brought together with sutures. Only the skin without the cartilage should be sutured, and general treatment for encouraging union should be employed. If the wound fails to heal immedi- ately, a treatment calculated to encourage granula- tions should be undertaken. This same method of treatment will be of service whenever we happen to have a patient who, in order to commit suicide, has cut his throat. Paul's exact term is, perhaps, best translated by the expression, slashed his larynx. One of the features of Paul's " Treatise on Sur- gery " is his description of a radical operation for hernia. He describes scrotal hernia under the name enterocele, and says that it is due either to a tearing or a stretching of the peritoneum. It may be the consequence either of injury or of violent efforts, GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 53 made during crying. When the scrotum contains only omentum, he calls the condition epiplocele; when it also contains intestine, an epiplo-enterocele. Hernia that does not descend into the scrotum he calls bubonocele. For operation the patient should be placed on the back, and, the skin of the inguinal region being stretched by an assistant, an oblique incision in the direction in which the blood vessels run should be made. The incision should then be stretched by means of retractors, until the contents of the sac can be lifted out. All adhesions should be broken up and the fat be removed, and the hernia replaced within the abdomen. Care should be taken that no loop of intestine is allowed to remain. Then a large needle with double thread made of ten strands should be run through the middle of the in- cision in the end of the peritoneum, and tied firmly in cross sutures. The outer structures should be brought together with a second ligature, and the lower end of the incision should have a wick placed in it for drainage, and the site of operation should be covered with an oil bandage. The Arab writer, Abul Farag, to whose references we owe the definite placing of the time when Paul lived, said that " he had special experience in women's diseases, and had devoted himself to them with great industry and success. The midwives of the time were accustomed to go to him and ask his counsel with regard to accidents that happen during and after parturition. He willingly imparted his information, and told them what they should do. For this reason he came to be known as the Ob- stetrician. ' ' Perhaps the term should be translated 54 OLD-TIME MAKEBS OF MEDICINE the man-midwife, for it was rather unusual for men to have much knowledge of this subject. His knowl- edge of the phenomena of menstruation was as wide and definite. He knew a great deal of how to treat its disturbances. He seems to have been the first one to suggest that in metrorrhagia, with severe hemorrhage from the uterus, the bleeding might be stopped by putting ligatures around the limbs. This same method has been suggested for severe hemorrhage from the lungs as well as from the uterus in our own time. In hysteria he also sug- gested ligature of the limbs, and it is easy to under- stand that this might be a very strongly suggestive treatment for the severer forms of hysteria. It is possible, too, that the modification of the circulation to the nervous system induced by the shutting off of the circulation in large areas of the body might very well have a favorable physical effect in this af- fection. Paul's description of the use of the spec- ulum is as complete as that in any modern text- book of gynaecology. FURTHER CHRISTIAN PHYSICIANS Another distinguished Christian medical scientist was Theophilus Protosbatharius, who belonged to the court of the Greek Emperor Heraclius, in the seventh century. He seems to have had a life very full of interest and surprisingly varied duties. He was a bishop, and, at the same time, commander of the imperial bodyguard, and the author of a little work on the fabric of the human body. The most surprising chapter in the history of the book is GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 55 that for some two centuries, in quite modern times, it was used as a text-book of anatomy at the Uni- versity of Paris. -It was printed in a number of editions early in the history of printing, at least one very probably before 1500, and several later. There are very interesting phases of medicine de- lightfully surprising in their modernity to be found here and there in many of these early Christian writers on medicine. For instance, in a compend of medicine written by one Leo, who, under the Em- peror Theophilus, seems to have been a prominent physician of Byzantium (the compend was written for a young physician just beginning practice), we find the following classification of hydrops or ab- dominal dilatation : i4 There are three kinds ; the first is ascites, due to the presence of watery fluid, for which we do paracentesis; second, tympany, when the abdomen is swollen from the presence of air or gas. This may be differentiated by percussion of the belly. When air is present the sound given forth is like that of a drum, while in the first form ascites the sound is like that from a sack [the word used is the same as for a wine sack] ; the third form is called anasarca, when the whole body swells." It has often been the subject of misunderstanding as to why medicine should have developed among the Latin Christian nations so much more slowly than among the Arabs during the early Middle Ages. Anyone who knows the conditions in which Chris- tianity came into existence in Italy will not be sur- prised at that. The Arabs in the East were in con- tact with Greek thought, and that is eminently prolific and inspiring. At the most, the Christians in 56 OLD-TIME MAKERS OF MEDICINE Italy got their inspiration at second hand through the Romans. The Romans themselves, in spite of in- timate contact with Greek physicians, never made any important contributions to medical science, nor to science of any kind. Their successors, the Chris- tians of Rome and Italy, then could scarcely be ex- pected to do better, hampered especially, as they were, by the trying social conditions created by the invasion of the barbarians from the North. When- ever the Christians were in contact with Greek thought and Greek medicine, above all, as at Alex- andria, or in certain of the cities of the near East, we have distinguished contributions from them. AKABIAN CHKISTIAN PHYSICIANS That this is not a partial view suggested by the desire to make out a better case for Christianity in its relation to science will be very well understood, besides, from the fact that a number of the original physicians of Arab stock who attracted attention during the first period of Arabian medicine, that is, during the eighth and ninth centuries, were Chris- tians. There are a series of physicians belonging to the Christian family Bachtischua, a name which is derived from Bocht Jesu, that is, servant of Jesus, who, from the middle of the eighth to the middle of the eleventh century, acquired great fame. The first of them, George (Dschordschis), after ac- quiring fame elsewhere, was called to Bagdad by the Caliph El-Mansur, where, because of his med- ical skill, he reached the highest honors. His son became the body-physician of Harun al-Raschid. GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 57 In the third generation Gabriel (Dschibril) acquired fame and did much, as had his father and grand- father, for the medicine of the time, by translations of the Greek physicians into Arabian. These men may well be said to have introduced Greek medicine to the Mohammedans. It was their teaching that aroused Moslem scholars from the apathy that had characterized the attitude of the Arabian people toward science at the beginning of Mohammedanism. As time went on, other great Christian medical teachers distinguished them- selves among the Arabs. Of these the most prom- inent was Messui the elder, who is also known as Janus Damascenus. Both he and his father prac- tised medicine with great success in Bagdad, and his son became the body-physician to Harun al-Easchid either after or in conjunction with Gabriel Bach- tischua. Like his colleague or predecessor in of- ficial position, he, too, made translations from the Greek into Arabic. Another distinguished Arabian Christian physician was Serapion the elder. He was born in Damascus, and flourished about the middle of the ninth century. He wrote a book on medicine called the " Aggregator, ' ' or " Brevi- arium," or " Practica Medicine," which appeared in many printed editions within the century after the invention of printing. During the ninth cen- tury, also, we have an account of Honein Ben Ischak, who is known in the West as Johannitius. After travelling much, especially in Greece and Persia, he settled in Bagdad, and, under the patronage of the Caliph Mamum, made many translations. He translated most of the old Greek medical writers, 58 OLD-TIME MAKERS OF MEDICINE and also certain of the Greek philosophic and mathe- matical works. The accuracy of his translations became a proverb. His compendium of Galen was the text-book of medicine in the West for many cen- turies. It was known as the " Isagoge in Artem Parvam Galeni." His son, Ishac Ben Honein, and his nephew, Hobeisch, were also famous as medical practitioners and translators. Still another of these Arabian Christians, who acquired a reputation as writers in medicine, was Alkindus. He wrote with regard to nearly every- thing, however, and so came to be called the philoso- pher. He is said altogether to have written and translated about two hundred works, of which twenty-two treat of medicine. He was a contem- porary of Honein Ben Ischak in the ninth century. Another of the great ninth-century Christian physi- cians and translators from the Greek was Kostaben Luka. He was of Greek origin, but lived in Armenia and made translations from Greek into Arabic. Nearly all of these men took not alone medical science, but the whole round of physical science, for their special subject. A typical example in the ninth century was Abuhassan Ben Korra, many of whose family during succeeding genera- tions attracted attention as scholars. He became the astronomer and physician of the Caliph Mo- tadhid. His translations in medical literature were mainly excerpts from Hippocrates and Galen meant for popular use. These Christian translators, thor- oughly scientific as far as their times permitted them to be, were wonderfully industrious in their work as translators, great teachers in every sense GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES 59 of the word, and they are the men who formed the traditions on which the greater Arabian physicians from Rhazes onward were educated. It would be easy to think that these men, oc- cupied so much with translations, and intent on the re-introduction of Greek medicine, might have de- pended very little on their own observations, and been very impractical. All that is needed to coun- teract any such false impression, however, is to know something definite about their books. Grurlt, in his " History of Surgery,' ' has some quotations from Serapion the elder, who is often quoted by Rhazes. In the treatment of hemorrhoids Sera- pion advises ligature and insists that they must be tied with a silk thread or with some other strong thread, and then relief will come. He says some people burn them medicinis acutis (touching with acids, as some do even yet), and some incise them with a knife. He prefers the ligature, how- ever. He calmly discusses the removal of stones from the kidney by incision of the pelvis of the kidney through an opening in the loin. He con- siders the operation very dangerous, however, but seems to think the removal of a stone from the bladder a rather simple procedure. His descrip- tion of the technique of the use of a catheter and of a stylet with it, and apparently also of a guide for it in difficult cases, is extremely interesting. He suggests the opening of the bladder in the median line, midway between the scrotum and the anus, and the placing of a canula therein, so as to permit drainage until healing occurs. Even this brief review of the careers and the 60 OLD-TIME MAKERS OF MEDICINE writings of the physicians of early Christian times shows how well the tradition of old Greek medicine was being carried on. There was much to hamper the cultivation of science in the disturbances of the time, the gradual breaking up of the Eoman Empire, and the replacement of the peoples of southern Europe by the northern nations, who had come in, yet in spite of all this, medical tradition was well preserved. The most prominent of the con- servators were themselves men whose opinions on problems of practical medicine were often of value, and whose powers of observation frequently cannot but be admired. There is absolutely no trace of anything like opposition to the development of med- ical science or medical practice, but, on the contrary, everywhere among political and ecclesiastical authorities, we find encouragement and patronage. The very fact that, in the storm and stress of the succeeding centuries, manuscript copies of the writ- ings of the physicians of this time were preserved for us in spite of the many vicissitudes to which they were subjected from fire, and war, and acci- dents of various kinds for hundreds of years, until the coming of printing, shows in what estimation they were held. During this time they owed their preservation to churchmen, for the libraries and the copying-rooms were all under ecclesiastical control. in GEEAT JEWISH PHYSICIANS 1 Any account of Old-Time Makers of Medicine with- out a chapter on the Jewish Physicians would indeed be incomplete. They are among the most important factors in medieval medicine, representing one of the most significant elements of medical progress. In spite of the disadvantages under which their race labored because of the popular feeling against them on the part of the Christians in the earlier centuries and of the Mohammedans later, men of genius from the race succeeded in making their influence felt not only on their own times, but accomplished so much in making and writing medicine as to influence many subsequent generations. Living the segregated life that as a rule they had to, from the earliest times 1 My attention was called to the interesting story of the Jewish physicians of the Middle Ages and their scientific accomplishment while writing the article on Joseph Hyrtl for the Catholic En- cyclopedia. His " Das Arabische und Hebraische in der Anatomie " (Wien, 1879) has some interestingly suggestive material on these im- portant chapters of the history of medicine. (I owe my opportunity to consult it to the courtesy of the Surgeon-General's library.) Biographic material has been obtained from Carmoly's " History of the Jewish Physicians," translated by Dr. Dunbar for the Maryland Medical and Surgical Journal, some extra copies of which were printed by John Murphy and Co., Baltimore, about the middle of the nineteenth century. Baas and Haeser's Histories of Medicine and Puschmann and Pagel's " Handbook " provided additional material, and I have found Landau's " Geschichte der Jiidischen Aerzte " (Ber- lin, 1895) of great service. 61 62 OLD-TIME MAKERS OF MEDICINE (the Ghettos have only disappeared in the nineteenth century), it would seem almost impossible for them to have done great intellectual work. It is one of the very common illusions, however, that great intellectual work is accomplished mainly in the midst of comfortable circumstances and as the result of encouraging conditions. Most of our great makers of medicine at all times, and never more so than during the past century, have been the sons of the poor, who have had to earn their own living, as a rule, before they reached manhood, and who have always had the spur of that necessity which has been so well called the mother of invention. Their hard living condi- tions probably rather favored than hampered their intellectual accomplishments. It is not unlikely that the difficult personal circum- stances in which the Jews were placed had a good deal to do at all times with stimulating their am- bitions and making them accomplish all that was in them. Certain it is that at all times we find a won- derful power in the people to rise above their con- ditions. With them, however, as with other peoples, luxury, riches, comfort, bring a surfeit to initiative and the race does not accomplish so much. At vari- ous times in the early Middle Ages, particularly, we find Jewish physicians doing great work and obtain- ing precious acknowledgment for it in spite of the most discouraging conditions. Later it is not un- usual to find that there has been a degeneration into mere money-making as the result of opportunity and consequent ease and luxury. At a number of times, however, both in Christian and in Moham- GREAT JEWISH PHYSICIANS 63 medan countries, great Jewish physicians arose whose names have come to us and with whom every student of medicine who wants to know something about the details of the course of medical history must be familiar. There are men among them who must be considered among the great lights of medicine, significant makers always of the art and also in nearly all cases of the science of medicine. A little consideration of the history of the Jewish people and their great documents eliminates any sur- prise there may be with regard to their interest in medicine and successful pursuit of it during the Middle Ages. The two great collections of Hebrew documents, the Old Testament and the Talmud, con- tain an immense amount of material with reference to medical problems of many kinds. Both of these works are especially interesting because of what they have to say of preventive medicine and with regard to the recognition of disease. Our prophylaxis and diagnosis are important scientific departments of medicine dependent on observation rather than on theory. While therapeutics has wandered into all sorts of absurdities, the advances made in pro- phylaxis and in diagnosis have always remained valuable, and though at times they have been for- gotten, re-discovery only emphasizes the value of preceding work. It is because of what they contain with regard to these two important medical subjects that the Old Testament and the Talmud are land- marks in the history of medicine as well as of re- ligion. Baas, in his " Outlines of the History of Medi- 64 OLD-TIME MAKERS OF MEDICINE cine," says: " It corresponds to the reality in both the actual and chronological point of view to con- sider the books of Moses as the foundation of sani- tary science. The more we have learned about sanitation in the prophylaxis of disease and in the prevention of contagion in the modern time, the more have we come to appreciate highly the teach- ings of these old times on such subjects. Moses made a masterly exposition of the knowledge neces- sary to prevent contagious disease when he laid down the rules with regard to leprosy, first as to careful differentiation, then as to isolation, and finally as to disinfection after it had come to be sure that cure had taken place. The great lawgiver could insist emphatically that the keeping of the laws of God not only was good for a man's soul but also for his body." With this tradition familiarly known and deeply studied by the mass of the Hebrew people, it is no surprise to find that when the next great Hebrew development of religious writing came in the Tal- mud during the earlier Middle Ages, that also con- tains much with regard to medicine, not a little of which is so close to absolute truth as never to be out of date. Friedenwald, in his " Jewish Phy- sicians and the Contributions of the Jews to the Science of Medicine, ' ' a lecture delivered before the Gratz College of Philadelphia fifteen years ago, summed up from Baas' " History of Medicine " the instructions in the Talmud with regard to health and disease. The summary represents so much more of genuine knowledge of medicine and surgery than might be expected at the early period at which it was GREAT JEWISH PHYSICIANS 65 written, during the first and second century of our era, that it seems well to quote it at some length. " Fever was regarded as nature's effort to expel morbific matter and restore health ; which is a much safer interpretation of fever, from a practical point of view, than most of the theories bearing on this point that have been taught up to a very recent period. They attributed the halting in the hind legs of a lamb to a callosity formed around the spinal cord. This was a great advance in the knowledge of the physiology of the nervous system. An emetic was recommended as the best remedy for nausea. In many cases no better remedy is known to-day. They taught that a sudden change in diet was injuri- ous, even if the quality brought by the change was better. That milk fresh from the udder was the best. The Talmud describes jaundice and correctly ascribes it to the retention of bile, and speaks of dropsy as due to the retention of urine. It teaches that atrophy or rupture of the kidneys is fatal. In- duration of the lungs (tuberculosis) was regarded as incurable. Suppuration of the spinal cord had an early, grave meaning. Babies was known. The following is a description given of the dog's condi- tion : ' His mouth is open, the saliva issues from his mouth; his ears drop; his tail hangs between his legs; he runs sideways, and the dogs bark at him; others say that he barks himself, and that his voice is very weak. No man has appeared who could say that he has seen a man live who was bitten by a mad dog.' The description is good, and this prog- nosis as to hydrophobia in man has remained un- altered till in our day when Pasteur published his startling revelation. The anatomical knowledge of the Talmudists was derived chiefly from dissection of the animals. As a very remarkable piece of prac- tical anatomy for its very early date is the procuring 66 OLD-TIME MAKERS OF MEDICINE of the skeleton from the body of a prostitute by the process of boiling, by Eabbi Ishmael, a physician, at the close of the first century. He gives the num- ber of bones as 252 instead of 232. The Talmudists knew the origin of the spinal cord at the foramen magnum and its form of termination ; they described the oesophagus as being composed of two coats ; they speak of the pleura as the double covering of the lungs ; and mention the special coat of fat about the kidneys. They had made progress in obstetrics ; de- scribed monstrosities and congenital deformities; practised version, evisceration, and Caesarian section upon the dead and upon the living mother. A. H. Israels has clearly shown in his ' Dissertatio His- torico-Medica Inauguralis ' that Caesarian section, ac- cording to the Talmud, was performed among the Jews with safety to mother and child. The surgery of the Talmud includes a knowledge of dislocation of the thigh bone, contusions of the skull, perforation of the lungs, oesophagus, stomach, small intestines, and gall bladder; wounds of the spinal cord, wind- pipe, of fractures of the ribs, etc. They described imperforate anus and how it was to be relieved by operation. Chanina Ben Chania inserted natural and wooden teeth as early as the second century, C. E." There is a famous summing up of the possibilities of life and happiness in the Talmud that has been often quoted — its possible wanting in gallantry be- ing set down to the times in which it was written. "Life is compatible with any disease, provided the bowels remain open ; any kind of pain, provided the heart remain unaffected ; any kind of uneasiness, pro- vided the head is not attacked; all manner of evils, except it be a bad woman. ' ' There are many other interesting suggestions in GREAT JEWISH PHYSICIANS 67 the Talmud. Sometimes they have come to be gen- erally accepted in the modern time, sometimes they are only curious notions that have not, however, lost all their interest. The crucial incision for carbuncle is a typical example of the first class and the sug- gestion of the removal of superfluous fat from within the abdomen or in the abdominal wall itself by operation is another. That they had some idea of the danger of sepsis may be gathered from the fact that they suspected iron surgical instruments and advised the use of others of less enduring character. The Talmud itself was indeed a sort of encyclo- pedia in which was gathered knowledge of all kinds from many sources. It was not particularly a book of medicine, though it contains so many medical ideas. In many parts of it the authors' regard for science is emphatically expressed. Landau, in his " History of Jewish Physicians,' ' closes his account of the Talmud with this paragraph: " I conclude this brief review of Talmudic medi- cine with some reference to how high the worth of science was valued in this much misunderstood work. In one place we have the expression i occupation with science means more than sacrifice. ' In another ' science is more than priesthood and kingly dig- nity. i 11 1 2 Of course there are many absurd things 'recommended in the Tal- mud, We cannot remind ourselves too often, however, that there have been absurd things at all times in medicine, and especially in therapeu- tics. It is curious how often some of these absurdities have repeated themselves. We are liable to think it very queer that men should have presumed, or somehow jumped to the conclusion, that portions of ani- mals might possess wonderful virtue for the healing of diseases of the corresponding special parts of man. We ourselves, however, within a 68 OLD-TIME MAKERS OF MEDICINE After all this of national tradition in medicine be- fore and after Christ, it is only what we might quite naturally expect to find, that there is scarcely a cen- tury of the Middle Ages which does not contain at least one great Jewish physician and sometimes there are more. Many of these men made distinct contributions to medical science and their names have been held in high estimation ever since. Per- haps I should say that they were held in high estima- tion until that neglect of historical studies which characterized the eighteenth century developed, and that there has been a reawakening of interest in our time. We forget this curious decadence of the later seventeenth and eighteenth centuries which did so much to obscure history and especially the history of the sciences. Fortunately the scholars of the six- teenth and early seventeenth centuries accomplished successfully the task of printing many of the books of these old-time physicians and secured their pub- lication in magnificent editions. These were bought eagerly by scholars and libraries all over Europe little more than a decade, had a phase of opotherapy — how much less absurd it seems under that high-sounding Greek term— that was appar- ently very learned in its scientific aspects yet quite as absurd as many phases of old-time therapy, as we look at it. We administered cardin for heart disease and nephrin for kidney trouble, cerebrin for insanity (save the mark !), and even prostate tissue for prostatism — and with re- ported good results ! How many of us realize now that in this we were only repeating the absurdities, so often made fun of in old medicine, with regard to animal tissue and excrement therapeutics? The Talmud has many conclusions with regard to the symptoms of patients drawn from dreams ; as, for instance, it is said to be a certain sign of sanguine- ous plethora when one dreams of the comb of a cock. One phase of our psycho-analysis in the modern time, however, has taken us back to an interpretation of dreams different of course from this, yet analogous enough to be quite striking. GREAT JEWISH PHYSICIANS 69 in spite of the high price they commanded in that era of slow, laborious printing. The Eenaissance exhibits some of its most admirable qualities in its reverence for these old workers in science and above all for the careful preparation by its scholars of the text of these first editions of old-time physicians. The works have often been thus literally preserved for us, for some of them at least would have disap- peared among the vicissitudes of the intervening time, most of which was anything but favorable to the preservation of old-time works, no matter what their content or value. During the second and third centuries of our era, while the Talmudic writings were taking shape, three great Jewish physicians came into prominence. The first of them, Chanina, was a contemporary of Galen. According to tradition, as we have said, he inserted both natural and artificial teeth before the close of the second century. The two others were Bab or Eaw and Samuel. Eab has the distinction of having studied his anatomy from the human body. According to tradition he did not hesitate to spend large sums of money in order to procure subjects for dissection. At this time it is very doubtful whether Galen, though only of the preceding gen- eration, ever had the opportunity to study more than animals or, at most, a few human bodies. Samuel, the third of the group, was an intimate friend of Bab's, perhaps a disciple, and his fame depends rather on his practice of medicine than of research in medical science. He was noted for his practical development of two specialties that cannot but seem to us rather distant from each other. His reputa- 70 OLD-TIME MAKERS OF MEDICINE tion as a skilful obstetrician was only surpassed by the estimation in which he was held as an oculist. He seems to have turned to astronomy as a hobby, and was highly honored for his knowledge of this science. Probably there is nothing commoner in the story of great Jewish physicians than their success- ful pursuit of some scientific subject as a hobby and reaching distinction in it. Their surplus intellectual energy needed an outlet besides their vocation, and they got a rest by turning to some other interest, often accomplishing excellent results in it. Like most great students with a hobby, the majority of them were long-lived. Their lives are a lesson to a generation that fears intellectual overwork. During the fourth century we have a number of very interesting traditions with regard to a great Jewish physician, Abba Oumna, to whom patients flocked from all over the world. He seems particu- larly to have been anxious to make his services avail- able to the scholars of his time. He looked upon them as brothers in spirit, fellow-laborers whose in- vestigations were as important as his own and whose labors for mankind he hoped to extend by the helpful- ness of his profession. In order that it might be easy for them to come to him without feeling abashed by their poverty, and yet so that they might pay him anything that they thought they were able to, he hung up a box in his anteroom in which each patient might deposit whatever he felt able to give. His kindliness towards men became the foundation for many legends. Needless to say he was often im- posed upon, but that seems to have made no differ- ence to him, and he went on straightforwardly doing GREAT JEWISH PHYSICIANS 71 what lie thought he ought to do, regardless of the devious ways of men, even those whom he was gen- erously assisting. While we do not know much of his scientific medicine, we do know that he was a fine example of a practitioner of medicine on the highest professional lines. With the foundation of the school at Djondisabour in Arabistan or Khusistan by the Persian monarch Chosroes, some Jewish physicians come into promi- nence as teachers, and this is one of the first impor- tant occasions in history when they teach side by side with Christian colleagues. Djondisabour seems distant from us now, lying as it does in the province just above the head of the Persian Gulf, and it is a little hard to understand its becoming a centre of culture and education, yet according to well- grounded historical traditions students flocked here from all parts of the world, and its medical instruc- tion particularly became famous. According to the documents and traditions that we possess, clinical teaching was the most significant feature of the school work and made it famous. As a consequence graduates from here were deemed fully qualified to become professors in other institutions and were eagerly sought by various medical schools in the East. With the rise of the strong political power of the Mohammedans enough of peace came to the East at least to permit the cultivation of arts and sciences to some extent again, and then at once the eminence of Jewish physicians, both as teachers and practi- tioners of medicine, once more becomes manifest. The first of the race who comes into prominence is 72 OLD-TIME MAKERS OF MEDICINE Maser Djawah Ebn Djeldjal, of Basra. To him we owe probably more than to anyone else the preserva- tion of old scientific writings and the cultivation of arts and sciences by the Mohammedans. He pre- vailed on Caliph Moawia I, whose physician he had become, to canse many foreign works, and especially those written in Greek, to be translated into Arabic. He seems to have taken a large share of the labor of the translation on himself and prevailed npon his pupil, the son of Moawia, to translate some works on chemistry. The translation for which Maser Djawah is best known is that of the Pandects of Haroun, a physician of Alexandria. The transla- tion of this work was made toward the end of the seventh century. Unfortunately the " Pandects " has not come down to us, either in original or trans- lation, but we have fragments of the translation preserved by Ehazes, the distinguished Arabian medical writer and physician of the ninth century, and there seems no doubt that it contained the first good description of smallpox, a chapter in medicine that is often — though incorrectly — attributed to Ehazes himself. Ehazes quoted Maser Djawah freely and evidently trusted his declarations im- plicitly. The succeeding Caliphs of the first Arabian dy- nasty did not exhibit the same interest in education, and above all in science, that characterized Moawia. Political ambition and the desire for military glory seem to have filled up their thoughts and perhaps they had not the good fortune to fall under the in- fluence of physicians so wise and learned as Maser Djawah. More probably, however, they themselves GREAT JEWISH PHYSICIANS 73 lacked interest. Toward the end of the seventh cen- tury they were succeeded by the Abbassides. Al- mansor, the second Caliph of this dynasty, was at- tacked by a dangerous disease and sent for a physician of the Nestorian school. After his res- toration to health he became a liberal patron of science and especially medical science. The new city of Bagdad, which had become the capital of the realm of the Abbassides, was enriched by him with a large number of works on medicine, which he caused to be translated from the Greek. He did not confine him- self to medicine, however, but also brought about translations of works with regard to other sciences. One of these, astronomy, was a favorite. He made it a particular point to search out and encourage the translation of such books as had not previously been translated from Greek into Arabic. While he pro- vided a translation of Ptolemy he also had transla- \JJons made of Aristotle and Galen. It is not surprising, then, that the school of Bag- dad became celebrated. Jewish physicians seem to have been most prominent in its foundation, and the most distinguished product of it is Isaac Ben Emran, almost as celebrated as a philosopher as he is as a physician. One of his expressions with regard to the danger of a patient having two physicians whose opinions disagree with regard to his illness has been deservedly preserved for us. Zeid, an Emir of one of the chief cities of the Arabs in Barbary, fell ill of a tertian fever and called Isaac and another phy- sician in consultation. Their opinions were so widely in disaccord that Isaac refused to prescribe any- thing, and when the Emir, who had great confidence 74 OLD-TIME MAKERS OF MEDICINE in him, demanded the reason, he replied, ' ' disagree- ment of two physicians is more deadly than a tertian fever.' ' This Isaac, who is said to have died in 799, is the great Jewish physician, one of the most im- portant members of the profession in the eighth cen- tury. His principal work was with regard to poisons and the symptoms caused by them. This is often quoted by medical writers in the after time. The prominent Jewish physician of the ninth century was Joshua Ben Nun. Haroun al-Baschid, whose attempts to secure justice for his people are the subject of so much legendary lore, and whose place in history may be best recalled by the fact that he is a contemporary of Charlemagne, was particu- larly interested in medicine. He founded the city of Tauris as a memorial of the cure of his wife. He was a generous patron of the school of Djondisabour and established a medical school also at Bagdad. He provided good salaries for the professors, insisted on careful examinations, and raised the standard of medical education for a time to a noteworthy de- gree. The greatest teacher of this school at Bagdad was Joshua Ben Nun, sometimes known as the Babbi of Seleucia. His teaching attracted many students to Bagdad and his fame as one of the great practi- tioners of medicine of this time brought many pa- tients. Among his disciples was John Masuee, whose Arabian name is so different, Yahia Ben Masoviah, that in order to avoid confusion in reading it is im- portant to know both. Almost better known, per- haps, at this time was Abu Joseph Jacob Ben Isaac Kendi. Fortunately for the after time, these men devoted themselves not only to their own observa- GREAT JEWISH PHYSICIANS 75 tions and writings but made a series of valuable translations. Joshua Ben Nun seems to have been particularly zealous in this matter, following the example of Maser Djawah of Basra. Bagdad then became a centre for Arabian culture. Mahmoud, one of Haroun's successors, provided in Bagdad a refuge for the learned men of the East who were disturbed by the wars and troubles of the time. He became a liberal patron of literature and education. When the Emperor Michael III of Con- stantinople was conquered in battle, one of the obli- gations imposed upon him was to send many camel loads of books to Bagdad, and Aristotle and Plato were studied devotedly and translated into Arabic. The era of culture affected not only the capital but all the cities, and everywhere throughout the Ara- bian empire schools and academies sprang up. We have records of them at Basra, Samarcand, Is- pahan. From here the thirst for education spread to the other cities ruled by the Mohammedans, and each town became affected by it. Alexandria, the cities of the Barbary States, those of Sicily and Provence, where Moorish influences were prominent, and of distant Spain, Cordova, Seville, Toledo, Granada, Saragossa, all took up the rivalry for culture which made this a glorious period in the history of the intellectual life. Already, in the chapter on " Great Physicians in Early Christian Times,' ' I have pointed out that many of the teachers of the Arabs were Christian physicians. Here it is proper to emphasize the other important factor in Arabian medicine, the Jewish physicians, who influenced the great Arabian rulers, 76 OLD-TIME MAKEMS OF MEDICINE and were the teachers of the Arabs in medicine and science generally. These Christian and Jewish phy- sicians particularly encouraged the translation of the works of the great Greek physicians and thus kept the Greek medical tradition from dying out. It is not until the end of the ninth, or even the begin- ning of the tenth, century that we begin to have important contributors to medicine from among the Arabs themselves. Even at this time they have dis- tinguished rivals among Jewish physicians. Indeed these acquired such a reputation that they became the physicians to monarchs and even high ecclesi- astics, and we find them nearly everywhere through- out Europe. Their success was so great that it is not surprising that after a time the vogue of the Jewish physicians should have led to jealousy of them and to the passage of laws and decrees limiting their sphere of activity. The great Jewish physician of the ninth century was Isaac Ben Soliman, better known as Isaac el Israili, and who is sometimes spoken of as d 'Israeli. He was a pupil of Isaac Ben Amram the younger, probably a grandson of another Isaac Ben Amram, who, after having become famous in Bagdad, went to Cairo and became the physician of the Emir Zi- jadeth III. The younger Isaac established a school, and it was with him that Israeli obtained his intro- duction to medicine. He practised first as an oculist and then became body-physician to the Sultan of Morocco. Because of the sympathy of his character and his unselfishness he acquired great popularity. Hyrtl refers to him respectfully as " that scholarly son of Israel. ' ' Curiously enough, considering racial GREAT JEWISH PHYSICIANS 11 feeling in the matter, he never married, and when asked why he had not, and whether he did not think that he might regret it, he replied, i ' I have written four books through which my memory will be better preserved than it would be by descendants. ' ' The four books are his " Treatise on Fevers," his " Treatise on Simple Medicines and Ailments,' ' a treatise on the " Elements," and a treatise " On the Urine." Besides these, we have from him shorter works, " On the Pulse," " On Melancholy," and " On Dropsy." His hope with regard to his fame from these works was fulfilled, for they were printed as late as 1515 at Leyden, and Sprengel declared them the best compendium of simple remedies and diet that we have from the Arabian times. One of his translators into Latin has called him the monarch of physicians. Some of his maxims are extremely interesting in the light of modern notions on the same subjects. He declared emphatically that " the most important duty of the physician is to prevent illness." " Most patients get better without much help from the phy- sician by the powerofnatoe. " He emphasized his distrust of using many medicines at the same time in the hope that some of them would do good. He laid it down as a rule : ' ' Employ only one medicine at a time in all your cases and note its effects care- fully. ' ' He was as wise with regard to medical ethics as therapeutics. He advised a young physician, " Never speak unfavorably of other physicians. Every one of us has his lucky and unlucky hours." It is pleasant to learn that the old gentleman lived to fill out a full hundred years of life, and that in his 78 OLD-TIME MAKERS OF MEDICINE declining years he was surrounded by the good will and the affection of many who had learned to know his precious qualities of heart and mind. More than of any other class of physicians do we find the large human sympathies of the Jewish physicians of the Middle Ages praised by their contemporaries and succeeding generations. During the next centuries a number of Jewish phy- sicians became prominent, though none of them until Maimonides impressed themselves deeply upon the medical life of their own and succeeding centuries. Very frequently they were the physicians to royal personages. Zedkias, for instance, was the physician to Louis the Pious and later to his son Charles the Bald. His reputation as a physician was great enough to give him the popular estimation of a ma- gician, but it did not save him from the accusation of having poisoned Charles when that monarch died suddenly. There seem to be no good grounds, how- ever, for the accusation. There were a number of schools of medicine, in Sicily and the southern part of Italy, in which Jewish, Arabian, and Christian physicians taught side by side. One of these teachers was Jude Sabatai Ben Abraham, usually known by the name of Donolo, who was famous both as a writer on medicine and on astronomy. Donolo studied and probably taught at Tarentum, and there were similar schools at Palermo, at Bari, and then later on the mainland at Salerno. The foundation of Salerno, in which Jewish physicians also took part, we shall discuss later in the special chapter devoted to that subject. One of the great translators whose work meant GREAT JEWISH PHYSICIANS 79 very much for the medical science of his own and succeeding generations was the distinguished Jewish physician, Faradj Ben Salim, sometimes spoken of as Farachi Faragut or Ferrarius, who was born at Girgenti in Sicily. He made his medical studies in Salerno and did his work under the patronage of Charles of Anjou towards the end of the thirteenth century. His greatest work is the translation of the whole of the " Continens " of Ehazes. The trans- lation is praised as probably the best of its time made in the Middle Ages. Faradj came at the end of a great century, when the intellectual life of Eu- rope had reached a high power of expression, and it is not surprising that he should have proved equal to his environment. This translation has also some ad- ditions made by Faradj himself, notably a glossary of Arabian names. In Spain also Jewish physicians rose to distinc- tion. The most distinguished in the tenth century was Chasdai Ben Schaprut. Like many other of the great physicians of this tinxe, he had studied astron- omy as well as the medical sciences. He became the physician of the Caliph Abd-er-Eahman III of Cor- dova. He seems also to have exercised some of the functions of Prime Minister to the Caliph, and took advantage of diplomatic relations between his sovereign and the Byzantine Emperor to obtain some works of Dioscorides. These he translated into Arabian with the help of a Greek monk, whom he seems also to have secured through the diplomatic relations. Undoubtedly he did much to usher in that enthusiasm for education and study which charac- terized the next centuries, the eleventh and twelfth, 80 OLD-TIME MAKERS OF. MEDICINE at Cordova in Spain, when such men as Avenzoar, Avicenna, and Averroes attracted the attention of the educational world of the time. Jewish writers have sometimes claimed one of the most distin- guished of these, Avenzoar himself, as a Jew, but Hyrtl and other good authorities consider him of Arabic extraction and point to the fact that his an- cestors bore the name of Mohammed. This is not absolutely conclusive evidence, but because of it I have preferred to class Avenzoar among the Arabian physicians. The one historical fact of importance for us is that everywhere in Europe at that time Jews were being accorded opportunities for the study and practice of medicine. There are local incidents of persecution, but we are not so far away from the feelings that brought these about as to misunderstand them or to think that they were anything more than local, pop- ular manifestations. The more we know about the details of the medical history of these times the deeper is the impression of academic freedom and of opportunities for liberal education. Much has been said about the intolerance of ec- clesiastical authorities toward the Jews, and of Church decrees that either absolutely forbade their practice of the medical profession and their devo- tion to scientific study, or at least made these pur- suits much more difficult for them than for others. Of course it has to be conceded, even by those who most insistently urge the existence of formal legis- lation in the matter, that in spite of these decrees and intolerance and opposition, Jews continued to practise medicine and to be the chosen physicians of GREAT JEWISH PHYSICIANS 81 kings and even of high ecclesiastical dignitaries, as well indeed of the Popes themselves. This, it is usually declared, must be attributed to the surpass- ing skill of the Jewish physicians, causing men to overcome their prejudices and override even their own legal regulations. There is no doubt at all about the skill of Jewish physicians at many times during the Middle Ages. There is no doubt also of the sen- timent of opposition that often developed between the Christian peoples and the Jews. Any excuse is good enough to justify men, to themselves at least, in putting obstacles in the paths of those who are more successful than they are themselves. Eeligion often became a cloak for ill-will and persecution. The state of affairs that has been presumed how- ever, according to which laws and decrees were being constantly issued forbidding the practice of medicine to Jews by the ecclesiastical authorities, while at the same time they themselves and those who were nearest to them were employing Jewish physicians, is an absurdity that on the face of it calls for investi- gation of the conditions and from its very appear- ance would indicate that the ordinary historical assumption in the matter must be wrong. I have been at some pains, then, to try to find out just what were the conditions in Europe with regard to the practice of medicine by the Jews. There is no doubt that at Salerno, where the influ- ence of the Benedictines was very strong and where the influence of the Popes and the ecclesiastical au- thorities was always dominant, full liberty of study- ing and teaching was from the earliest days allowed to the Jews. Down at Montpellier it seems clear that 82 OLD-TIME MAKERS OF MEDICINE Jewish physicians had a large part in the foundation of the medical school, and continued for several cen- turies to be most important factors in the mainte- nance of its reputation and the upbuilding of that fame which draw students from even distant parts of Europe to this medical school of the south of France. During the ninth, tenth, eleventh, and twelfth centuries Jewish physicians were frequently in attendance on kings and the higher nobility, on bishops and archbishops, cardinals, and even Popes. Every now and then the spirit of intolerance among the populace was aroused, and occasionally the death of some distinguished patient while in a Jewish phy- sician's hands was made the occasion for persecu- tion. W e must not forget, after all, that even as late as Elizabeth's time, when Shakespeare wrote " The Merchant of Venice," he was taking advantage of the popular sentiment aroused by the execution of Lopez, the Queen's physician, for a real or supposed participation in a plot against her Majesty's life. Shylock was presented the next season for the sake of adventitious popularity that would thus accrue to the piece. The character was played so as to depict all the worst traits of the Jew, and was scorn- fully laughed at at every representation. This is an index of the popular feeling of the time. Bitter intolerance of the Jew has continued. Down almost to our own time the Ghettos have existed in Europe, and popular tumults against them continue to occur. Quite needless to say, these do not depend on Chris- tianity, but on defective human nature. During the Middle Ages the best possible criterion of the attitude of the Church authorities towards the GREAT JEWISH PHYSICIANS 83 Jews is to be found in the legislation of Pope Inno- cent III. He is the greatest of the Popes of the Middle Ages; he shaped the policy of the Church more than any other ; his influence was felt for many generations after his own time. His famous edict , with regard to them was well known : " Let no Chris- tian by violence compel them to come dissenting or unwilling to Baptism. Further, let no Christian ven- ture maliciously to harm their persons without a judgment of the civil power or to carry off their property or change their good customs which they have hitherto in that district which they inhabit." Innocent himself and several of his predecessors and successors are known to have had Jewish physicians. Example speaks even louder than precept, and the example of such men must have been a wonderful advertisement for the Jewish physicians of the time. Besides Innocent III, many of the Popes of the twelfth and thirteenth centuries issued similar decrees as to the Jews. It may be recalled that this was the time when the Papacy was most powerful in Europe and when its decrees had most weight in all coun- tries. Alexander II, Gregory IX, and Innocent IV all issued formal documents demanding the protec- tion of the Jews, and especially insisting that they must not be forced to receive Baptism nor disturbed in the celebration of their festivals. Clement VI did the same thing in the next century, and even offered them a refuge from persecution throughout the rest of France at Avignon. Distinguished Jewish schol- ars, who know the whole story from careful study, have given due credit to the Popes for all that they did for their people. They have even declared that 84 OLD-TIME MAKEES OF. MEDICINE if the Jews were not exterminated in many of the European countries it was because of the protection afforded by the Church. We have come to realize in recent years that persecution of the Jews is not at all a religious matter, but is due to racial prejudice and jealousy of their success by the peoples among whom they settle. All sorts of pretexts are given for this persecution at all times. Formal Church documents and the personal activities of the responsible Church officials show that during the Middle Ages the Church was a protector and not a persecutor of the Jews. There is abundant historical authority for the statement that the Popes were uniformly beneficent in their treatment of the Jews. In order to demon- strate this there is no need to quote Catholic his- torians, for non-Catholics have been rather emphatic in bringing it out. Neander, the German Protestant historian, for instance, said : " It was a ruling principle with the Popes after the example of their great predecessor, Gregory the Great, to protect the Jews in the rights which had been conceded to them. When the banished Popes of the twelfth century returned to Borne, the Jews went forth in their holiday garments to meet them, bearing before them the ' thorn,' and Innocent II, on an occasion of this sort, blessed them." English non-Catholic historians can be quoted to the same effect. The Anglican Dean Milman, for in- stance, said: " Of all European sovereigns, the Popes, with some exceptions, have pursued the most humane policy towards the Jews. In Italy, and even in Rome, they have been more rarely molested than in the other countries.' ' GREAT JEWISH PHYSICIANS 85 Hallam has expressed himself to the same effect, especially as regards the protection afforded to the Jew by the laws of the Church from the injustice of those around him. Laws sometimes fail of their purpose and the persecuting spirit of the populace is often hard to control, but everything that the cen- tral authority could do to afford protection was done and essential justice was enshrined in the Church laws. Prominent ecclesiastics would naturally follow the lines laid down by their Papal superiors. The atti- tude of those whose lives mark epochs in the history of Christianity and who had more to do almost with the shaping of the policy of the Church at many times than the Popes themselves, can be quoted readily to this same effect. Neander has called par- ticular attention to St. Bernard's declarations with regard to the evils that would follow any tolerance of such an abuse as the persecution of the Jews. " The most influential men of the Church protested against such un-Christian fanaticism. When the Abbot Bernard of Clairvaux was rousing up the spirit of the nations to embark in the second crusade, and issued for this purpose, in the year 1146, his let- ters to the Germans (East Franks), he at the same time warned them against the influence of those enthusiasts who strove to inflame the fanaticism of the people. He declaimed against the false zeal, without knowledge, which impelled them to murder the Jews, a people who ought to be allowed to live in peace in the country. ' ' But it has been said that there are decrees against Jewish physicians, issued especially in the south of 86 OLD-TIME MAKERS OF MEDICINE France, by various councils and synods of the Church. Attention needs to be called at once to the fact that these are entirely local regulations and have nothing to do with the attitude of the Church as a whole, but represent what the ecclesiastical au- thorities of a particular part of the country deem necessary for some special reason in order to meet local conditions. Indeed at the end of the thirteenth and the early fourteenth century, when these de- crees were being issued in France, full liberty was allowed in Italy, and there were no restrictions either as to medical practice or education founded on adhesion to Judaism. What need to be realized in order to understand the issuance of certain local ecclesiastical regula- tions forbidding Jews to practise medicine are the special conditions which developed in France at this time. Many Jews had emigrated from Spain to France, and the reputation acquired by Jewish phy- sicians at Montpellier led to a number of the race taking up the practice of medicine without any fur- ther qualification than the fact that they were Jews. That gave them a reputation for curative powers of itself because of the fame of some Jewish doctors and their employment by the nobility and the highest ecclesiastics. It was hard to regulate these wander- ing physicians. As a consequence of this, the fac- ulty at Paris, always jealous of its own rights and those of its students, at the beginning of the four- teenth century absolutely forbade Jews from prac- tising on Christian patients within its jurisdiction. Of course the faculty of the University of Paris was dominated by ecclesiastical authorities. The medical GREAT JEWISH PHYSICIANS 87 school was, however, almost entirely independent of ecclesiastical influence, and was besides largely re- sponsible for this decree. It was felt that something had to be done to stop the evil that had arisen and the charlatanry and quackery which was being prac- tised. This was, however, rather an attempt to regulate the practice of medicine and keep it in the hands of medical school graduates than an example of intolerance towards the Jews. Practically no Jews had graduated at its university, Montpellier being their favorite school, and Paris was not a little jealous of its rights to provide for physicians from the northern part of France. We have not got away from manifestations of that spirit even yet, as our non-reciprocating state medical laws show. During the next quarter of a century decrees not unlike those of the University of Paris were issued in the south of France, especially in Provence and Avignon. Anyone who knows the conditions which existed in the south of France at this time with re- gard to medical practice will be aware that a number of attempts were made by the ecclesiastical authori- ties just at this time to regulate the practice of medi- cine. Great abuses had crept in. Almost anyone who wished could set up as a physician, and those who were least fitted were often best able to secure a large number of patients by their cleverness, their knowledge of men, and their smooth tongues. The bishops of various dioceses met, and issued decrees forbidding anyone from practising medicine unless he was a graduate of the medical school of the neigh- boring University of Montpellier. After a time it was 88 OLD-TIME MAKERS OF MEDICINE found that the greatest number of violators of these decrees were Jews. Accordingly special regulations were made against them. They happen to be ec- clesiastical regulations, because no other authority at that time claimed the right to regulate medical edu- cation and the practice of medicine. What is sure is that many Jewish physicians reached distinction under Christian as well as Ara- bian rulers at all times during the Middle Ages. It would be quite impossible in the limited space at command here to give any adequate mention of what was accomplished by these Jewish physicians, whose names we have scarcely been able to more than cata- logue, nor of the place they hold in their times. As the physicians of rulers, their influence for culture and the cultivation of science was extensive, and as a rule they stood for what was best and highest in education. The story of one of them, who is gen- erally known in the Christian world at least, Mai- monides, given in some detail, may serve as a type of these Jewish physicians of the Middle Ages. He lived just before the flourishing period of university life in the thirteenth century brought about that wonderful development of medicine and surgery in the west of Europe that meant so much for the final centuries of the Middle Ages. His works influenced not a little the great thinkers and teachers whose own writings were to be the foundations of education for several centuries after their time. Maimonides was well known in the Western universities. Though his life had been mainly spent in the East, and he died there, there was scarcely a distinguished scholar of Europe who was not acquainted directly GREAT JEWISH PHYSICIANS 89 or indirectly with his works, and the greater the reputation of the scholar, as a rule, the more he knew of Maimonides, Moses iEgyptaeus, as he was called, and the more frequently he referred to his writings. IV MAIMONIDES The life of one of the great Jewish physicians, who has come to be known in history as Maimonides, is of such significance in medical biography that he deserves to have a separate sketch. Born in Spain, his life was lived in the East, where his con- nection as royal physician with the great Sultan Saladin of Crusades fame made his influence widely felt. He is a type of the broadly educated man, conversant with the culture of his time and of the past, knowing much besides medicine, who has so often impressed himself deeply on medical prac- tice. While the narrow specialists in each genera- tion, the men who are quite sure that they are cur- ing the special ills of men to which they devote themselves, have always felt that whatever of progress there was in any given time was due to them, they occupy but little space as a rule in the history of medicine. The men who loom large were the broad-minded, humanely sympathetic, deeply educated physicians, who treated men and their ills rather than their ills without due consideration of the individual, and who not only relieved the dis- comfort of their patients and greatly lessened human suffering, and added to the sum of human happiness in their time, but also left precious deeply significant lessons for succeeding generations of 90 MAIMONIDES 91 their profession. Hippocrates, Galen, Sydenham, Auenbrugger, Morgagni, these are representatives of this great class, and Maimonides must be con- sidered one of them. Moses Ben Maimum, whose Arabic name was Abu Amran Musa Ben Maimum Obaid Alia el-Cordovi, who was called by his Jewish compatriots Eamban or Rambam, was born at Cordova in Spain, on the 30th of March in 1135 or 1139, the year is in doubt. It might not seem of much import now after nearly eight centuries, but not a little ink is spilt over it yet by devoted biographers. We are rather prone to think in our time that the conditions in which men were born and reared before what we are pleased to call modern times, and, above all, in the Middle Ages, must have made a distinct handicap for their intellectual development. Most of us are quite sure that the conditions in medieval cities were eminently unsuited for the stimulation of the intellect, for incentive to art impulse, for up- lift in the intellectual life, or for any such broad interest in what has been so well called the human- ities — the humanizing things that lift us above ani- mal necessities — as would make for genuinely lib- eral education. We are likely to be set in the opinion that the environment of the growing youth of an old-time city, especially so early as the middle of the twelfth century, was poor and sordid. The cares of the citizens are presumed to have been mainly for material concerns, and, indeed, mostly for the wants of the body. They were only making a start on the way from barbarism to something like our glorious culmination of civilization. As " the 92 OLD-TIME MAKERS OF MEDICINE heirs to all the ages in the foremost files of time " we are necessarily far in advance of them, and we are only sorry that they did not have the oppor- tunity to live to see our day and enjoy the benefits of the evolution of humanity that is taking place during the eight centuries that have elapsed. As a matter of fact, there was much more of abid- ing profound interest in real civilization in many a medieval city, much more general appreciation of art, much more breadth of intelligence and sym- pathy with what we call the humanities, than in most of our large cities. The large city, as we know it, is eminently a discourager of breadth of intelligence. Specialism in the various phases of money-making obscures culture. Maimonides, born in Cordova, was brought up amid surroundings that teemed with incentives of every kind to the development of in- telligence, of artistic taste, and everything that makes for cultivation of intellect rather than of in- terest in merely material things. It is well said that it is hard to judge the Cor- dova of old by its tawdry ruins of to-day. The edu- cated visitor still stands in awe and admiration of the great mosque which expressed the high cul- tivation of the Moors of this time. It is a never- ending source of wonder to Americans. The city itself has many reminders of that fine era of Moorish culture and refinement of taste and of art ex- pression, which made it in the best sense of the word a city beautiful. The Arab invaders had found a great prosperous country which had been the most cultured province of the Eoman Empire, and on this foundation they made a marvellous de- MAIMONIDES 93 velopment. " The banks of the Guadalquivir,'' says Mr. S. Lane-Poole in " The Moors in Spain " (London, 1887), " were bright with marble houses, mosques, and gardens, in which the rarest flowers and trees of other countries were carefully culti- vated, and the Arabs introduced their system of ir- rigation which the Spaniards both before and since have never equalled.' ' The greatest beauty of the city, of course, had come, and some of it had gone, before Maimonides ' time. So much remains in spite of time and war, and many unfortunate influences, that we can have some idea how beautiful it must have been in his youth seven centuries ago, and how even more beautiful in the foretime. Of the great mosque writers of travel can scarcely say enough. Mr. Lane-Poole says: " Travellers stand amazed among the forest of columns which open out apparently endless vistas on all sides. The por- phyry, jasper, and marbles are still in their places ; the splendid glass mosaics, which artists from By- zantium came to make, still sparkle like jewels in the walls ; the daring architecture of the sanctuary, with its fantastic crossed arches, is still as imposing as ever; the courtyard is still leafy with the orange trees that prolong the vistas of columns. As one stands before the loveliness of the great mosque, the thought goes back to the days of the glories of Cor- dova, the palmy days of the Great Khalif, which will never return." Of all the countries in which the Jews all down the centuries have lived there is probably none of which they have been more loud in praise than Spain. Their poets sang of it as if it were their 94 OLD-TIME MAKERS OF MEDICINE own country; for centuries the people were happier here than probably they have been anywhere else for so long a period. Elsewhere in this book I have called attention to all that Spain meant in Europe during all the centuries from the beginning of the Roman Empire down to the end of the Middle Ages. Maimonides was fortunate in his birthplace, then, and while circumstances compelled the family to move away, this change did not come until a good effect had been produced on the mind of the grow- ing youth. Even when persecution came, Maimon- ides clung to Spain with a tenacity born of deep affection and emphasized by admiration for all that she was and had been. Cordova was the jewel of the Spain of this time, and though much less than she had been in the long preceding time, when she was the birthplace of Lucan and the two Senecas, or even than what she had been in Abd-er-Rahman's days, or when she was the birthplace of Averroes, still she remained wonderfully beautiful and at- tractive, winning and holding the affections of men. Maimonides' father, Maimum Ben Joseph, was a member of the Rabbinical College of Cordova, and famous for his knowledge of the Talmud. There are some writings of his on mathematics and astronomy extant. He directed the education of his son, who, like many another distinguished scholar in later life, seems to have exhibited very little talent in his early years. There is no rule in the matter. Precocity often disappoints. Genius is often dull in childhood, but there are exceptions that prove both rules. The basis of education in Spain at that time among the Jews was the Bible, the MAIMONIDES 95 Talmud, mathematics, and astronomy, a good rounded education in literature, the basis of law, and some exact physical science. After his prelim- inary education at home Maimonides studied the natural sciences and medicine with Moorish teach- ers. Nature-study, in spite of frequent expressions that declare it new in modern times, is as old as man. He also received a grounding in philosophy as a preparation for his scientific studies. At the age of twenty-three he began the composition of a commentary on the Talmud, which he continued to work at on his journeys in Spain and in Egypt. This is considered to be one of the most important of this class of works extant, though, almost need- less to say, similar writings are very numerous. In the light of wanderings in philosophy during the centuries since, it is rather interesting to quote from that work the end of man as this Jewish philosopher of the middle of the twelfth century saw it. Eecent teleological tendencies in biology add to the interest of his views. According to Maimonides, ' ' Man is the end of the whole creation, and we have only to look to him for the reason for its existence. Every object shows the end for which it was created. The palm-trees are there to provide dates ; the spider to spin her webs. All the properties of an animal or a plant are directed so as to enable it to reach its purpose in life. What is the purpose of man? It cannot lie alone in eating and drinking or yielding to passion, nor in the building of cities and the ruling of others, since these objects lie outside of him, and do not touch his essential being. Such material striving he has in 96 OLD-TIME MAKERS OF MEDICINE common with the animal. A man is lifted from a lower to a higher condition by his reason. Only through his reason is he placed above the animals. He is the only reasonable animal. His reason en- ables him to understand all things, especially the Unity of Glod, and all knowledge and science serve only to direct man to the knowledge of God. Pas- sions are to be subdued, since the man who yields to passion subjects his spirit to his body, and does not reveal in himself the divine power which in him lies in his reason, but is swallowed up in the ocean of matter.' ' Not long after Maimonides passed his twentieth year the family, consisting of the father and his two sons, Moses and David, and a daughter, moved from Cordova to Fez, compelled by Jewish persecu- tions. Here it is said that they had to submit to wearing the mask of Islam in order to lead a peace- ful existence. This has been doubted, however, and his whole life is in flagrant contradiction with any such even apparent apostasy from the faith of his fathers. Father and son took advantage of the opportunity of intercourse with Moorish physicians and philosophers to increase their store of knowl- edge, but could not be content in the political and religious conditions in which they were compelled to live. About 1155, then, they went to Jerusalem, but found conditions even more intolerable there, and turned back to Egypt, where they settled down in Old Cairo. In 1166 the father died, and after this we learn that the sons made a livelihood, and even laid the foundation of a fortune, by carrying on a jewelry trade. Moses still devoted most of his MAIMONIDES 97 time to study, while his brother did most of the business, but the brother was lost in the Indian Ocean, and with him went not only a large sum of his own money, but also much that had been en- trusted to him by others. Maimonides undertook to pay off these debts and at the same time had to meet the necessities not only of himself and sister, but also of the family of his dead brother. It was then that he took up the practice of medicine and succeeded in making a great name and reputation for himself. He continued to write, however, and completed his commentary on the Talmud. About the age of fifty Maimonides, as seems to be true of a good many men who live to old age, be- came rather discouraged and despondent about him- self. He refers to himself in his letters and writings rather frequently as an old and ailing man. He had nearly twenty years of active life ahead of him, but he had the persuasion that comes to many that he was probably destined to an early death. His son was born shortly after this time, and that seems to have had not a little to do with brightening his life. While in Egypt Maimonides married the sister of one of the royal secretaries, who, in turn, wedded Maimonides ' sister. Maimonides took on himself the education of his son, who also became a physician, though his father was not to have the satisfaction of watching his success in the practice of his chosen profession. This son, Abraham, be- came the physician of Malie Alkamen, the brother of Saladin, and, besides, was a physician to the hos- pital at Cairo. His son, David, the grandson of Maimonides, practised medicine also at Cairo till 98 OLD-TIME MAKERS OF MEDICINE 1300. He in turn left two sons, Abraham and Solo- mon, who achieved reputation in the chosen pro- fession of their great-grandfather. Maimonides, after the birth of his son, became one of the busiest of practising physicians. Indeed, it is hard to understand how he had the time to do any writing in his busy life. Still less can we un- derstand his time for teaching. He was the physi- cian to Saladin, whose relations with Eichard Cceur de Lion have made him known to English-speaking people. Every morning, as the Court physician, Maimonides went to the palace, situated half a mile away from his dwelling, and if any of the many of- ficials and dependents that then, as now, were at Oriental courts, were ill, he stayed there for some time. As a rule he could only get back to his own home in the afternoon, and then he was, as he says himself, " almost dying with hunger.' ' Knowing the scantiness of the Oriental breakfast, we are not surprised. There he found his waiting-room full of patients, " Jews and Mohammedans, prominent and unimportant, friends and enemies,' ' he says himself, " a varied crowd, who are looking for my medical advice. There is scarcely time for me to get down from my carriage and wash myself and eat a little, and then until night I am constantly occupied, so that, from sheer exhaustion, I must lie down. Only on the Sabbath day have I the time to occupy myself with my own people and my studies, and so the day is away from me." What a picture it is of the busy medical teacher at all times in the world's history, yet it must not be forgotten that it is from these busy men that we have derived our MAIMONIDES 99 most precious lessons in caring for patients rather than disease, in the art of medicine rather than med- ical science — and their practical lessons have been valuable long after the fine-spun theories of the scientist that took so long to elaborate have been placed definitely in the lumber room. His reputation as a writer on medical topics is not as great as that which has been accorded him for his writings on philosophy and in Talmudic literature, but he well deserves a place among the great practical masters of medicine, as well as high rank among the physicians of his time. There is little that is original in his writing, but his thorough- going common sense, his wide knowledge, and his discriminating, eclectic faculty make his writings of special value. As might have been expected, the Aphorisms of Hippocrates attracted his attention, and, besides, he wrote a series of aphorisms of his own. The most interesting of his writings, how- ever, is a series of letters on dietetics written for the son of his patron Saladin. The young prince seems to have suffered from one of the neurotic con- ditions that so often develop in those who have their lives all planned for them, and little incentive to do things for themselves. The main portion of his complaints centred, as in the case of many another individual of leisure, in disturbances of digestion. Besides, he suffered from constipation and feelings of depression. Doubtless, like many a young per- son of the modern time, he was quite sure that these symptoms portended some insidious organic ail- ment that would surely bring an early death. When fathers, having done all that there is to do, just ex- 100 OLD-TIME MAKERS OF MEDICINE pect their sons to enjoy the fruits of the paternal accomplishments, conditions of this kind very often develop, unless the young man proceeds to occupy himself with even more dangerous distractions than he finds in unending thought about his own feelings. The rules of life and health that Maimonides laid down in these letters have become part of our pop- ular medical tradition. Probably more of the ordinarily current maxims as to health have been derived from them than would possibly be suspected by anyone not familiar with them. In various forms his rules have been published a number of times. A good idea of them can be obtained from the following compendium of them, which I ab- breviate from a biographical sketch of Maimonides by Dr. Oppler, which appeared in the " Deutsches Archiv fur Geschichte der Medizin und Medicinische Geographie " (Bd. 2, Leipzig, 1879). 1. Man is bound to lead a life pleasing to God if he wants to have a healthy body, and he must hold himself far from everything that can hurt his health and accustom himself to whatever renews his strength. He should eat and drink only when hungry and thirsty and should be particularly careful of the regular evacuation of his bowels and of his bladder. He must not delay either of these operations, but as far as possible satisfy the inclination at once. 2. A man must not overload his stomach but be content always with something less than is neces- sary to make him feel quite satisfied. He should not drink much during the meal and only of water and wine mixed, taking somewhat more after digestion has begun and after digestion is completed, in mod- eration according to his needs. Before a man sits down to table he should note whether he has any MAIMONIDES 101 tendency to evacuation and should make the body warm by movement and activity. After this exercise he should rest a little before taking food. It is very beneficial after work to take a bath and then the meal. 3. Food should be taken always in the sitting position. There should be no riding nor walking, nor movements of the body until digestion is finished. The man who takes a walk or any strenuous occu- pation immediately after eating subjects himself to serious dangers of disease. 4. Day and night should be divided into twenty- four hours. Men should sleep for eight hours, and so arrange their sleep that the end of it comes with the dawn, so that from the beginning of sleep until sunrise there should be an eight-hour interval. We should all leave our beds about the time that the sun rises. 5. During sleep a man should lie neither on his face nor on his back but on his side, the beginning of the night on his left and at the end on his right. He should not go to sleep for three or four hours after eating and should not sleep during the day. 6. Fruits that are laxative, as grapes, figs, melons, gourds, should be taken only before meal time and not mixed with other food. It would be better to let these get into the abdominal organs and then take other food. 7. Eat what is easily digestible before what is difficult of digestion. The flesh of birds before beef and the flesh of calves before that of cows and steers. (Birds were then thought more digestible than other flesh; we have reversed the ruling. The note shows how light and digestible their flesh was considered and the reason therefor.) 8. In summer eat cooling food, acids, and no spices. In winter, on the contrary, eat warming foods, rich in spices, mustard, and other heating sub- 102 OLD-TIME MAKERS OF MEDICINE stances. In cold and warm climates one should eat according to the climatic conditions. 9. There are certain harmful foods that should be avoided. Large salt fish, old cheese, old pickled meat, young new wine, evil-smelling and bitter foods are often poisonous. There are also some which are less harmful, but are not to be recommended as ordi- nary nutritive materials. Large fish, cheese, milk more than twenty-four hours after milking, the flesh of old oxen, beans, peas, unleavened bread, sauer- kraut, onions, radishes and the like. These are to be taken only in small quantities and only in the winter time and they should be avoided in the summer. Beans and lentils are to be recommended neither in winter nor summer. 10. As a rule one should avoid the eating of tree fruits, or not eat much of them, especially when they are dry and even less when they are green. If they are unripe they may cause serious damage. Jo- hannesbrod is very harmful at all times, as are also all the sour fruits, and only small amounts of them should be eaten in summer or in warm countries. 11. The fruits that are to be recommended dry as well as fresh, are figs, grapes, and almonds. These may be eaten as one has the appetite for them, but one should not accustom himself to eat them much, though they are healthier than all other fruits. 12. Honey and wine are not good for children, though they are beneficial for older people, especially in winter. In summer one-third less of them should be eaten than in winter. 13. Special care should be taken to have regular movements of the bowels that carry off the impuri- ties of the body. It is an axiom in medicine, that so long as evacuations are absent, or difficult, or re- quire strong efforts, the individual is liable to seri- ous disease. Every medical means should be taken to overcome constipation in order to escape its dan- MAIMONIDES 103 gers. For this purpose young people should be given salty food, materials that have been soaked in olive oil, salt itself, or certain vegetable soups with olive oil and salt. Older people should take honey mixed with warm water early in the morning and four hours later should take their breakfast. This proceeding should be followed up from one to four days until the constipation is overcome. 14. Another axiom of medicine is that so long as a man is able to be active and vigorous, does not eat until he is over-full, and does not suffer from constipation, he is not liable to disease. Even such men, however, are much safer if they do not take food that may disagree with them. 15. Whoever gives himself up to inactivity, or puts off evacuations of the bowels, or suffers from constipation, will be sure to suffer from many dis- eases and will see his strength disappear even should he eat the best food in the world and make use of all the remedies that physicians have. Immoderate eat- ing is a poison for men and the cause of many dis- eases which attack them. Most diseases come from either eating too much or partaking of unsuitable food. That was what Solomon meant with his proverb : ' ' He who puts a guard over his mouth and his tongue protects himself from many evils," that is to say, whoever protects his mouth from the over- indulgence in food and his tongue from unsuitable speech protects himself from many evils. 16. Every week at least a man should take a warm bath. One should not bathe when hungry, nor after eating until the food is digested, and bathe the whole body in warm but not too hot water and the head in hot water. Afterwards the body should be washed in lukewarm and cool water until finally cold water is used. One should pour neither cold nor even lukewarm water on the head, nor bathe in cold water in the winter time, nor when the body is 104 OLD-TIME MAKERS OF MEDICINE tired and in perspiration. At such times the bath should be put off for a while. 17. As soon as one leaves the bath one should cover oneself, and especially cover the head, so that no draught may strike it. Even in summer, care must be taken to observe this rule. After this one should rest for a while until the heat of the body passes off and then should go to table. If one could sleep a little just before a meal it is often very bene- ficial. Neither during the bath nor immediately after it should cold water be drunk, and if there is an inappeasable thirst a little wine and water or water and honey should be taken. In winter it is beneficial to rub the body with oil after the bath. 18. Venesection should not be practised fre- quently, for it is only meant for serious illness. It should not be permitted in winter or summer, nor during the months of April or September ( thej ' r " months). After passing his fiftieth year an indi- vidual should abstain from venesection. Venesec- tion should not be practised on the day when one takes a bath or goes on a journey or returns from it. On the day when it is practised less than usual should be eaten and drunk, and the patient should give himself to rest, undertake no work nor bother- some occupation, and take no walk. 19. Whoever observes these rules of life faith- fully I guarantee him a long life without disease. He shall reach a good old age, and when he comes to die will not need a physician. His body will re- main always strong and healthy, unless of course he has been born with a weak nature, or has had an unfortunate bringing up, or should be attacked by epidemic disease or by famine. 20. Only the healthy should keep these rules. Whoever is ill or a sufferer from any injuries, or has lost his health through bad habits, for him there are special rules for each disease, only to be found MAIMONIDES 105 in the medical books. Let it be remembered that every change in a life habit is the beginning of an ailment. 21. If no physician can be secured, then ailing people may use these rules as well as the healthy. These rules are, of course, full of the common sense of medicine that endures at all times. For the tropical climate of the Eastern countries they probably represent as good advice as could be given even at the present time. With them before us it is not surprising to find that on other subjects Mai- monides was just as sensible. Perhaps in nothing is this more striking than in his complete rejection of astrology. Considering how long astrology, in the sense of the doctrine of the stars influencing human health and destinies, had dominated men's minds, and how universal was the acceptance of it, Mai- monides' strong expressions show how much genius lifts itself above the popular persuasions of its time, even among the educated, and how much it anticipates subsequent knowledge. It is well to remind ourselves that as late as the middle of the eighteenth century Mesmer's thesis on ' l The Influence of the Stars on Human Constitu- tions " was accepted by the faculty of the University of Vienna as a satisfactory evidence not only of his knowledge of medicine, but of his power to reason about it. At the end of the twelfth century Maimon- ides was trying to argue it out of existence on the best possible grounds. " Know, my masters," he writes, " that no man should believe anything that is not attested by one of these three sanctions : — ra- tional proof as in mathematical science, the percep- 106 OLD-TIME MAKERS OF MEDICINE tion of the senses, or traditions from the prophets and learned men." His biographer in the mono- graph " Maimonides," published by the Jewish Publication Society of America, 1 expresses his further views on the subject in compendious form, and then gives his final conclusion as follows : " ' Works on astrology are the product of fools, who mistook vanity for wisdom. Men are inclined to believe whatever is written in a book, especially if the book be ancient; and in olden times disaster befell Israel because men devoted themselves to such idolatry instead of practising the arts of martial de- fence and government. ' He says, that he had him- self studied every extant astrological treatise, and had convinced himself that none deserved to be called scientific. Maimonides then proceeds to distinguish between astrology and astronomy, in the latter of which lies true and necessary wisdom. He ridicules the supposition that the fate of man could be de- pendent on the constellations, and urges that such a theory robs life of purpose, and makes man a slave of destiny. ' It is true,' he concludes, ' that you may find strange utterances in the Rabbinical literature which imply a belief in the potency of the stars at a man's nativity, but no one is justified in surrendering his own rational opinions because this or that sage erred, or because an allegorical remark is expressed literally. A man must never cast his own judgment behind him ; the eyes are set in front, not in the back.' " While Maimonides could be so positive in his opinions with regard to a subject on which he felt competent to say something, he was extremely mod- 1 " Maimonides," by David Yellin and Israel Abrahams, Philadelphia, 1903. MAIMONIDES 107 est with regard to many of the great problems of medicine. He often uses the expression in his writings, " I do not see how to explain this matter.' ' He quotes with approval from a Rabbi of old who had counselled his students, " teach thy tongue to say, I do not know. ' ' In this, of course, he has given the best possible evidence of his largeness of mind and his capacity for making advance in knowledge. It is when men are ready to say, " I do not know, ' ' that progress becomes possible. It is very easy to rest in a conscious or unconscious pretence of knowl- edge that obscures the real question at issue. A great thinker, who lived in the century in which Maimon- ides died, Roger Bacon, set down as one of the four principal obstacles to advance in knowledge indeed, as the one of the four that hampered intel- lectual progress the most, the fact that men feared to say, " I do not know." One of the most interesting features of Maimon- ides' career for the modern time is the influence that his writings exerted over the rising intellectual life of Europe within a half century after his death. Most people would be rather inclined to think that this Jewish author of the East would have very little influence over the thinkers and teachers of Europe within a generation after his death. He died in 1204, just at the beginning of one of the great productive centuries of humanity, perhaps one of the greatest of them all. In literature, in art, in architecture, in philosophy, and in educa- tion, this century made wonderful strides. Two of its greatest teachers, Albertus Magnus and his pupil, Thomas Aquinas, quote from Moses iEgyp- 108 OLD-TIME MAKEMS OF MEDICINE taeus, the European name for Maimonides at that time, and evidently knew his writings very well. Maimonides was for them an important connecting link with the world of old Greek thought. Others of the writers and teachers of this time, as "William of Auvergne, and the two great Franciscans, Alex- ander of Hales and Duns Scotus, were also in- fluenced by Maimonides. In a word, the educa- tional world of that time was much more closely united than we might think, and it did not take long for a great writer's thoughts to make them- selves felt several thousand miles away. Maimon- ides was, then, in his own time one of the world teachers, and, in a certain sense, he must always re- main that, as representing a special development of what is best in human nature. V GEEAT AEABIAN PHYSICIANS In order to understand the place of the Arabs in medicine and in science, a few words as to the rise of this people to political power, and then to the cul- tivation of literature and of science, are necessary. We hear of the Arabs as hireling* soldiers fighting for others during the centuries just after Christ, and especially in connection with the story of the famous Queen Zenobia at Palmyra. After the de- struction of this city we hear nothing more of them until the time of Mohammed. During these six and a half centuries there is little question of education of any kind among them except that at the end of the sixth century, the Persian King Chosroes I, who was much interested in medicine, encouraged the medical school in Djondisabour, in Arabistan, founded at the end of the fifth century by the Nes- torian Christians, who continued as the teachers there until it became one of the most important schools of the East. It was here that the first Arab physicians were trained, and here that the Chris- tian physicians who practised medicine among the Arabs were educated. Among the Arabs themselves, before the time of Mohammed, there had been very little interest in medicine. Gurlt notes that even the physician of the Prophet himself was, according to tradition, a 109 110 OLD-TIME MAKERS OF MEDICINE Christian. Mohammed's immediate successors were not interested in education, and their people mainly turned to Christian and Jewish physicians for whatever medical treatment they needed. "When the Caliphs came to be rulers of the Mohammedan Empire, they took special pains to encourage the study of philosophy and medicine; though dissec- tion was forbidden by the Koran, most of the other medical sciences, and especially botany and all the therapeutic arts, were seriously cultivated. Until the coming of Mohammed, the Arabs had been wandering tribes, getting some fame as hireling soldiers, but now, under the influence of a feeling of community in religion, and led by the military genius of some of Mohammed's successors, whose soldiers were inspired by the religious feelings of the sect, they made great conquests. The Moham- medan Empire extended from India to Spain within a century after Mohammed's death. Carthage was taken and destroyed, Constantinople was threat- ened. In 661, scarcely forty years after the hegira or flight of Mohammed, from which good Moham- medans date their era, the capital was transferred from Medina to Damascus, to be transferred from here to Bagdad just about a century later, where it remained until the Mongols made an end of the Abbasside rulers about the middle of the thirteenth century. At the beginning the followers of Mo- hammed were opposed to knowledge and education of all kinds. Mohammed himself had but little. According to tradition, he could not read or write. The story told with regard to the Caliph Omar and the great library of Alexandria, seems to have a GREAT ARABIAN PHYSICIANS 111 foundation in reality, though such legends usually are not to be taken literally. Certainly it represents the traditional view as to the attitude of the earlier Moslem rulers to education. Omar was asked what should be done with the more than two million vol- umes. He said that the books in it either agreed with the Koran, or they did not. If they agreed with it they were quite useless. If they did not, they were pernicious. In either case, they should be done away with, because there was an element of danger in them. Accordingly, the precious volumes that had been accumulating for nearly ten centuries, served, it is said, to heat the baths of Alexandria for some six months — probably the most precious fuel ever, used. Fortunately for posterity, the edict was not quite as universal in its application as the story would indicate, and exceptions were made for books of science. In the course of their conquests, however, the Mohammedan Arabs captured the Greek cities of Asia Minor. They were brought closely in contact with Greek culture, Greek literature, and Greek thought. As has always been the case, captive Greece took its captors captive. What happened to the Eomans earlier came to pass also among the Arabs. Inspired by Greek philosophy, science, and literature, they became ardent devotees of science and the arts. While not inventing or discovering anything new, like the Romans they carried on the old. Damascus, Basra, Bagdad, Bokhara, Samar- cand all became centres of culture and of educa- tion. Large sums were paid for Greek manu- scripts, and for translations from them. Under the 112 OLD-TIME MAKERS OF MEDICINE famous Harun al-Baschid, at the end of the eighth century, whose name is better known to us than that of any others, because of the stories of his wander- ing by night among his people in order to see if justice were done, three hundred scholars were sent at the cost of the Caliph to the various parts of the world in order to bring back treasures of science, and especially of geography and medicine. It is an interesting historical reflection that the Japanese and Chinese are doing the same thing now. The Arabs were very much taken by the philoso- phy of Aristotle, and it became the foundation of all their education. Greek thought, as always, inspired its students to higher things. Soon everywhere in the dominions of the Caliphs, philosophy, science, art, literature, and education flourished. Medicine was taken up with the other sciences and cultivated assiduously. Freind, in his " Historia Medicinse," says that the writings of the old Greeks which treated of medicine were saved from destruction with the other books at Alexandria, for the desire of health did not have less strength among the Arabs than among other nations. Since these books taught them how to preserve health, and were not otherwise contrary to the laws of the Prophet, that served to bring about their preservation. Freind also calls attention to the fact that grammars and books which treated of the science of language were likewise saved from destruction. Besides the library, the Arabs, after their conquest of Alex- andria in the eighth century, came under the in- fluence of the university still in existence there. In the West, in Spain, the Arabs enjoyed the GEEAT ARABIAN PHYSICIANS 113 same advantages as regards contact with culture and education as their conquest of the Eastern cities and Alexandria brought them in the East. While it is not generally realized, Spain was, as we have pointed out, the province of the Eoman Em- pire in the West that advanced most in culture be- fore the breaking up of the Empire. The Silver Age of Latin literature owes all of its geniuses to Spain. Lucan, the Senecas, Martial, Quintilian, are all Spaniards. Spain itself was a most flourish- ing province, and under the Spanish Caesars, from the end of the first to about the end of the second century, increased rapidly in population. Spain was the leader in these prosperous times, and the tradition of culture maintained itself. When Spain became Christian the first great Christian poet, Prudentius, born about the middle of the fourth century, came from there. He has been called the Horace and Virgil of the Christians. The coming down of the barbarians from the North disturbed Spain's prosperity and the peace and culture of her inhabitants, but it should not be forgotten that the first medieval popularization of science, a sort of encyclopedia of knowledge, the first of its kind after that of Pliny in the classical period, came from St. Isidore of Seville, a Spanish bishop. There has been considerable tendency to insist that Spanish culture and intellectuality owe nearly all to the presence of the Moors in Spain. This can only be urged, however, by those who know nothing at all of the Spanish Caesars, the place of Spain in the history of the Roman Empire, and the continu- 114 OLD-TIME MAKERS OF MEDICINE ance of the culture that then reached a climax of expression during succeeding centuries. On the contrary, the Moors who came to Spain owe most of their tendency to devote themselves to culture and education to the state of affairs existent in Spain when they came. There is no doubt that they raised standards of education and of culture above the level to which they had sunk under the weight of the invading barbarians from the North, and Spain owes much to the wise ruling and devo- tion to the intellectual life of her Moorish invaders. All the factors, however, must be taken together in order to appreciate properly the conditions which developed under the Arabs in both the East and the West. The Arabs invented little that was new in science or philosophy ; they merely carried on older traditions. It is for that that the modern time owes them a great debt of gratitude. RHAZES The most distinguished of the Arabian physicians was the man whose rather lengthy Arabian name, beginning with Abu Bekr Mohammed, finished with el-Eazi, and who has hence been usually referred to in the history of medicine as Ehazes. He was born about 850 at Eaj, in the Province of Chorasan in Persia. He seems to have had a liberal early education in philosophy and in philology and litera- ture. He did not take up medicine until later in life, and, according to tradition, supported himself as a singer until he was thirty years of age. Then he devoted himself to medical studies with the GREAT ARABIAN PHYSICIANS 115 ardor and the success so often noted in those whose opportunity to study medicine has been delayed. His studies were made at Bagdad, where Ibn Zein el-Taberi was his teacher. He returned to his na- tive town and was for some time the head of the hospital there. Later he was called by the Sultan to Bagdad to take charge of the renovated and en- larged hospital of the capital. His medical career, then, is not unlike that of many another successful physician, especially of the modern time. At Bagdad he had abundant opportunities for study, and the ambition to make medicine as well as to make money and gain fame. His studies in science were all founded on Aris- totle. Though he was called the Galen of his time, and looked up to the Greek physician as his master, even the authority of Galen did not override that of the Stagirite in his estimation. One of his apho- risms is said to have been, " If Galen and Aristotle are of one mind on a subject, then surely their opinion is true. When they differ, however, it is extremely difficult for the scholar to decide which opinion should be accepted. ' ' He drew many pupils to Bagdad, and, when one knows his teaching, this is not surprising. Some of his aphorisms are very practical. While the expressions just quoted with regard to Galen and Aristotle might seem to in- dicate that Ehazes was absolutely wedded to author- ity, there is another well-known maxim of his which shows how much he thought of the value of experi- ence and observation. " Truth in medicine," he said, " is a goal which cannot be absolutely reached, and the art of healing, as it is described in books, 116 OLD-TIME MAKERS OF MEDICINE is far beneath the practical experience of a skilful, thoughtful physician." Some of his other medical aphorisms are worth noting. ' ' At the beginning of a disease choose such remedies as will not lessen the patient's strength.' ' " When you can heal by diet, prescribe no other remedy, and, where simple remedies suffice, do not take complicated ones." Ehazes knew well the value of the influence of mind over body even in serious organic disease, and even though death seemed impending. One of his aphorisms is : " Physicians ought to console their patients even if the signs of impending death seem to be present. For the bodies of men are dependent on their spirits." He considered that the most valuable thing for the physician to do was to in- crease the patient's natural vitality. Hence his ad- vice: " In treating a patient, let your first thought be to strengthen his natural vitality. If you strengthen that, you remove ever so many ills with- out more ado. If you weaken it, however, by the remedies that you use you always work harm." The simpler the means by which the patient's cure can be brought about, the better in his opinion. He insists again and again on diet rather than artificial remedies. "It is good for the physician that he should be able to cure disease by means of diet, if possible, rather than by means of medicine." An- other of his aphorisms seems worth while quoting: ' i The patient who consults a great many physicians is likely to have a very confused state of mind. ' ' Some idea of Ehazes' strenuous activity as a writer on medical subjects may be obtained from the fact that thirty-six of his works are still extant, GHEAT ARABIAN PHYSICIANS 117 and there are nearly two hundred others of which only the titles have been preserved. Some of these are doubtless the works of pupils and students of succeeding generations, published under his name to attract attention. His principal work is " Con- tineus," or " Comprehensor, ' * which owes its title to the fact that it was meant to contain the whole practice of medicine and surgery. It includes references to the writings of all previous distin- guished medical writers, from Hippocrates to Honein Ben Ishac, also known as Johannitius, a Christian Arabian physician, one of Ehazes' teach- ers. The most frequently quoted of these authori- ties are Galen, Oribasius, Aetius, and Paul of iEgina. The work, however, is not made up entirely of quo- tations, but contains many observations made by the author himself. Gurlt says that the foundation of the theoretic medicine of Ehazes is the system of Galen, while in practice he seems to cling more to the aphorisms of Hippocrates. He has many prac- tical points which show that he thought for himself. For instance, in wounds of the abdomen, if the in- testines are extruded and cannot be replaced, he suggests the suspension of the patient by his hands and feet in a bath in order to facilitate their return. If they do not go back readily, compresses dipped in warm wine should be used. Cancer he declares to be almost incurable. He has much to say about the bites of animals and their tendency to be poisonous, knew rabies very well, and knew also that the bites of men might have similar serious conse- quences. It is impossible to give any adequate idea of the 118 OLD-TIME MAKERS OF MEDICINE thoroughly practical character of Rhazes' medical writing in a few lines, but it may suffice to say that there is scarcely any feature of modern medicine and surgery that he does not touch, and oftener than not his touch is sure and rational and frequently much better than the advice of successors long after him in the same matters. An example or two will suffice to illustrate this. In the treatment of nasal polyps he says that whenever drug treatment of these is not successful, they should be removed with a snare made of hair. For fall of the uvula he sug- gests gargles, but when these fail he advises re- section and cauterization. Among the affections of the tongue he numbers abscess, fissure, ulcer, can- cer, ranula, shortening of the ligaments, hypertro- phy, erythema of the mucous membrane, and in- flammatory swelling. In general his treatment of the upper respiratory tract is much farther ad- vanced than we might think possible at this time. He advises tracheotomy whenever there is great dif- ficulty of respiration, and describes how it should be done. After the dyspnea has passed the edges of the wound should be brought together with sutures. It is not surprising, then, to find that the treatment of fractures and luxations is eminently practical, and, indeed, on any subject that he touches he throws practical light. In the introduction to his edition of the works of Ambroise Pare, Malgaigne says that the first refer- ence to a metal band in connection with trusses is to be found in Rhazes. Hernia was, of course, one of the serious ailments that, because of its super- ficial character, was rather well understood, and so GREAT ARABIAN PHYSICIANS 119 it is not surprising to find that much of our modern treatment of it was anticipated. The manipulations for taxis, the use of a warm bath for the relaxation of the patient by means of heat and by putting the head and feet higher than the abdomen while in the bath, and the employment of various kinds of trusses to prevent strangulation of the hernia recur over and over again, in the authors of the Middle Ages. Many of the suggestions are to be found in the early Greek authors, but subsequent writers give a cer- tain personal expression to them which shows how much they had learned by personal observation in the employment of various methods. Pagel, in Puschmann's " Handbook of the His- tory of Medicine," declares that Rhazes' most im- portant work for pure medicine is his monograph on smallpox. Its principal value is due to the fact that, though he has consulted old authorities care- fully, his discussion of the disease is founded al- most entirely on his own experience. His descrip- tion of the various stages of the disease, of the forms of the eruption, and of the differential diagnosis, is very accurate. He compares the course of the fever with that of other fevers, and brings out exactly what constitutes the disease. His suggestions as to prognosis are excellent. Those cases, he de- clares, are particularly serious in which the erup- tion takes on a dark, or greenish, or violet color. The prognosis is also unfavorable for those cases which, having considerable fever, have only a slight amount of rash. His treatment of the disease in young persons was by venesection and cool douches. Cold ^ater and acid drinks should be administered 120 OLD-TIME MAKERS OF MEDICINE freely, so that sweat and other excretions may carry off poisonous materials. Care must be taken to watch the pulse, the breathing, the appearance of the feet, the evacuations from the bowels, and to modify therapy in accordance with these indications. The eruption is to be encouraged by external warmth and special care must be taken with regard to com- plications in the eyes, the ears, the nose, the mouth, and the pharynx. A fact that will, perhaps, give the best idea to modern readers of the place of Ehazes in the his- tory of medicine is that Vesalius considered it worth his while to make a translation of his principal work. Unfortunately that translation has not come down to us. When Vesalius, pestered by the con- troversies that had come upon him because of his venturing to make his observations for himself, ac- cepted the post of physician to the Emperor Charles V, he burnt a number of his manuscripts. Among these were his translation of Ehazes and some annotations on Galen, which, as he says him- self, had grown into a huge volume. The G-alenists were bitterly decrying his refusal to accept G-alen on many points, and both of these works would have added fuel to the flame of controversy. He deemed it wiser, then, not to give any further opportunities for rancorous criticism, and, feeling presumably that in his new and important post it was not worth while to bother further over the matter, he burnt them. He tells the reason in his letters to Joachin Eoelant : ' ' When I was about to leave Italy to go to Court, since a number of the physicians whom you know had made the worst kind of censure of GREAT ARABIAN PHYSICIANS 121 my books, both to the Emperor himself, and to other rulers, I burned all the manuscripts that were left, although I had never suffered a moment under the displeasure of the Emperor because of these com- plaints, and in spite of the fact that a number of friends who were present urged me not to destroy them. ' ' Vesalius ' translation of Ehazes was probably un- dertaken because he recognized in him a kindred spirit of original investigation and inquiry, whose work, because it was many centuries old, would command the weight of an authority and at the same time help in the controversy over Galenic questions. This, of itself, would be quite enough to make the reputation of Ehazes, even if we did not know from the writings themselves and from the admiration of many distinguished men as well as the incentive that his works have so often proved to original ob- servation, that he is an important link in the chain of observers in medicine, who, though we would naturally expect them to be so frequent, are really so rare. ALI ABBAS Ehazes lived well on into the tenth century. His successor in prestige, though not his serious rival, was Ali Ben el-Abbas, usually spoken of in medical literature as Ali Abbas, a distinguished Arabian physician who died near the end of the tenth cen- tury. He wrote a book on medicine which, because of its dedication to the Sultan, to whom he was body- physician, is known as the " Liber Eegius," or 122 OLD-TIME MAKERS OF MEDICINE " Eoyal Book of Medicine." This became the lead- ing text-book of medicine for the Arabs until re- placed by the ' ' Canon of Avicenna ' ' some two cen- turies later. The " Liber Regius " was an ex- tremely practical work and, like most of the Arabian books of the early times, is simple and direct, quite without many of the objectionable features that de- veloped later in Arabian medicine. It is valuable mainly for its contributions to diet and the fact that Ali Abbas tested many of his medicines on ail- ing animals before applying them to men. Of course, it owes much to earlier writers on medicine, and especially to Paul of ^Egina. An example of its practical value is to be found in his description of the treatment of a wound of the brachial artery, when, as happened often in venesection from the median basilic vein, it was in- jured through carelessness or inadvertence. If astringent or cauterizing methods do not stop the bleeding, the artery should be exposed, carefully isolated, tied in two places above and below the wound, and then cut across between them. He has many similar practical bits of technique. For in- stance, in pulling a back tooth he recommends that the gums be incised so as to loosen them around the roots, and then the tooth itself may be drawn with a special forceps which he calls a molar forceps. In ascites he recommends that when other means fail an opening should be made three finger-breadths below the navel with a pointed phlebotomy knife, and a portion of the fluid allowed to evacuate itself. A tube should then be inserted, but closed. The next day more of the fluid should be allowed to GREAT ARABIAN PHYSICIANS 123 come away, and then the tube removed and the ab- domen wrapped with a firm bandage. It is easy to understand that Ali Abbas' book should have been popular, and the more we know of it the easier it is to explain why Constantine Africanus should have selected it for translation. It contains ten theoretic and ten practical books, and gives an excellent idea of the medical knowledge and medical practice of the time. Probably the fact that Constantine had translated it led to its early printing, so that we have an edition of it published at Venice in 1492, and another at Lyons in 1523. During the Middle Ages the book was often spoken of as " Eegalis Dispositio, ' ' the " Royal Disposi- tion of Medicine. ' ' MOORISH PHYSICIANS After Rhazes, the most important contributors to medical literature from among the Arabs, with the single exception of Avicenna, were born in Spain. They are Albucasis or Abulcasis, the surgeon; Avenzoar, the physician, and Averroes, the philo- sophic theorist in medicine. Besides, it may be re- called here that Maimonides, the great Jewish physi- cian, was born and educated at Cordova, in Spain. It might very well be a surprise that these distin- guished men among the Arabs should have flour- ished in Spain, so far from the original seat of Arabian and Mohammedan dominion in the East, where, owing to conditions in the modern time, the English-speaking world particularly is not likely to assume that the environment was favorable for the 124 OLD-TIME MAKERS OF MEDICINE development of science and philosophy. Anyone who recalls, however, the history of Spanish in- tellectual influence in the Eoman Empire, as we have traced it at the beginning of this chapter, will appreciate how favorable conditions were in Spain for the fostering of intellectual development. With the disturbances that had come from political strife and the invasion of the barbarians in Italy, Spain had undoubtedly come to hold the primacy in the in- tellectual life of Europe at the time when the Arabs took possession of the peninsula. ABULCASIS The most important of the Arabian surgeons of the Middle Ages is Albucasis or Abulcasis, also Abulkasim, who was born near Cordova, in Spain. The exact year of his birth is not known, but he flourished in the second half of the tenth century. He is said to have lived to the age of 101. The name of his principal work, which embraces the whole of medicine, is " Altasrif," or " Tesrif," which has been translated i ' The Miscellany. ' ' Most of what he has to say about medical matters is taken from Ehazes. His work on surgery, however, in three books, represents his special contribution to the medical sciences. It contains a number of il- lustrations of instruments, and is the first illustrated medical book that has come to us. It was translated into Latin, and was studied very faithfully by all the surgeons of the Middle Ages. G-uy de Chauliac has quoted Albucasis about two hundred times in his " Chirurgia Magna.' ' Even as late as the be- GREAT ARABIAN PHYSICIANS 125 ginning of the sixteenth century Fabricius de Ac- quapendente, the teacher of Harvey, confessed that he owed most to three great medical writers, Celsus (first century), Paul of iEgina (seventh century), and Abulcasis (tenth century). Abulcasis insisted that for successful surgery a detailed knowledge of anatomy was, above all, neces- sary. He said that the reason why surgery had declined in his day was that physicians did not know their anatomy. The art of medicine, he added further, required much time. Unfortunately, to quote Hippocrates, there are many who are physi- cians in name only, and not in fact, especially in what regards surgery. He gives some examples of surgical mistakes made by his professional brethren that were particularly called to his attention. They are the perennially familiar instances of ignorance causing death because surgeons were tempted to operate too extensively. His description of the procedure necessary to stop an artery from bleeding is an interesting ex- ample of his method of teaching the practical tech- nique of surgery. Apply the finger promptly upon the opening of the vessel and press until the blood is arrested. Having heated a cautery of the ap- propriate size, take the finger away rapidly and touch the cautery at once to the end of the artery until the blood stops. If the spurting blood should cool the cautery, take another. There should be several ready for the purpose. Take care, he says, not to cauterize the nerves in the neighborhood, for this will add a new ailment to the patient's affec- tion. There are only four ways of arresting arterial 126 OLD-TIME MAKERS OF MEDICINE hemorrhage. First, by cautery ; second, by division of the artery, when that is not complete — for then the extremities contract and the blood clots — or by a ligature, or by the application of substances which arrest blood flow, aided by a compressive bandage. Other means are inefficient, and seldom and, at most, accidentally successful. His instruction for first aid to the injured in case of hemorrhage in the ab- sence of the physician, is to apply pressure directly upon the wound itself. The development of the surgical specialties among the Arabs is particularly interesting. Abulcasis has much to say about nasal polyps. He divided them into three classes: (1) cancerous, (2) those with a number of feet, and (3) those that are soft and not living, — these latter, he says, are neither malignant nor difficult to treat. He recommends the use of a hook for their removal, or a snare for those that cannot be removed with that instrument. His instructions for the removal of objects from the external ear are interestingly practical. He ad- vises the use of bird lime on the end of a sound to which objects will cling, or, where they are smaller, suction through a silver or copper canula. Hooks and pincettes are also suggested. Insects should be removed with a hook, or with a canula, or, having been killed by warm oil, removed by means of a syringe. Some of his observations with regard to genito-urinary surgery are quite as interesting. He even treated congenital anomalies. He suggests cut- ting of the meatus when narrowed, dilatation of strictures with lead sounds, and even suggests plans of operations to improve the condition in hypo- GREAT ARABIAN PHYSICIANS 127 spadias. He gives the signs for differentiation be- tween epitheliomata and condylomata, and distin- guishes various forms of ulceration of the penis. Abulcasis discusses varicose veins in very much the same spirit as a modern surgeon does. They occur particularly in people who work much on their feet, and especially who have to carry heavy burdens. They should not be operated on unless they produce great discomfort, and make it impos- sible for the sufferer to make his living. They may be operated on by means of incision or extirpation. Incision consists of cutting the veins at two or three places when they have been made prominent by means of tight bandages around the limb. The blood should be allowed to flow freely out of the cut ends, and then a bandage applied. For extirpation, the skin having been shaved beforehand, the vein should be made prominent, and then carefully laid bare. When freed from all adhesions, it should be lifted out on a hook, and either completely extirpated or several rather long pieces removed. He lays a good deal of stress on the necessity for freeing the vein thoroughly and lifting it well out of tissues before incising it. In old cases special care must be taken not to tear the vein. Minute details of technique are often found in these old authors. Abulcasis, for instance, treats of adherent fingers with up-to-date completeness. They can occur either congenitally or from injury, as, for instance, burning. They should be separated, and then separation maintained by means of bandages or by the insertion between them of a thin lead plate, which prevents their readhesion. Adhesions of the 128 OLD-TIME MAKERS OF MEDICINE fingers with the palm of the hand, which Abulcasis has also seen, should be treated the same way. At times there is surprise at finding some rare lesion treated with modern technique, and a hint at least of our modern apparatus. Fracture of the pubic arch, for instance, is described in Abulcasis quite as if he had had definite experience with it. When this occurs in a woman, the reposition of the bone is often greatly facilitated by a cotton tampon in the vagina. This tampon must be re- moved at every urination. There is another way, however, of better securing the same purpose of counterpressure. One may take a sheep's bladder into the orifice of which a tube is fastened. One should introduce the bladder into the vagina, and then blow strongly through the tube, until the blad- der becomes swollen and fills up the vaginal cavity. The fracture will, as a rule, then be readily re- duced. Here is, of course, not alone the first hint of the colpeurynter, but a very practical form of the apparatus complete. Old-time physicians used the bladders of animals very generally for nearly all the medical purposes for which we now use rub- ber bags. AVICENNA Undoubtedly the most important of Abulcasis' contemporaries is the famous physician whose Arabic name, Ibn Sina, was transformed into Avi- cenna. He was born toward the end of the tenth century in the Persian province of Chora san, at the height of Arabian influence, and is sometimes spoken GREAT ARABIAN PHYSICIANS 129 of as the chief representative of Arabian medicine, of as much importance for it as Galen for later Greek medicine. His principal book is the so-called " Canon." It replaced the compendinm " Con- tinens " of Rhazes, and, in the East, continued un- til the end of the fifteenth century to be looked upon as the most complete and best system of medicine. Avicenna came to be better known in the West than any of the other Arabian writers, and his name car- ried great weight with it. There are very few sub- jects in medicine that did not receive suggestive, if not always adequate, treatment at the hands of this great Arabian medical thinker of the eleventh cen- tury. He copied freely from his predecessors, but completed their work with his own observations and conclusions. One of his chapters is devoted to leprosy alone. He has definite information with re- gard to bubonic plague and the filaria medinensis. Here and there one finds striking anticipations of what are supposed to be modern observations. Nothing was too small for his notice. One portion of the fourth book is on cosmetics, in which he treats the affections of the hair and of the nails. He has special chapters with regard to obesity, emaciation, and general constitutional conditions. His book, the ' * Antidotarium, ' ' is the foundation of our knowledge of the drug-giving of his time. Some idea of the popularity and influence of Avi- cenna, five centuries after his time, can be readily derived from the number of commentaries on him issued during the Renaissance period by the most distinguished medical scholars and writers of that time. Hyrtl, in his " Das Arabische und Hebraische 130 OLD-TIME MAKERS OF MEDICINE in der Anatomie," quotes some of them, — Bartholo- maeus de Varignana, Gentilis de Fulgineis, Jacobus de Partibus, Didacus Lopez, Jacobus de Forlivio, Ugo Senesis, Dinus de Garbo, Matthaeus de Gradi- bus, Nicolaus Leonicenus, Thaddaeus Florentinus, Galeatus de Sancta Sophia. A more complete list, with the titles of the books, may be found in Haller's " Bibliotheca Anatomica." For over three cen- turies after the foundation of medical schools in Europe (and even after Mondino's book had been widely distributed), Avicenna was still in the hands of all those who had an enthusiasm for medical science. AVENZOAR Another of the distinguished Arabian physicians was Avenzoar — the transformation of his Arabic family name, Ibn-Zohr. He was probably born in Penaflor, not far from Seville. He died in Seville in 1162 at the age, it is said, of ninety-two years. He was the son of a physician descended from a family of scholars, jurists, physicians, and officials. He received the best education of the time not only in internal medicine, but in all the specialties, and must be counted among the greatest of the Spanish Arabian physicians. He was the teacher of Aver- roes, who always speaks of him with great respect. He is interesting as probably being the first to sug- gest nutrition per rectum. A few words of his description show how well he knew the technique. His apparatus for the purpose consisted of the bladder of a goat or some similar animal structure, GREAT ARABIAN PHYSICIANS 131 with a silver canula fastened into its neck, to be used about as we use a fountain syringe. Having first carefully washed out the rectum with cleansing and purifying clysters, he injected the nutriment — eggs, milk, and gruels — into the gut. His idea was that the intestine would take this, and, as he said, suck it up, carrying it back to the stomach, where it would be digested. He was sure that he had seen his patients benefited by it. Some light on his studies of cases that would re- quire such treatment may be obtained from what he has to say about the handling of a case of stricture of the esophagus. He says that this be- gins with some discomfort, and then some difficulty of swallowing, which is gradually and continuously increased until finally there comes complete impos- sibility of swallowing. It was in these cases that he suggested rectal alimentation, but he went farther than this, and treated the stricture of the esophagus itself. The first step in this treatment is that a canula of silver or tin should be inserted through the mouth and pushed down the throat till its head meets an obstruction, always being withdrawn when there is a vomiting movement, until it becomes engaged in the stricture. Then freshly milked milk, or gruel made from farina or barley, should be poured through it. He says that in these cases the patient might be put in a warm milk or gruel bath, since there are some physicians who believe that through the lower parts of the body, and also through the pores of the whole body, nutrition might be taken up. While he considers that this latter method 132 OLD-TIME MAKERS OF MEDICINE should be tried in suitable cases, he has not very much faith in it, and says that the reasons urged for it are weak and rather frivolous. It is easy to understand that a man who has reached the place in medicine where he can recommend manipulative treatments of this kind, and discuss nutritional modes so rationally, knew his practical medicine well, and wrote of it judiciously. AVERROES Among the distinguished contributors to medi- cine at this time, though more a philosopher than a physician, is the famous Averroes, whose full Arabic name among his contemporaries was Abul-Welid Mohammed Ben Ahmed Ibn Roschd el-Maliki. Like Avenzoar, of whom he was the intimate persona] friend, and Abulcasis and Maimonides, he was born in the south of Spain. He was in high favor with the King of Morocco and of Spain, El-Mansur Jacub, often known as Almansor, who made him one of his counsellors. His works are much more important for philosophy than for medicine, and his philo- sophical writings gave him a place only second to that of Aristotle in the Western world during the Middle Ages. Averroism is still a subject of at least academic interest, and Renan's monograph on it and its author was one of the popular books of the latter half of the nineteenth century in philosophic circles. In spite of his friendship with the Moorish King and with Avenzoar, he fell under the suspi- cion of free thinking and was brought to trial with a number of personal friends, who occupied high GREAT ARABIAN PHYSICIANS 133 positions in the Moorish government. He escaped with his life, but only after great risks, and he was banished to a suburb of Cordova, in which only Jews were allowed to live. By personal influence he suc- ceeded in securing the pardon of himself and friends, and then was summoned to the court of the son and successor of El-Mansur in Morocco. He died, not long after, in 1198. Altogether there are some thirty-three works of Averroes on philosophy and science. Only three of these are concerned with medicine. One is the " Colliget," so-called, containing seven books, on anatomy, physiology, pathology, diagnostics, ma- teria medica, hygiene, and therapy. Then there is a commentary on the ' \ Cantica of Avicenna, ' ' and a tractate on the ' ' Theriac. ' ' Averroes y idea in writ- ing about medicine was to apply his particular sys- tem of philosophy to medical science. His intimate relations with other great physicians of the time, and in particular his close friendship with Avenzoar, enabled him to get abundant medical information in faultless order so far as knowledge then went, but his theoretic speculations, instead of helping medi- cine, as he thought they would, and as philosophers have always been inclined to think as regards their theoretic contributions, were not only not of value, but to some extent at least hindered human progress by diverting men from the field of observation to that of speculation. It is interesting to realize that Averroes did in his time what Descartes did many centuries later, and many another brilliant thinker has done before and since. 134 OLD-TIME MAKERS OF MEDICINE ARABIAN INFLUENCE The fame of these great thinkers and writers in philosophy and in medicine came to be known not only through the distribution of their books long after their death, but during their lifetime, and in immediately subsequent generations, ardent seekers after knowledge, who were themselves afterwards to become famous by their teaching and writing, found their way into the Arabian dominions in order to take advantage of the educational oppor- tunities afforded. These were better than they could secure at home in Christian countries, be- cause the process of bringing culture and devotion to literature and science into the minds of the North- ern nations, who had replaced the old Romans in Europe, was not yet completed. Bagdad and Cor- dova were the two favorite places of educational pilgrimage. The names that are most familiar among the scholars in the Middle Ages in Europe are those of whom it is recorded that they made long journeys in order to get in touch with what the Arabs had preserved of the old Greek civiliza- tion and culture. Among them are such men as Michael Scot or Scotus, Matthew Platearius, who was afterwards a great teacher at Salerno; Daniel Morley, Adelard of Bath, Egidius, otherwise known as Grilles de Corbeil; Romoaldus, Gerbert of Auvergne, who later became Pope under the name of Sylvester II; Gerard of Cremona, and the best known of them all, at least in medicine, Constantine Africanus, whose wanderings, however, were prob- GREAT ARABIAN PHYSICIANS 135 ably not limited to Arabian lands, but who seems also to have been in Hindustan. We are rather prone to think that this great spirit of going far afield for knowledge's sake is recent, or, at least, quite modern. As a matter of fact, one finds it everywhere in history. Long before Herodotus did his wanderings there were many vis- itors who went to Egypt, and many more later who went to Crete, and many more a few centuries later who went to the shores of Asia Minor seeking for the precious pearl of knowledge, and sometimes find- ing it without finding the even more precious pearl of wisdom, " whose worth is from the farthest coasts.' ' To the Arabs we owe the foundation of a series of institutions for the higher learning, like those which had existed around them in Asia Minor and in Egypt at the time they made their conquests. Alexandria, Pergamos, Cos, Cnidos, Tarsus, and many other Eastern cities had had what we would call at least academies, and many of them deserved the name of universities. The Arabs continued the tradition in education that they found, and estab- lished educational institutions which attracted wide attention. As we have said, the two most famous of these were at Bagdad and at Cordova. Mostan- ser, the predecessor of the last Caliph of the family of the Abbassides, built a handsome palace, in which the academy of Bagdad was housed. It is still in existence, and gives an excellent idea of the benefi- cent interest of this monarch and of other of the Abbasside rulers in education. Its fate at the pres- ent time is typical of the attitude of the Moham- 136 OLD-TIME MAKEHS OF MEDICINE medans towards education. Though the building is still standing, the institution of learning is no longer there. As Hyrtl remarks, it is not ideas that are exchanged in it now, but articles of commerce. It has become the chief office of the Turkish customs department in Bagdad. These institutions of the higher learning, founded by the Arabs, at first as rather strict imitations of the museums or academies of Egypt and Asia Minor, gradually changed their character under the Arabs. Their courses became much more formal, examinations became much more important. Schol- arship was sought not so much for its own sake, as because it led to positions in the civil service, to the favor of princes, and, in general, to reputation and pecuniary reward. Formal testimonials proclaim- ing education, signed by the academic authorities, were introduced and came to mean much. Lawyers could not practise without a license, physicians also required a license. These formalities were adopted by the Western medieval universities to a consid- erable degree and have been perpetuated in the mod- ern time. Undoubtedly they did much to hamper real education among the Arabs by setting in place of the satisfaction of learning for its own sake and the commendation of teachers the formal recog- nition of a certain amount of work done as recog- nized by the educational authorities. There was al- ways a tendency among the Arabs to formulate and formalize, to over-systematize what they were at; to think that new knowledge could be obtained simply by speculating over what was already ac- quired, and developing it. There are a number of GREAT ARABIAN PHYSICIANS 137 comparisons between this and later periods of edu- cation that might be suggested if comparisons were not odious. The influence of Arabian medicine on modern medicine can, perhaps, best be judged from the num- ber of words in our modern nomenclature, which, though bearing Latin forms, often with suggestion of Greek origins, still are not derived from the old Latin or Greek authors, but represent Arabic terms translated into Latin during the Eenaissance period. Hyrtl, without pretence of quoting them all, gives a list of these which is surprising in its compre- hensiveness. For instance, the mediastinum, the sutura sagittalis, the scrobiculus cordis, the mar- supium cordis, the chambers of the heart, the velum palati, the trochanter, the rima glottidis, the fon- tanels s, the alae of the nose, all have their present names, not from original Latin expressions, but from the translation of Arabic terms. For all such words the Greeks and Eomans have quite other ex- pressions, in which the sense of our modern terms is not contained. This has given rise to many mis- understandings, and to many attempts in the mod- ern times to return to the classic terminology rather than preserve what in many cases are the barba- risms introduced through the Arabic, but it is doubt- ful whether any comprehensive reform in the matter can be effected, so strongly entrenched in medical usage have these terms now become. Freind, in his " History of Medicine,' ' already cited, calls attention to the fact that the Arabs had an unfortunate tendency to change by addition or subtraction of their own views the authors that they 138 OLD-TIME MAKERS OF MEDICINE studied, and wished to translate to others. This seems to have been true even of some of the most distinguished of them. Of course, the idea of pre- serving an author's text untouched, and making it clear just where note and commentary came in, had not yet come to men's view, but quite apart from this the Arabs apparently often tried to gain ac- ceptance for their own ideas by having them masquerade as the supposed ideas of favorite classic authors. Another unfortunate tendency among the Arabs was their liking for the discussion of many trivial questions. Hyrtl, in his volume on " Arabian and Hebrew Words in Anatomy," 1 declares that it is almost incredible how earnestly some trivial ques- tions in anatomy and physiology were discussed by the Arabs. He gives some examples. Why does no hair grow on the nose of men? Why does the stomach not lie behind the mouth? Why does the windpipe not lie behind the esophagus? Why are the breasts not on the abdomen? Why are not the calves on the anterior portion of the legs? Even such men as Rhazes and Avicenna discuss such questions. It was this tendency of the Arabs that passed over to the Western Europeans with Arabian com- mentaries on philosophy and science, and brought so many similar discussions in the scholastic period. These trivialities have usually been supposed to originate with the scholastics themselves, for they are not to be found in the Greek authors on whom J "Das Arabische und Hebraische in der Anatomie," Dr. Joseph Hyrtl, Wien, 1879. GREAT ARABIAN PHYSICIANS 139 the scholastics were writing commentaries, but they are typically Oriental in character, and it must be remembered that during the twelfth and early thir- teenth centuries, at least, Greek philosophy found its way largely into Europe in Arab versions, and these characteristically Arabian additions of the discussion of curious trivial questions came with them and produced an imitative tendency among the Europeans. As a rule the more careful has been the study of Arabian writers in the modern time, particularly by specialists, the clearer has it become that they lacked nearly all originality. Especially were they faulty in their observations; besides, they had a definite tendency to replace observation by theory, a fatal defect in medicine. The fine development of surgery that came at the end of the Arabian period of medicine in Europe could never have come from the Arabs themselves. Gurlt has brought this out particularly, but it will not be difficult to cite many other good authorities in support of this opinion. Hyrtl, in his " Thesis on the Earer Old Anato- mists," 1 says that " the Arabs paid very little at- tention to anatomy, and, of course, because of the prohibition in the Koran, added nothing to it. What- ever they knew they took from the Greeks, and espe- cially Galen. Not only did they not add anything new to this, but they even lost sight of much that was important in the older authors. The Arabs were much more interested in physiology; they could study this by giving thought to it without soil- l " Anat. Antiq. Rariores," Vienna, 1835. 140 OLD-TIME MAKERS OF MEDICINE ing their hands. They delighted in theory, rather than in observation. ' ' While we thus discuss the lack of originality and the tendency to over-refinement among the Arabian medical writers, it must not be thought that we would make little of what they accomplished. They not only preserved the old medical writers for us, but they kept alive practical medicine with the prin- ciples of the great Greek thinkers as its basis. There are a large number of writers of Arabian medicine whose names have secured deservedly a high place in medical history. If this were a formal history of Arabian medicine, their careers and works would require discussion. For our purpose, how- ever, it seems better to confine attention to a few of the most prominent Arabian writers on medi- cine, because they will serve to illustrate how thor- oughly practical were the Arabian physicians and how many medical problems that we are prone to think of as modern they occupied themselves with, solving them not infrequently nearly as we do in the modern time. VI THE MEDICAL SCHOOL AT SALERNO The Medical School at Salerno, probably organized early in the tenth century, often spoken of as the darkest of the centuries, and reaching its highest point of influence at the end of the twelfth century, is of great interest in modern times for a number of reasons. First it brought about in the course of its development an organization of medical education, and an establishment of standards that were to be maintained whenever and wherever there was a true professional spirit down to our own time. They in- sisted on a preliminary education of three years of college work, on at least four years of medical train- ing, on special study for specialist's work, as in surgery, and on practical training with a physician or in a hospital before the student was allowed to practise for himself. At Salerno, too, the depart- ment of women's diseases was given over to women professors, and we have the text-books of some of these women medical teachers. The license to prac- tise given to women, however, seems to have been general and did not confine them merely to the care of women and children. We have records of a num- ber of these licenses issued to women in the neigh- borhood of Salerno. This subject of feminine med- ical education at Salerno, because of its special inter- est in our time, will have a chapter by itself. 141 142 OLD-TIME MAKERS OF MEDICINE These are the special features of medical education in our own time that we are rather prone to think of as originating with ourselves and as being indices of that evolution of humanity and progress in man- kind which are culminating in our era. It is rather interesting, then, to study just how these develop- ments came about and what the genesis of this great school was. The books of its professors were widely read, not only in their own generation but for cen- turies afterwards. With the invention of printing at the time of the Eenaissance most of them were printed and exerted profound influence over the re- vival of medicine which took place at that time. Salerno became the first of the universities in the modern sense of the word. Here there gathered round the medical school, first a preparatory depart- ment representing modern college work, and then departments of theology and law, though this latter department particularly was never quite successful. The fact that the first university, that of Salerno, should have been organized round a medical school, the second, that of Bologna, around a law school, and the third, that of Paris, around a school of theology and philosophy, would seem to represent the ordi- nary natural process of development in human inter- ests. First man is interested in himself and in his health, then in his property, and finally in his rela- tions to his fellow-man and to God. Though much work has been done on the subject in recent years, it is not easy to trace the origin of the medical school at Salerno. The difficulty is em- phasized by the fact that even the earliest chron- iclers whose accounts we have were not sure as to its THE MEDICAL SCHOOL AT SALERNO 143 origin, and even had some doubt about the age of the school. Alphanus, usually designated Alphanus I be- cause there are several of the name, who is one of the earliest professors whose name and fame have come down to us, gives us the only definite detail as to the age of the school. He was a Benedictine monk, distinguished as a literary man, known both as poet and physician, who was afterwards raised to the Bishopric of Salerno. As a bishop he was one of the beneficent patrons, to whom the school owed much. He lived in the tenth century, and states that medicine flourished in the town before the time of Guimarus II, who reigned in the ninth century. In the ancient chronicle of Salerno, re-discovered by De Eenzi and published in his 6 ' Collectio Salernitana, ' • it is definitely recorded that the medical school was founded by four doctors, — a Jewish Eabbi Elinus, a Greek Pontus, a Saracen Adala, an Arab, and a native of Salerno, each of whom lectured in his native language. There are many elements in this tradition, however, that would seem to indicate its mythical origin and that it was probably invented after the event to account for the presence of teach- ers in all these languages and the coming of students from all over the world. The names, for instance, are apparently corruptions of real names, as can be readily recognized. Elinus, the Jew, is probably Elias or Eliseus, Adala is a corruption of Abdallah, and Pontus, as pointed out by Puschmann in his " History of Medical Education,' ' should probably be Gario-Pontus. While we do not know exactly when the medical school at Salerno was founded, we know that a hos- 144 OLD-TIME MAKERS OF MEDICINE pital was established there as early as 820. It was founded by the Archdeacon Adelmus, and was placed under the control of the Benedictines after it was realized that a religious order, by its organiza- tion, was best fitted for carrying on such charitable work continuously. Other infirmaries and charitable institutions, mainly under control of the religious, sprang up in Salerno. It was the presence of these hospitals in a salubrious climate that seems first to have attracted the attention of patients and then of physicians from all over Europe and even adjacent Africa and Asia. Puschmann says that it is uncer- tain whether clinical instruction was imparted in these institutions or not, but the whole tenor of what we know about the practical character of the teach- ing at Salerno and of the fine development of profes- sional medicine there, would seem to argue that probably those who came to study medicine here were brought directly in contact with patients. As early as the ninth century Salerno was famous for its great physicians. We know the names of at least two physicians, Joseph and Joshua, who prac- tised there about the middle of the ninth century. Eagenifrid, a Lombard by his name, was private physician to Prince Wyamar of Salerno in the year 900. The fact that he was from North Italy indi- cates that already foreigners were being attracted, but more than this that they were obtaining oppor- tunities unhampered by any Chauvinism. From early in the tenth century physicians from Salerno were frequently brought to foreign courts to become the attending physicians to rulers. Patients of the highest distinction from all over Europe began to THE MEDICAL SCHOOL AT SALEBNO 145 flock to Salerno, and we have the names of many of them. In the tenth century Bishop Adalberon, when ailing, went there, though he found no cure for his ills. Abbot Desiderius, however, the great Benedictine scholar of the time, who afterwards be- came Pope Victor III, regained his health at Sa- lerno under the care of the great Constantine Afri- canus, who was so much impressed by the gentle kindness and deep learning and the example of the saintly life of his patient that not long after he went to Monte Cassino to become a Benedictine under Desiderius, who was abbot there. Duke Guiscard sent his son Bohemund to Salerno for the cure of a wound received in battle, which had refused to heal under the ordinary surgical treatment of the time. William the Conqueror, early in the eleventh century and while still only the Duke of Normandy, is said to have passed some time at Salerno for a similar reason. The most interesting feature of the medical life at Salerno at this time is the relations between the clergy and the physicians. In the sketch of the life of Constantine Africanus, which follows this chap- ter, there is some account of the friendship between Abbot Desiderius of Monte Cassino and Constantine Africanus, and the latter 's withdrawal from his pro- fessorship to become a Benedictine. One of the phy- sicians of the early tenth century who stood high in favor with Prince Gisulf was raised to the Bishopric of -Salerno. This was Alphanus, whom we have al- ready mentioned as a chronicler, a monk, a poet, a physician, and finally the Bishop of Salerno. The best proof of how thorough was the medical 146 OLD-TIME MAKEES OF MEDICINE education at Salerno and how much influence it ex- erted even over public opinion is to be found in the regulation of the practice of medicine, which soon began, and the insistence upon proper training be- fore permission to practise medicine was granted. The medical school at Salerno early came to be a recognized institution in the kingdom of the Two Sicilies, representing a definite standard of medical training. It is easy to understand that the attrac- tion which Salerno possessed for patients soon also brought to the neighborhood a number of irregular physicians, travelling quacks, and charlatans. Wealthy patients were coming from all over the world to be treated at Salerno. Many of them doubt- less were sufferers from incurable diseases and noth- ing could be done for them. Often they would be quite unable to return to their homes and would be surely unwilling to give up all hope if anybody prom- ised them anything of relief. There was a rich field for the irregular, and of course, as always, he came. Salerno had already shown what a good standard of medical education should be, and it is not surprising, then, that the legal authorities in this part of the country proceeded to the enforcement of legal regu- lations demanding the attainment of this standard, in order that unfit and unworthy physicians might not practise medicine to their own benefit but to the detriment of the patients. Accordingly, as early as the year 1140, King Rug- giero (Roger) of the Two Sicilies promulgated the law : ' ' Whoever from this time forth desires to prac- tise medicine must present himself before our of- ficials and judges, and be subject to their decision. THE MEDICAL SCHOOL AT SALERNO 147 Anyone audacious enough to neglect this shall be punished by imprisonment and confiscation of goods. This decree has for its object the protection of the subjects of our kingdom from the dangers arising from the ignorance of practitioners." Just about a century later the Emperor Frederick II, the Hohenstaufen, in the year 1240, extended this law, emphasized it, and brought it particularly into connection with the great medical school of the Two Sicilies, of which territory he was the ruler. This law has often been proclaimed as due to his person- ality rather than to his times, — as representing his very modern spirit and his progressive way of look- ing at things. There is no doubt that certain per- sonal elements for which he should be given due credit are contained in the law. To understand it properly, however, one must know the law of King Eoger of the preceding century; and then it is easy to appreciate that Frederick's regulation is only such a development of the governmental attitude to- ward medical practice as might have been expected during the century since Roger's time. It has some- times been suggested that this law made by the Em- peror Frederick, who was so constantly in bitter opposition to the Papacy, was issued in despite of the Church authorities and represents a policy very dif- ferent from any which they would have encouraged. The early history of Salerno, even briefly as we have given it, completely contradicts any such idea. The history of medical regulation at the beginning of the next century down at Montpellier moreover, where the civil authorities being weak the legal or- dering of the practice of medicine was effectively 143 OLD-TIME MAKERS OF MEDICINE taken up by the Church, and the authority for the issuance of licenses to practise was in the hands of the bishops of the neighborhood, shows clearly that it is not because of any knowledge of the real medical history of the times that such remarks are made, but from a set purpose to discredit the Church. The Emperor Frederick's law deserves profound respect and consideration because of the place that it holds in the legal regulation of the practice of medicine. Anyone who thinks that evolution must have brought us in seven centuries much farther in this matter than were the people of the later Middle Ages should read this law attentively. Everyone who is interested in medical education should have a copy of it near him, because it will have a chasten- ing effect in demonstrating not only how little we have done in the modern time rather than how much, but above all how much of decadence there was dur- ing many periods of the interval. The law may be found in the original in " The Popes and Science ,? (Fordham University Press, N. Y., 1908). Three years of preliminary university education be- fore the study of medicine might be taken up, four years of medical studies proper before a degree was given, a year of practice with a regularly licensed physician before a license to practise could be ob- tained, a special course in anatomy if surgery were to be practised ; all this represents an ideal we are ^striving after at the present time in medical edu- cation. Besides this, Frederick's law also regulates medical fees, requires gratuitous attendance on the poor for the privilege of practice accorded by the license, though the general fees are of a thoroughly THE MEDICAL SCHOOL AT SALERNO 149 professional character and represent for each visit of the physician about the amount of daily wage that \ the ordinary laborer of that time earned. Curiously enough, this same ratio of emolument has maintained itself. This law was also a pure drug law, regulat- ing the practice of pharmacy, and the price as well as the purity of drugs, and the relations of phy- sicians, druggists, and the royal drug inspectors whose business it was to see that only proper drugs were prepared and sold. All this is so much more advanced than we could possibly have imagined, only that the actual docu- ments are in our possession, that most people refuse to let themselves be persuaded in spite of the law that it could have meant very much. Especially as regards medical education are they dubious as to conditions at this time. To them it seems that it can make very little difference how much time was required for medical study or for studies prelim- inary to medicine, since there was so little to be learned. The age was ignorant, men knew but little, and so very little could be imparted no matter how much time was taken. This is, I fear, a common impression, but an ut- terly false one. The preliminary training that is the undergraduate work at the universities consisted of the Seven Liberal Arts- — the trivium and quad- rivium, which embraced logic, rhetoric, grammar, metaphysics, under which was included not a little of physics, cosmology in which some biology was studied, as well as psychology and mathematics^ as- tronomy, and music. This was a thoroughly rounded course in intellectual training. No wonder 150 OLD-TIME MAKERS OF MEDICINE that Professor Huxley said in his Inaugural Ad- dress as Eector of Aberdeen, " I doubt if the cur- riculum of any modern university shows so clear and generous a comprehension of what is meant by cul- ture as this old trivium and quadrivium does." There is no doubt at all about the value of the under- graduate training, nor of the scholarship of the men who were turned out under the system, nor of their ability to concentrate their minds on difficult sub- jects — a faculty that we strive to cultivate in our time and do not always congratulate ourselves on securing to the degree, at least, that we would like. As to the medical teaching, -ZEgidius, often called Gilles of Corbeil, who was a graduate of Salerno and afterward became the physician-in-ordinary to Philip Augustus, King of France, thought that he could not say too much for the training in medicine that was given at this first of the medical schools. One thing is sure, the professors were eminently serious, the work taken up was in many ways thor- oughly scientific, and some of the results of the medical investigations of that early day are inter- esting even now. The descriptions of diseases that we have from the Salernitan school are true to na- ture and are replete with many original observa- tions. Puschmann says : * ' The accounts given of intermittent fever, pneumonia, phthisis, psoriasis, lupus, which they called the malum mortuum, of ulcers on the sexual organs, among which it is easy to recognize chancre, and of the disturbances of the mental faculties, especially deserve mention. ' ' They seem to have been quite expert in their knowledge of phthisis. In the treatment of it they laid great THE MEDICAL SCHOOL AT SALERNO 151 stress upon the giving up of a strenuous life, the living a rather easy existence in the open air, and a suitable diet. When the commencement of consump- tion was suspected, the first prescription was a good course of strengthening nourishment for the pa- tient. On the other hand, they declared that the cases in which diarrhea supervened during consump- tion soon proved fatal. In general, with regard to people who were liable to respiratory diseases, they insisted upon life in an atmosphere of equable tem- perature. Though the custom was almost unheard of in the Salerno of that time, and indeed at the present time there is very little heating during the winter in southern Italy, they insisted that patients who were liable to pulmonary affections should have their rooms heated. On the other hand, they suggested the cooling of the air of the sick-room, as we have noted in the chapter on Constantine Africanus, and Afflacius rec- ommended the employment of an apparatus from which water trickled continuously in drops to the ground and then evaporated. Baths and bleeding were employed according to definite indications and diet was always a special feature. They had a num- ber of drugs and simples, and the employment of some of them is interesting. Iron was prescribed for enlargement of the spleen. The internal use of sea sponge, in which of course there is a noteworthy proportion of iodine, was recommended for relief from the symptoms of goitre by reducing its size. Iodine has been used so much ever since in this af- fection, even down to our own day, that this employ- ment of one of its compounds is rather striking. 152 OLD-TIME MAKERS OF MEDICINE Massage of the goitre was also recommended, and this mode of treatment was commonly employed for a number of ailments. Probably the best idea that can be obtained in brief space of the achievements of the University of Salerno is to be found in Pagel's appreciation of Salerno's place in the history of medicine in his chapters on " Medicine in the Middle Ages " in Puschmann's " Handbuch der Geschichte der Me- dizin ' ' (Berlin, 1902) . He said : ' ' If we take up now the accomplishments of the school of Salerno in the different departments there is one thing that is very remarkable. It is the rich independent productivity with which Salerno advanced the banners of medical science for hundreds of years almost as the only au- tochthonous centre of medical influence in the whole West. One might almost say that it was like a versprengten Keim — a displaced embryonic ele- ment — which, as it unfolded, rescued from destruc- tion the ruined remains of Greek and Eoman medi- cine. This productivity of Salerno, which may well be compared in quality and quantity with that of the best periods of our science, and in which no de- partment of medicine was left without some ad- vance, is one of the striking phenomena of the history of medicine. While positive progress was not made, there are many noteworthy original observations to be chronicled. It must be acknowledged that pupils and scholars set themselves faithfully to their tasks to further as far as their strength allowed the sci- ence and art of healing. In the medical writers of the older period of Salerno who had not yet been disturbed by Arabian culture or scholasticism, we THE MEDICAL SCHOOL AT SALERNO 153 cannot but admire the clear, charmingly smooth, light-flowing diction, the delicate and honest setting forth of cases, the simplicity of their method of treatment, which was to a great extent dietetic and expectant, and while we admire the carefulness and yet the copiousness of their therapy, we cannot but envy them a certain austerity in their pharmaceutic formulas and an avoidance of medicamental poly- pragmasia. The work in internal medicine was espe- cially developed. The contributions to it from a theoretic and a literary standpoint, as well as from practical applications, found ardent devotees.' ' Less than this could scarcely have been expected from the medical school which brought such an up- lift of professional dignity and advance in the stand- ards of medical education that are to be noticed in connection with Salerno. Eegistration, licensure, preliminary education, adequate professional studies, clinical experience under expert guidance, even spe- cial training for surgical work, all came in connec- tion with this great medical school. Such practical progress in medical education could not have been made but by men who faced the problems of the prac- tice of medicine without self-deception and solved them as far as possible by common-sense, natural, and rational methods. It is usually said that at Salerno surgery occupied an inferior position. It is true that we have less record of it in the earlier years of Salerno than we would like to see. It was somewhat handicapped by the absence of human dissection. This very impor- tant defect was not due to any Church opposition to anatomy, as has often been said, but to the objection a 154 OLD-TIME MAKERS OF MEDICINE that people have to seeing the bodies of their friends or acquaintances used for anatomical purposes. In the comparatively small towns of the Middle Ages there were few strangers, and therefore very seldom were there unclaimed bodies. The difficulty was in the obtaining of dissecting material. We had the same difficulty in this country until about two gen- erations ago, and the only way that bodies could be obtained regularly was by " resurrecting " them, as it was called, from graveyards. In the ab- sence of human subjects, anatomy was taught at Salerno upon the pig. The principal portion of the teaching in anatomy consisted of the demonstration of the organs in the great cavities of the body and their relations, with some investigations of their form and the presumed functions of the correspond- ing organs in man. Copho 's well-known ' i Anatomy of the Pig ' ' was a text-book written for the students of Salerno. In spite of its limitations, it shows the beginnings of rather searching original inquiry and even some observations in pathological anatomy. It is simple and straightforward and does not profess to be other than it is, though it must be set down as the first reasonably complete contribution to com- parative anatomy. When their surgery came to be written down, however, it gave abundant evidence of the thorough- ness with which this department of medicine had been cultivated by the Salernitan faculty. We have the text-book of Eoger, with the commentary of Eo- lando, and then the so-called commentary of the Four Masters. These writings were probably made rather for the medical school at Bologna than that THE MEDICAL SCHOOL AT SALERNO 155 of Salerno, though there is no doubt that at least Eoger and Rolando received their education at Sa- lerno and embodied in their writings the surgical traditions of that school. While I have preferred, in order to have a connected story of surgical develop- ment, to treat of their contributions to their specialty under the head of the ' ' Great Surgeons of the Me- dieval Universities, ' ' it seems well to point out here that they must be considered as representing espe- cially the surgical teaching of the older medical school of Salerno. There are many interesting fea- tures of the old teaching that they have embodied in their books. For instance, at Salerno both sutures and ligatures were employed in order to prevent bleeding. We are rather accustomed to think of such uses of thread, and especially the ligature, as being much later inventions. The fact of the matter is, however, that ligatures and sutures were reinvented over and over again and then allowed to go out of use until someone who had no idea of their dangers came to reinvent them once more. 1 *It seems hard to understand how so useful an auxiliary to the surgeon as the ligature, — it seems indispensable to us, — could pos- sibly be allowed to go out of use and even be forgotten. It will not be difficult, however, for anyone who recalls the conditions that obtained in old-time surgery. The ligature is a most satisfying immediate resource in stopping bleeding from an artery, but a septic ligature inevitably causes suppuration and almost inevitably leads to secondary hemorrhage. In the old days of septic surgery sec- ondary hemorrhage was the surgeon's greatest and most dreaded bane. Some time from the fifth to the ninth day a septic ligature came away under conditions such that inflammatory disturbance had prevented sealing of the vessel. If the vessel was large, then the hemorrhage was fast and furious and the patient died in a few minutes. After a surgeon had had a few deaths of this kind he 156 OLD-TIME MAKERS OF MEDICINE Much is often said about the place of Arabian sur- gery and medicine at this time, and the influence that they had over the medical teaching and think- ing of the period. To trust many of the shorter histories of medicine the Arabs must be given credit for more of the medical thought of this time than any other medical writers or thinkers. It is forgotten, however, apparently, that in the southern part of Italy, where Salerno was situated, Greek influence never died out. This had been a Greek colony in the olden time and continued to be known for many centuries after the Christian era as Magna Graecia. Greek medicine, then, had more influence here than anywhere else. As a matter of fact, the beginnings of Salernitan teaching are all Greek and not at all Arabian. This is as true in surgery as in medicine. I have quoted Gurlt in the chapter on " Great Sur- geons of the Medieval Universities, " insisting that the Salernitan school owed nothing at all to Arabian surgery. Salernitan medicine was, during the twelfth century, just as free from Arabian influence. When Arabian medicine makes itself felt, as pointed out by Pagel in his " Geschichte der Heilkunde im Mittelalter, ' ' x far from exerting a beneficial influ- dreaded the ligature. He abandoned its use and took kindly to such methods as the actual cautery, red-hot knives for amputations, and the like, that would sear the surfaces of tissues and the blood- vessels, and not give rise to secondary hemorrhage. A little later, however, someone not familiar with secondary risks would reinvent the ligature. If he were cleanly in his methods and, above all, if he were doing his work in a new hospital, the ligature worked very well for a while. If not, it soon fell into innocuous desuetude again, ^uschmann: " Handbuch der Geschichte der Medizin," Vol. I, page 652. THE MEDICAL SCHOOL AT SALERNO 157 ence, it had a rather unfortunate effect. It led espe- cially to an oversophistication of medicine from the standpoint of drug therapeutics. The Arabian physicians trusted nature very little. In this they were like our forefathers of medicine one hundred years ago, of whom Rush was the typical representa- tive — so history repeats itself. Before the introduction of Arabian medicine the Salernitan school of medicine was noted for its common- sense methods and its devotion to all the natural modes of healing. It looked quite as much to the prevention of disease as its treatment. Diet and air and water were always looked upon as sig- nificant therapeutic aids. With the coming of Ara- bian influence there began, says Pagel, " as the lit- erature of the times shows very well, that rule of the apothecary in therapeutics which was an unfor- tunate exaggeration. Now all the above-mentioned complicated prescriptions came to be the order of the day. Apparently the more complicated a pre- scription the better. Dietetics especially was rele- gated to the background. Salerno, at the end of the twelfth century, had already reached its highest point of advance in medicine and was beginning to decline. Decadence was evident in so far as all the medical works that we have from that time are either borrowings or imitations from Arabian medicine with which eventually Salernitan medical literature became confounded. Only a few independent au- thors are found after this time." This is so very different from what is ordinarily presumed to have been the case and openly proclaimed by many his- torians of medicine because apparently they would 158 OLD-TIME MAKERS OF MEDICINE prefer to attribute scientific advance to the Arabs than to the Christian scholars of the time, that it is worth while noting it particularly. Salerno was particularly rich in its medical lit- erary products. Very often we have not the names of the writers. Apparently there is good reason to think that a number of the professors consulted to- gether in writing a book, and when it was issued it was considered to be a text-book of the Salernitan school of medicine rather than of any particular pro- fessor. This represents a development of co-opera- tion on the part of colleagues in medical teaching that we are likely to think of as reserved for much later times. The most important medical writing that comes to us from Salerno, in the sense at least of the work that has had most effect on succeeding generations, has been most frequently transcribed, most often trans- lated and committed to memory by many generations of physicians, is the celebrated Salernitan medical poem on hygiene. The title of the original Latin was " Eegimen Sanitatis Salernitanum. ' ' It was probably written about the beginning of the twelfth century. A century or so later it came to be the cus- tom to call medical books after flowers, and so we had the " Lilium Medicine " and the " Flos Medi- cines " down at Montpellier, and this became the " Flos Medicinae " of Salerno. Pagel calls it the quintessence of Salernitan therapeutics. For many centuries portions at least of this Latin medical poem were as common in the mouths of physicians all over Europe as the aphorisms of Hip- pocrates or the sayings of Galen. Probably this en- THE MEDICAL SCHOOL AT SALERNO 159 ables us to understand the great reputation that the Salernitan school enjoyed and the influence that it wielded better than anything else. The poem is di- vided into ten principal parts, containing altogether about 3,500 lines. The first part on hygiene has 855 lines in eight chapters. The second part on materia medica, though containing only four chapters, has also about 800 lines. Anatomy and physiology are crowded into about 200 lines, etiology has some- thing over 200, semiotics has about 250, pathology has but thirty lines more or less, and therapeutics about 400 ; nosology has about 600 more, and finally there is something about the physician himself, and an epilogue. As Latin verses go, when written for such purposes, these are not so bad, though some of them would grate on a literary ear. The whole work makes a rather interesting compendium of medicine, with therapeutic indications and contra- indications, and whatever the physician of the me- dieval period needed to have ready to memory. Some of its prescriptions, both in the sense of formulae and of directions to the patient, have quite a modern air. One very interesting contribution to medical lit- erature that comes to us from Salerno bears the title, " The Coming of a Physician to His Patient, or An Instruction for the Physician Himself.' ' We have had a number of such works published in recent years, but it is a little surprising to have the subject taken up thus early in the history of modern pro- fessional life. It is an extremely valuable document, as demonstrating how practical was the teaching at Salerno. The work is usually ascribed to Archi- 160 OLD-TIME MAKERS OF MEDICINE mattheas, and it certainly gives a vivid picture of the medical customs of the time. The instruction for the immediate coming of the physician to his patient runs as follows : ' ' When the doctor enters the dwell- ing of his patient, he should not appear haughty, nor covetous, but should greet with kindly, modest demeanor those who are present, and then seating himself near the sick man accept the drink which is offered him (sic) and praise in a few words the beauty of the neighborhood, the situation of the house, and the well-known generosity of the family, — if it should seem to him suitable to do so. The pa- tient should be put at his ease before the examination begins and the pulse should be felt deliberately and carefully. The fingers should be kept on the pulse at least until the hundredth beat in order to judge its kind and character; the friends standing round will be all the more impressed because of the delay and the physician's words will be received with just that much more attention.' ' The old physician evidently realized very well how much influence on the patient's mind meant for the course of the disease. For instance, he recommends that the patient should be asked to confess and re- ceive the sacraments of the Church before the doc- tor sees him, for if mention is afterwards made of this the patient may believe that it is because the doctor thinks that there is no hope for him. For the purpose of producing an effect upon the patient's mind, the old physician does not hesitate even to suggest the taking advantage of every possible source of information, so as to seem to know all about the case. " On the way to see the sick person he THE MEDICAL SCHOOL AT SALERNO 161 [the physician] should question the messenger who has summoned him upon the circumstances and the conditions of the illness of the patient; then, if not able to make any positive diagnosis after examining the pulse and the urine, he will at least excite the patient's astonishment by his accurate knowledge of the symptoms of the disease and thus win his confidence. ' ' At the end of these preliminary instructions there is a rather diplomatic — to say the least — bit of ad- vice that might perhaps to a puritanic conscience seem more politic than truthful. Since the old pro- fessor insists so much on not disturbing the pa- tient's mind by a bad prognosis or any hint of it, and since even some exaggeration of what he might think to be the serious outlook of the case to friends would only lead to greater care of the patient, there is probably much more justification for his sugges- tion than might be thought at first glance. He says, ' ' When the doctor quits the patient he should prom- ise him that he will get quite well again, but he should inform his friends that he is very ill ; in this way, if a cure is affected, the fame of the doctor will be so much the greater, but if the patient dies people will say that the doctor had foreseen the fatal issue." The story of the medical school of Salerno, even thus briefly and fragmentary told, illustrates very well how old is the new in education, — even in medi- cal education. There is scarcely a phase of modern interest in medical education that may not be traced very clearly at Salerno though the school began its career a thousand years ago, and ceased to attract 162 OLD-TIME MAKERS OF MEDICINE much attention over six hundred years ago. We owe most of our knowledge of the details of its organiza- tion and teaching to De Benzi. Without the devo- tion of so ardent a scholar it would have been almost impossible for us to have attained so complete a pic- ture of Salernitan activities. As it is, as a conse- quence of his work we are able to see this first of modern medical schools developing very much as do our most modern medical schools. There has been an accumulation of medical information in the thou- sand years, but the ways and modes of facing prob- lems and many of the solutions of them do not differ from what they were in the distant past. The more | we know about any particular period, the more is this i brought home to us. It is for this that study of par- [ ticular periods and institutions of the olden time, as of Salerno, grows increasingly interesting, because each new detail helps to fill in sympathetically the new-old picture of human activity as it may be seen at all times. VII CONSTANTINE AFBICANUS Probably the most important representative of the medical school at Salerno, certainly the most significant member of its faculty, if we consider the wide influence for centuries after his time that his writings had, was Constantine Africanus. He is in- teresting, too, for many other reasons, for he is the first representative, in modern times, that is, who, after the incentive of antiquity had passed, devoted himself to creating a medical literature by transla- tions, by editions, and by the collation of his own and others' observations on medical subjects. He is the connecting link between Arabian medicine and Western medical studies. The fact that he was first a traveller over most of the educational world of his time, then a professor at the University of Salerno who attracted many students, and finally a Bene- dictine monk in the great abbey at Monte Cassino, shows how his life ran the gamut of the various phases of interest in the intellectual world of his time. It was his retirement to the famous mon- astery that gave him the opportunity, the leisure, the reference library for consultation that a writer feels he must have near him, and probably also the means necessary for the publication of his works. Not only did the monks of Monte Cassino itself de- 163 164 OLD-TIME MAKERS OF MEDICINE vote themselves to the copying of his many books, but other Benedictine monasteries in various parts of the world made it a point to give wide diffusion to his writings. As a study in successful publication, that is, in the securing of wide attention to writings within a short time, the career of Constantine and the story of his books would be extremely interesting. Medieval distribution of books is usually thought to have been rather halting, but here was an exception. It was largely because Benedictines all over the world were deeply interested in what this brother Benedictine was writing that wide distribution was secured for his work within a very short time. His superiors among the Benedictines had a profound interest in what he was doing. The great Bene- dictine Abbot Desiderius of Monte Cassino, who afterwards became Pope, used all of his extensive influence in both positions to secure an audience for the books — hence the many manuscript copies of his writings that we have. It is probable that Con- stantine established a school of writers at Monte Cassino, for he could scarcely have accomplished so much by himself as has been attributed to him. Be- sides, his works attracted so much attention that writers of immediately succeeding generations who wanted to secure attention for their works some- times attributed them to him in order to take ad- vantage of his popularity. It is rather difficult, then, to determine with absolute assurance which are Constantine 's genuine works. Some of those attributed to him are undoubtedly spurious. What we know with certainty, however, is that his CONSTANTINE AFRICANUS 165 authentic works meant much for his own and after generations. Constantine was born in the early part of the elev- enth century, and died near its close, having lived probably well beyond eighty years of age, his years running nearly parallel with his century. His sur- name, Africanus, is derived from his having been born in Africa, his birthplace being Carthage. Early in life he seems to have taken up with ardor the study of medicine in his native town, devoting him- self, however, at the same time to whatever of phys- ical science was available. Like many another young man since his time, not satisfied with the knowledge he could secure at home, he made distant journeys, gathering medical and scientific informa- tion of all kinds wherever he went. According to a tradition that seems to be well grounded, some of these journeys took him even into the far East. During his travels he became familiar with a num- ber of Oriental languages, and especially studied the Arabian literature of science very diligently. At this time the Arabs, having the advantage of more intimate contact with the Greek medical tradi- tions in Asia Minor, were farther advanced in their knowledge of the medical sciences than the scholars in the West. They had better facilities for obtain- ing the books that were the classics of medicine, and, with any desire for knowledge, could scarcely fail to secure it. What was best in Arabian medicine was brought to Salerno by Constantine and, above all, his trans- lation of many well-known Arabian medical authors proved eminently suggestive to seriously investigat- 166 OLD-TIME MAKERS OF MEDICINE ing physicians all over the world in his time. Be- fore he was to be allowed to settle down to his literary work, however, Constantine was to have a very varied experience. Some of this doubtless was to be valuable in enabling him to set the old Arabian teachers of medicine properly before his generation. After his Oriental travels he returned to his native Carthage in order to practise medicine. It was not long, however, before his superior medical knowl- edge, or, at least, the many novelties of medical practice that he had derived from his contact with the East, drew upon him the professional jealousy of his colleagues. It is very probable that the repu- tation of his extensive travels and wide knowledge soon attracted a large clientele. This was followed quite naturally by the envy at least of his pro- fessional brethren. Feeling became so bitter, that even the possibility of serious personal conse- quences for him because of false accusations was not out of the question. Whenever novelties are introduced into medical science or medical practice, their authors are likely to meet with this opposition on the part of colleagues, and history is full of ex- amples of it. Galvani was laughed at and called the frogs' dancing-master; Auenbrugger was made fun of for drumming on people ; Harvey is said to have lost half of his consulting practice ; — all because they were advancing ideas that their contemporaries were not ready to accept. We are rather likely to think that this intolerant attitude of mind belongs to the older times, but it is rather easy to trace it in our own. In Constantine 's day men had ready to hand a CONSTANTINE AFRICANUS 167 very serious weapon that might be used against in- novators. By craftily circulated rumors the pop- ulace was brought to accuse him of magical prac- tices, that is, of producing his cures by association with the devil. We are rather prone to think little of a generation that could take such nonsense seri- ously, but it would not be hard to find analogous false notions prevalent at the present time, which sometimes make life difficult, if not dangerous, for well-meaning individuals. 1 Life seems to have been made very uncomfortable for Constantine in Carthage. Just the extent to which persecution went, however, we do not know. About this time Constantine's work attracted the attention of Duke Eobert of Salerno. He invited him to become his physician. After he had filled the position for a time a personal friendship developed, and, as has often happened to the physicians of kings, he became a royal counsellor and private secretary. When the post of professor of medicine at Salerno fell vacant, it is not surprising, then, that Constantine should have been made professor, and from here his teach- ing soon attracted the attention of all the men of his time. Constantine seems to have greatly enhanced the reputation of the medical school, and added to the medical prestige of Salerno. After teaching for some ten years there, however, he gave up his professor- ship — the highest position in the medical world of the time — apparently with certain plans in mind. J The first dentist who filled teeth with amalgam in New York, some eighty years ago, had to flee for his life, because of a hue and cry set up that he was poisoning his patients with mercury. 168 OLD-TIME MAKERS OF MEDICINE He wanted leisure for writing the many things in medicine that he had learned in his travels in the East, so as to pass his precious treasure of knowl- edge on to succeeding generations ; and then, too, he seems to have longed for that peace that would enable him not only to do his writing undisturbed, but to live his life quietly far away from the strife of men and the strenuous existence of a court and of a great school. There was probably another and more intimate personal reason for his retirement. Abbot Desi- derius of the Benedictine Abbey of Monte Cassino, not far away, had become a close and valued friend. Before having been made abbot, Desiderius and Constantine probably were fellow professors at Salerno, for we know that Desiderius himself and many of his fellow Benedictines taught in the under- graduate department there. Desiderius enjoyed the reputation of being one of the most learned men of the time when his election to the abbacy at Monte Cassino took him away from Salerno. His de- parture was a blow to Constantine, who had learned by years of friendship that to be near his intimate friend, the pious scholarly Benedictine, was a solace in life and a never failing incentive to his own in- tellectual work. Desiderius seems, indeed, to have been a large factor in influencing the great physi- cian to write his books rather than devote himself to oral teaching, since the circulation of his writing would confer so much more of benefit on a greater number of people. Perhaps another element in the situation was that Desiderius was desirous of hav- ing the learned physician, the travelled scholar, at CONSTANTINE AFBICANUS 169 Monte Cassino, for the sake of his influence on the scholarship of the abbey, and for the incentive that he would be to the younger monks to apply them- selves to the varied field of knowledge which the Benedictines had chosen for themselves at this time. Whatever hopes of mutual solace and helpfulness and of the joys of intimate close friendship may have been in the minds of these two most learned men of their time, they were destined to be grievously disappointed. Only a few years after Constantine 's entrance into the monastery at Monte Cassino Desi- derius was elected Pope. The humble Benedictine did not want to take the exalted position, but it was plainly shown to him that it was his duty, and that he must not shirk it. Accordingly, under the name of Pope Victor III, he became one of the great Popes of the eleventh century. One might think that he could have summoned Constantine to Eome, but perhaps he knew that his friend would prefer the quietude of the cloister, and then, too, probably he wanted to allow him the opportunity to accom- plish that writing for which Constantine and him- self had planned when the great physician entered the monastery. All that we know for sure is that some twenty years of Constantine 's life were spent as a monk in Monte Cassino, where he devoted his time mainly to the writing of his books. One bond of union there was. Each of the works, as soon as completed, was sent off to the Pope as long as he lived. On the other hand, though busy with his Papal duties, Pope Victor constantly stimulated Constantine, even from distant Rome, to go on with his work. There 170 OLD-TIME MAKERS OF MEDICINE were messages of brotherly interest and solicitude just as in the old days. The great African physi- cian^ best known work, the so-called " Liber Pan- tegni, ' ' which is really a translation of the ' ' Khitaab el Maleki " of Ali Ben el- Abbas, is dedicated to Desi- derius. Constantine wrote a number of other books, most of them original, but it is difficult now to de- cide just which of those that pass under his name are genuine. Many were subsequently attributed to him that are surely not his. These translators of the Middle Ages proved to be not only the channels through which informa- tion came to their generations, but they were also incentives to study and investigation. It is when men can get a certain amount of information rather easily that they are tempted to seek further in order to solve the problems that present themselves. There are three great translators whose work meant much for the Middle Ages at this time. They were, besides Constantine in the eleventh century, Gerard of Cremona, in the twelfth, and the Jewish Faradj Ben Salim, at Naples, in the thirteenth. Gerard did in Spain for the greater Arabian writers what Con- stantine had accomplished for those of lesser im- port. Under the patronage of the Emperor Fred- erick Barbarossa, he published translations of Ehazes, Isaac Judaeus, Serapion, Abulcasis, and Avi- cenna. His work was done in Toledo, the city in which, during the twelfth and thirteenth centuries, so many translators were at work making books for the Western world. Constantine did much more than merely bring out his translations of Arabian works. He gave a zest to CONSTANTINE AFRICANUS 171 the study of the old masters, issued editions of cer- tain, at least, of the works of Hippocrates (" Apho- risms ") and Galen (" Microtechnics "), and, in gen- eral, called attention to the precious treasure of med- ical lore that must be used to advantage if men were to teach the rising generation out of the accumulated knowledge of the past. Pagel, in Puschmann's 11 Handbook,' ' does not hesitate to say that " a farther merit of Constantine must be recognized, inasmuch as that not long after his career the sec- ond epoch of the school of Salerno begins, marked not only by a wealth of writers and writings on medicine, but, above all, because from this time on the study of Greek medicine received renewed en- couragement through the Latin versions of the Arabian literature. We may think as we will of the worth of these works, but this much is sure, that in many ways they brought about a broadening and an improvement of Greek knowledge, especially from the pharmacopeia standpoint. ' ' Probably the best evidence that we have for Con- stantine 's influence on his generation is to be found in what was accomplished by men who acknowledged with pride that he was their master, and who thought it a mark of distinction to be reckoned as his disciples. Among these especially noteworthy is Johannes Afflacius, or Saracenus (whose surname of the Sara- cen probably means that he, too, came from Africa, as his master did). He was the author of two treatises on " Fevers and Urines," and the so- called " Cures of Afflacius.' ' Some of these cures he directly attributed to Constantine. Then there is a 172 OLD-TIME MAKERS OF MEDICINE Bartholomew who wrote a ' ' Practica, "or" Manual of the Practice of Medicine/ ' with the sub-title, " Introductions to and Experiments in the Medical Practice of Hippocrates, Constantine, and the Greek Physicians." Bartholomew represents himself as a disciple of Constantine. This " Practica " of Bartholomew was one of the most commonly used books of the twelfth and thirteenth centuries throughout Europe. There are manuscript com- mentaries and translations, and abstracts from it not only in the Latin tongues, but especially in the Teutonic languages. Pagel refers to manuscripts in High and Low Dutch, and even in Danish. The Middle High Dutch manuscripts of this * ' Practica ' ' of Bartholomew come mainly from the thirteenth century, and have not only a special interest be- cause of their value in the history of philology, but because they are the main sources of all the later books on drugs which appeared in very large num- bers in German. They have a very great historico- literary interest, especially for pharmacology. To Afflacius we owe a description of a method of reducing fever that is not only ingenious, but, in the light of our recently introduced bathing methods for fever, is a little startling. In his book on " Fevers and Urines," Afflacius suggests that when the patient's fever makes him very restless, and especially if it is warm weather, a sort of shower bath should be given to him. He thought that rain water was the best for this purpose, and he de- scribes its best application as in rainy fashion, modo pluviali. The water should be allowed to flow down over the patient from a vessel with a number of CONSTANTINE AFEICANUS 173 minute perforations in the bottom. A number of the practical hints for treatment given by Afflacius have been attributed to Constantine. Constantine 's reputation has, in the opinion of some writers, been hurt by two features of his pub- lished works, as they have come to us, that we find it difficult to understand. One of these is that his translations from the Arabic were made mainly not of the books of the great leaders of Arabian medicine, but from certain of the less important writers. The other is that it does not seem always to have been made clear in the manuscripts that have come down to us, whether these writings were translations or original writings. Some have even gone so far as to suggest that Constantine himself would have been quite willing to receive the credit for these writings. As to the first of these objections, it may be said that very probably Constantine, in his travels, had come to realize that the books of the great Arabian physicians, Ehazes, Abulcasis, Avicenna, and others, already received so much attention that the best outlook for medicine was to call particular notice to the writings of such lesser lights as Ali Abbas, Isaac Judaeus, Abu Dschafer, and others of even less note. Certainly we cannot but feel that his judgment in the matter must have been directed by reasons that we may not be able to understand at present, but that must have existed, for all that we know of the man proves his character as a prac- tical, far-sighted scholar. Besides, it seems not un- likely that but for his interest in them we would not at the present time possess the translations of these 174 OLD-TIME MAKERS OF MEDICINE minor Arabian writers, and that would be an un- fortunate gap in medical history. The other misunderstanding with regard to Con- stantine refers to the fact that it is now almost im- possible to decide which are his own and which are the writings of others. It has been said that he even tried to palm off some of the writings of others as his own. This seems extremely unlikely, how- ever, knowing all that we do about his life ; and the suspicion is founded entirely on manuscripts as we have them at the present time, about a thousand years after he lived. "What mutilations these manu- scripts underwent in the course of various copyings is hard now to estimate. Monastic copyists might very well have left out Arabian names, because they were mainly interested in the fact that they were providing for their readers works that had received the approval of Constantine, and the translation of which at least had been made under his direction. It is quite clear that he did not do all the translat- ing himself, and that he probably must have organ- ized a school of medical translators at Monte Cas- sino. Then just how the various works would be looked at is very dubious. Undoubtedly many of the translations were done after his death, or certainly finished after his time, and at last attributed to him, because he was the moving spirit and had prob- ably selected the books that should be translated, and made suggestions with regard to them. For all of his monks he was, as masters have ever been for disciples, much more important, and rightly so, than those writers to whom he referred them. The whole question of plagiarism in these CONSTANTINE AFBICANUS 175 medieval times, as I have pointed out elsewhere, is entirely different from that of the present time. Now a writer may consciously or unconsciously claim another writing as his own. We have come to a time when men think much of their individual reputations. It was no uncommon thing, however, in the Middle Ages, and even later in the Benais- sance, for a writer to attribute what he had writ- ten to some distinguished literary man of the pre- ceding time, and sign that writer's name to his own work. The idea of the later author was to secure an audience for his thoughts. He seemed to be quite indifferent whether people ever knew just who the writer was, but he wanted to influence humanity by his writings. He thought much more of this than of any possible reputation that might come to him. Of course, there was no question of money. There never has been any question of money-making when- ever the things written have been really worth while. Literature that has deeply influenced mankind has never paid. Publications that have paid are insig- nificant works that have touched superficially a whole lot of people. To think of Constantine as a pla- giarist in our modern sense of the word, as trying to take the credit for someone else's writings, is to misunderstand entirely the times in which he lived, and to ignore the real problem of plagiarism at that time. With the accumulation of information with re- gard to the history of medicine in his time, Con- stantine 's reputation has been constantly enhanced. It is not so long since he was considered scarcely more than a monkish chronicler, who happened to 176 OLD-TIME MAKERS OF MEDICINE have taken medicine rather than history for his field of work. Gradually we have come to appre- ciate all that he did for the medicine of his time. Undoubtedly his extensive travels, his wide knowl- edge, and then his years of effort to make Oriental medicine available for the Western civilization that was springing up again among the peoples who had come to replace the Eomans, set him among the great intellectual forces of the Middle Ages. Salerno owed much to him, and it must not be for- gotten that Salerno was the first university of mod- ern times, and, above all, the first medical school that raised the dignity of the medical profession, established standards of medical education, edu- cated the public mind and the rulers of the time to the realization of the necessity for the regulation of the practice of medicine, and in many ways an- ticipated our modern professional life. That the better part of his life work should have been done as a Benedictine only serves to emphasize the place that the religious had in the preservation and the development of culture and of education during the Middle Ages. VIII MEDIEVAL WOMEN PHYSICIANS Very probably the most interesting chapter for us of the modern time in the history of the medical school at Salerno is to be found in the opportunities provided for the medical education of women and the surrender to them of a whole department in the medical school, that of Women's Diseases. While it is probable that Salerno did not owe its origin to the Benedictines, and it is even possible that there was some medical teaching there for all the cen- turies of the Middle Ages from the Greek times, for it must not be forgotten that this part of Italy was settled by Greeks, and was often called Magna Graecia, there is no doubt at all that the Bene- dictines exercised great influence in the counsels of the school, and that many of the teachers were Benedictines, as were also the Archbishops, who were its best patrons, and the great Pope Victor III, who did much for it. For several centuries the Benedictines represented the most potent influence at Salerno. For most people who are not intimately familiar with monastic life, and, above all, with the story of the Benedictines, their prestige at Salerno might seem to be enough of itself to preclude all possibility of the education of women in medicine at Salerno. For those who know the Benedictines well, however, 177 178 OLD-TIME MAKERS OF MEDICINE such a departure as the accordance of opportunities for women to study medicine would seem eminently in keeping with the practical wisdom of their rules and the development of their work. From the be- ginning the Benedictines recognized that a monastic career should be open to women as well as to men, and Benedict's sister, Scholastica, established con- vents for them, as her brother did the Benedictine monasteries, thus providing a vocation for women who did not feel called upon to marry. That the members of the order should recognize the advisabil- ity of affording women the opportunity to study medicine, and of handing over to them the depart- ment of women's diseases in a medical school in which they had a considerable amount of authority, seems, then, indeed, only what might have been ex- pected of them. We are prone in the modern time to think that our generation is the first to offer to women any facilities or opportunities for education in medicine. We are prone, however, just in the same way, to consider that a number of things that we are doing are now being done for the first time. As a matter of fact, it is extremely difficult to find any im- portant movement or occupation that is not merely a repetition of a previous interest of mankind. The whole question of feminine education we are apt to think of as modern, forgetting that Plato insisted in his " Bepublic," as absolutely as any modern fem- inist, that women should have the same opportuni- ties for education as men, and that at Borne, at the end of the Bepublic and the beginning of the Em- pire, the women occupied very much the same posi- MEDIEVAL WOMEN PHYSICIANS 179 tion in social life as our own at the present time. Their husbands supplied the funds, and they patronized the artists, gave receptions to the poets, lionized the musicians, and, in general, ' ' went after culture " in a way that is a startling reminder of what we are familiar with in our own time. Just as soon as Christianity began to influence education, women were given abundant opportunities for higher education in all forms. In Ireland, the first nation completely converted to Christianity, — where, therefore, the national policy in education could be shaped by the Church without hindrance, — St. B rigid 's school at Kildare was scarcely less famous than St. Patrick's at Armagh. It had sev- eral thousand students, and, to a certain extent at least, co-education existed. In Charlemagne's time, with the revival of education on the Continent, the women of the Imperial Court attended the Palace School, as well as the men. In the thirteenth cen- tury we find women professors in every branch at Italian universities. Some of them were at least assistants in anatomy. The Eenaissance women were, of course, profoundly educated. In a word, we have many phases of feminine education, though with intervals of absolutely negative interest, down the centuries. There had evidently been quite a considerable amount of opportunity, if not of actual encourage- ment, for women in medicine, both among the Greeks and the Romans, in the early centuries of the Chris- tian era. Galen, for instance, quotes certain pre- scriptions from women physicians. One Cleopatra is said to have written a book on cosmetics. This 180 OLD-TIME MAKERS OF MEDICINE name came afterwards to be confounded with that of Queen Cleopatra, giving new prestige to the book, but neither Galen nor Aetius, the early Christian physician, both of whom quote from her work, speak of her as anything except a medical writer. Some monuments to women physicians from these old times have escaped the tooth of time. There was the tomb of one Basila, and also of a Thecla, both of whom are said to have been physicians. Two other names of Greek women physicians we have, Origenia and Aspasia, the former mentioned by Galen, the latter by Aetius in his " Tetrabiblion. " Darem- berg, the medical historian, announced in 1851 that he had found a Greek manuscript with the title, 6 ' On Women's Diseases," written by one Metrodora, a woman physician. He promised to publish it. It was unpublished at the time of his death, but could not be found among his papers. There is a manu- script on medical subjects, bearing this name, men- tioned in the catalogue of the Greek Codices of the Laurentian Library at Florence, but this is said to give no indication of the time when its author lived. We have evidence enough, however, to show that Greek women physicians were not very rare. The Eomans imitated the Greeks so faithfully — one might almost say copied them so closely — that it is not surprising to find a number of Roman women physicians. The first mention of them comes from Scribonius Largus, in the first century after Christ. Octavius Horatianus, whom most of us know better as Priscian, dedicated one of his books on medicine to a woman physician named Victoria. The dedica- tion leaves no doubt that she was a woman in active MEDIEVAL WOMEN PHYSICIANS 181 practice, at least in women's diseases, and it is a book on this subject that Priscian dedicates to her. He mentions another woman physician, Leoparda. The word medica for a woman physician was very commonly used at Rome. Martial, whose epigrams have been a source of so much information in med- ical history, especially on subjects with regard to which information was scanty, mentions a medica in an epigram. Apuleius also uses the word. There are a number of inscriptions in which women physi- cians are mentioned. Among the Christians we find women physicians, and Theodosia, the mother of St. Procopius, the martyr, is said to have been very successful in the practice of both medicine and surgery. She is numbered among the martyrs, and occurs in the Roman Martyrology on the 29th of May. Father Bzowski, the Polish Jesuit, who com- piled " Nomenclatura Sanctorum Professione Medi- corum " (Rome, 1621; the book is usually catalogued under the Latin form of his name, Bzovius), has among his list of saints who were physicians by profession a woman, St. Nicerata, who lived at Con- stantinople in the reign of the Emperor Arcadius, and who is said to have cured St. John Chrysostom of a serious disease. The organization of the department of women's diseases at Salerno, under the care of women pro- fessors, and the granting of licenses to women to practise medicine, is not so surprising in the light of this tradition among Greeks and Romans, taken up with some enthusiasm by the Christians. "We are not sure just when this development took place. The first definite evidence with regard to it comes 182 OLD-TIME MAKERS OF MEDICINE in the life of Trotula, who seems to have been the head of the department. Some of her books are well known, and often qnoted from, and she con- tributed to a symposium on the treatment of disease, in which there are contributions, also, from men professors of Salerno at the time. She seems to have flourished about the middle of the eleventh century. Ordericus Vitalis, a monk of Utica, who wrote an ecclesiastical history, tells of one Eudolph Malcorona, who, in 1059, came to Utica and re- mained there for a long time with Father Eobert, his nephew. " This Eudolph had been a student all his life, devoting himself with great zeal to letters, and had become famous for his visits to the schools of France and Italy, in order to gather there the secrets of learning. As a consequence he was well informed not only in grammar and dialectics, but also in astronomy and in music. He also pos- sessed such an extensive knowledge of the natural sciences that in the town of Salerno, where, since ancient times, the best schools of medicine had ex- isted, there was no one to equal him with the ex- ception of a very wise matron.' ' This wise matron has been identified with Tro- tula, many of the details of whose life have been brought to light by De Eenzi, in his " Story of the School of Salerno. ' ' * According to very old tradi- tion, Trotula belonged to the family of Euggiero. This was a noble family of Salerno, many of the members of which were distinguished in their native town at least, but the name is not unusual in Italy, 1 " Storia de la Scuola di Salerno." MEDIEVAL WOMEN PHYSICIANS 183 as readers of Dante and Boccaccio are likely to know. It was, indeed, as common as our own Eogers, of which it is the Italian equivalent. De Eenzi has made out a rather good case for the tradition that Trotula was the wife of John Platearius I — so called because there were probably three professors of that name. Trotula was, ac- cording to this, the mother of the second Platearius, and the grandmother of the third, all of them dis- tinguished members of the faculty at Salerno. Her reputation extended far beyond her native town, and even Italy itself, and, in later centuries, her name was used to dignify any form of treat- ment for women's diseases that was being exploited. Eutebeuf, one of the trouveres, thirteenth-century French poets, has a description of the scene in which one of the old herbalist doctors who used to go round and collect a crowd by means of songs and music, and then talk medicine to them — just as is done even yet in many of the smaller towns of this country — is represented as saying to the crowd when he wants to make them realize that he is no ordinary quacksalver, that he is one of the disciples of the great Madame Trot of Salerno. The old- fashioned speech runs somewhat as follows: " Charming people: I am not one of these poor preachers, nor the poor herbalists, who carry little boxes and sachets, and who spread out before them a carpet. I am the disciple of a great lady, who bears the name of Madame Trot of Salerno. And I would have you know that she is the wisest woman in all the four quarters of the world." Two books are attributed to Trotula; one bears 184 OLD-TIME MAKERS OF MEDICINE the title, " De Passionibus Mulierum," and the other has been called " Trotula Minor," or " Summula Secundum Trotulam, ' ' and is a compendium of what she wrote. This is probably due to some disciple, but seems to have existed almost in her own time. Her most important work bears two sub-titles, " Trotula 's Unique Book for the Curing of Diseases of Women, Before, During, and After Labor,' ' and the other sub-title, " Trotula 's Wonderful Book of Experience {experiment alls) in the Diseases of Women, Before, During, and After Labor, with Other Details Likewise Relating to Labor." The book begins with a prologue on the nature of man and of woman, and an explanation of how the author, taking pity on the sufferings of women, came to devote herself to the study of their diseases. There are many interesting details in the book, all the more interesting because in many ways they an- ticipate modern solutions of difficult problems in women's diseases, and the care of the mother and child before, during, and after labor. For instance, there are a series of rules on the choice of the nurse, and on the diet and the regime which she should follow if the child is to be properly nourished with- out disturbance. Probably the most striking passage in her book is that with regard to a torn perineum and its re- pair. This passage may be found in De Renzi or in Gurlt. It runs as follows : ' ' Certain patients, from the severity of the labor, run into a rupture of the genitalia. In some even the vulva and anus be- come one foramen, having the same course. As a consequence, prolapse of the uterus occurs, and MEDIEVAL WOMEN PHYSICIANS 185 it becomes indurated. In order to relieve this con- dition, we apply to the uterus warm wine in which butter has been boiled, and these fomentations are continued until the uterus becomes soft, and then it is gently replaced. After this the tear between the anus and vulva we sew in three or four places with silk thread. The woman should then be placed in bed, with the feet elevated, and must retain that position, even for eating and drinking, and all the necessities of life, for eight or nine days. During this time, also, there must be no bathing, and care must be taken to avoid everything that might cause coughing, and all indigestible materials.' ' There is a passage, also, almost more interesting with regard to prophylaxis of rupture of the perineum. She says, " In order to avoid the afore- said danger, careful provision should be made, and precautions should be taken during labor somewhat as follows: A cloth should be folded in somewhat oblong shape, and placed on the anus, so that, during every effort for the expulsion of the child, that should be pressed firmly, in order that there may not be any solution of the continuity of tissue." Her book contains, also, some directions for vari- ous cosmetics. How many of these are original, however, is difficult to say. Tro tula's name had be- come a word to conjure with, and many a quack in the after time tried to make capital for his remedies in this line by attributing them to Trotula. As a consequence, many of these remedies gradually found their way into the manuscript copies of her book, and subsequent copyists incorporated them into the text, until it became practically impossible 186 OLD-TIME MAKERS OF MEDICINE to determine which were original. There are manu- scripts of Trotula's work in Florence, Vienna, and Breslau. Some of these contain chapters not in the others, undoubtedly added by subsequent hands. In one of these, that at Florence, from which the edi- tion of Strasburg was printed in 1544, and of Venice, 1547, one of the Aldine issues, there is a mention in the last chapter of spectacles. We have no record of these until the end of the thirteenth century, when this passage was probably added. It was also printed at Basle, 1566, and at Leipzig as late as 1778, which would serve to show how much atten- tion it has attracted even in comparatively recent times. After Trotula we have a number of women physi- cians of Salerno whose names have come down to us. The best known of these bear the names Constanza, Calendula, Abella, Mercuriade, Rebecca Guarna, who belonged to the old Salernitan family of that name, a member of which, in the twelfth century, was Romuald, priest, physician, and historian, Louise Trencapilli, and others. The titles of some of their books, as those of Mercuriade, who occupied her- self with surgery as well as medicine, and who is said to have written on " Crises,' ' on " Pestilent Fever, ' ' on " The Cure of Wounds, ' ' and of Abella, who acquired a great reputation with her work on " Black Bile," and on the " Nature of Seminal Fluid," have come down to us. Rebecca Guarna wrote on " Fevers,' ' on the " Urine," and on the " Embryo." The school of Salernitan women came to have a definite place in medical literature. While, as teachers, they had charge of the depart- MEDIEVAL WOMEN PHYSICIANS 187 ment of women's diseases, their writings wonld seem to indicate that they studied all branches of medi- cine. Besides, there are a number of licenses pre- served in the archives of Naples in which women are accorded the privilege of practising medicine. Apparently these licenses were without limitation. In many of these mention is made of the fact that it seems especially fitting that women should be al- lowed to practise in women's diseases, since they are by constitution likely to know more and to have more sympathy with feminine ills. The formula employed as the preamble of this license ran as follows : ' ' Since, then, the law permits women to exercise the profession of physicians, and since, besides, due regard being had to purity of morals, women are better suited for the treatment of women's diseases, after having received the oath of fidelity, we permit, etc." Salerno continued to enjoy a reputation for train- ing women physicians thoroughly, until well on in the fifteenth century, for we have the record of Con- stance Calenda, the daughter of Salvator Calenda, who had been dean of the faculty ojL medicine, at Salerno about 1415, and afterwards dean of the faculty at Naples. His daughter, under the diligent instruction of her father, seems to have obtained special honors for her medical examination. Not long after this, Salerno itself lost all the prestige that it had. The Kings of Naples endeavored to create a great university in their city in the thir- teenth century. They did not succeed to the extent that they hoped, but the neighboring rival institution hurt Salerno very much, and its downfall may be 188 OLD-TIME MAKERS OF MEDICINE traced from this time. Gradually its reputation waned, and we have practically no medical writer of distinction there at the end of the fourteenth cen- tury, though the old custom of opportunities for women students of medicine was maintained. This custom seems also to have been transferred to Naples, and licenses to practise were issued to woman graduates of Naples. This never achieved anything like the reputation in this department that had been attained at Salerno. Salerno influenced Bologna and the north Italian universities pro- foundly in all branches of medicine and medical edu- cation, particularly in surgery, as can be seen in the chapter on " Great Surgeons of the Medieval Universities, ' ' and the practice of allowing such women as wished to study medicine to enter the university medical schools is exemplified in the case of Mondino's assistant in anatomy, Alessandra Giliani, though there are also others whose names have come down to us. The University of Salerno had developed round a medical school. It was the first of the uni- versities, and, in connection with its medical school, feminine education obtained a strong foothold. It is not surprising, then, that with the further de- velopment of universities in Italy, feminine educa- tion came to be the rule. This rule has maintained itself all down the centuries in Italy, so that there has not been a single century since the twelfth in which there have not been one or more distinguished women teachers at the Italian universities. Uni- versity life gradually spread westward, and Paris came into existence as an organized institution of MEDIEVAL WOMEN PHYSICIANS 189 learning after Bologna, and, doubtless, with some of the traditions of Salerno in the minds of its founders. Feminine education, however, did not spread to the West. This is a little bit difficult to understand, considering the reverence that the Teu- tonic peoples have always had for their women folk and the privileges accorded them. A single un- fortunate incident, that of Abelard and Heloise, seems to have been sufficient to discourage efforts in the direction of opportunities for feminine edu- cation in connection with the Western universities. Perhaps, in the less sophisticated countries of the North and West of Europe, women did not so ardently desire educational opportunities as in Italy, for whenever they have really wanted them, as, indeed, anything else, they have always obtained them. In spite of the absence of formal opportunities for feminine education in medicine at the Western universities, a certain amount of scientific knowl- edge of diseases, as well as valuable practical train- ing in the care of the ailing, was not wanting for women outside of Italy. The medical knowledge of the women of northern France and Germany and England, however, though it did not receive the stamp of a formal degree from the university and the distinction of a license to practise, was none the less thorough and extensive. It came in connection with certain offices in their own communities, held by members of religious orders. Genuine informa- tion with regard to what the religious were doing during the Middle Ages was so much obscured by the tradition of laziness and immorality, created at 190 OLD-TIME MAKERS OF MEDICINE the time of the so-called reformation in order to justify the confiscation of their property by those whose one object was to enrich themselves, that we have only come to know the reality of their life and accomplishments in comparatively recent years. We now know that, besides being the home of most of the book knowledge of the earlier Middle Ages, the monasteries were the constant patrons of such practical subjects as architecture, agriculture in all its phases, especially irrigation, draining, and the improvement of land and crops; of art, and even what we now know as physical science. Above all, they preserved for us the old medical books and carried on medical traditions of practice. The greatest surprise has been to find that this was true not only for the monks, but also for the nuns. One of the most important books on medicine that has come to us from the twelfth century is that of a Benedictine abbess, since known as St. Hildegarde, whose life was spent in the Ehineland. Her works serve to show very well that in the convents of the tenth, eleventh, and twelfth centuries there was much more of interest in things intellectual than we have had any idea of until recent years, and that, indeed, one of the important occupations of convent life was the serious study of books of all kinds, some of them even scientific, as well as the writing of works in all departments. The century before St. Hildegarde there is the record of Hroswitha, who wrote a series of dramas in imitation of Terence, that were meant to replace, for the monks and nuns of that period, the reading of that rather too human MEDIEVAL WOMEN PHYSICIANS 191 author. Hroswitha, like Hildegarde, was a German, and we have the record, also, of another religions writer, abbess of the Odilian Cloister, at Hohenberg, who wrote a book called " Hortns Deliciarnm, the Garden of Delights/ ' a book of information on many subjects not unlike our popular encyclopedias of the modern time, the title of which shows that the place of information in life was considered to be the giving of pleasure. While this work deals mainly with Biblical and theological and mystical questions, there are many purely scientific passages and many subjects of strictly medical interest treated. The life of the Abbess Hildegarde is worthy of consideration, because it illustrates the period and makes it very clear that, in spite of the grievous misunderstanding of their life and work, so com- mon in the modern time, these old-time religious had most of the interests of the modern time, and pursued them with even more than modern zeal and success, very often. Her career illustrates very well what the foundation of the Benedictines had done for women. When St. Benedict founded his order for men, his sister, Scholastica, wanted to do a similar work for women. We know that the Benedictine monks saved the old classics for us, kept burning the light of the intellectual life, and gave a refuge to men who wanted to devote themselves in leisure and peace to the things of the spirit, whether of this world or the other. We have known much less of the Benedictine nuns un- til now the study of their books shows that they provided exactly the same opportunities for women 192 OLD-TIME MAKERS OF MEDICINE and furnished a vocation, a home, an occupation of mind, and a satisfaction of spirit for the women who, in every generation, do not feel themselves called to be wives and mothers, but who want to live their lives for others rather than for them- selves and their kin, seeking such development of mind and of spirit as may come with the leisure and peace of celibacy. Hildegarde was born of noble parents at Bockel- heim, in the county of Sponheim, about the end of the eleventh century (probably 1098). In her eighth year she went for her education to the Benedictine cloister of Disibodenberg. When her education was finished, she entered the cloister, of which, at the age of about fifty, she became abbess. Her writings, reputation for sanctity, and her wise saintly rule attracted so many new members to the community that the convent became overcrowded. Accord- ingly, with eighteen of her nuns, Hildegarde with- drew to a new convent at Eupertsberg, which Eng- lish and American travellers will remember because it is not far from Bingen on the Ehine. Here she came to be a centre of attraction for most of the world of her time. She was in active correspond- ence with nearly every important man of her gen- eration. She was an intimate friend of Bernard of Clairvaux, who was himself, perhaps, the most in- fluential man in Europe in this century. She was in correspondence with four Popes, and with the Em- perors Conrad and Frederick I, and with many dis- tinguished archbishops, abbots, and abbesses, and teachers and teaching bodies of various kinds. These correspondences were usually begun by her corre- MEDIEVAL WOMEN PHYSICIANS 193 spondents, who consulted her because her advice in difficult problems was considered so valu- able. In spite of all this time-taking correspondence, she found leisure to write a series of books, most of them on mystical subjects, but two of them on medical subjects. The first is called " Liber Sim- plicis Medicinas," and the second " Liber Composite Medicinal" These books were written in order to provide information mainly for the nuns who had charge of the infirmaries of the monasteries of the Benedictines. Almost constantly someone in the large communities, which always contained aged re- ligious, was ailing, and then, besides, there were other calls on the time and the skill of the sister infirmarians. There were no hotels at that time, and no hospitals, except in the large cities. There were always guest houses in connection with monasteries and convents, in which travellers were permitted to pass the night, and given what they needed to eat. There are many people who have had experiences of monastic hospitality even in our own time. Sometimes travellers fell ill. Not in- frequently the reason for travelling was to find health in some distant and fabulously health-giving resort, or at the hands of some wonder-working physician. Such high hopes are nearly always set at a distance. This of itself must have given not a little additional need for knowledge of medicine to the infirmarians of convents and monasteries. There were around many of the monasteries, more- over, large estates ; often they had been cleared and made valuable by the work of preceding genera- 194 OLD-TIME MAKERS OF MEDICINE tions of monks, and on these estates peasants came to live. Workingmen and workingwomen from neighboring districts came to help at harvest time, and, after a chance meeting, were married and settled down on a little plot of ground provided for them near the monastery. As these communi- ties grew up, they looked to the monasteries and convents for aid of all kinds, and turned to them particularly in times of illness. The need for definite instruction in medicine on the part of a great many of the monks and nuns can be readily understood, and it was this need that Hildegarde tried to meet in her books. The first of her books that we have mentioned, the " Liber Simplicis Medicinae," attracted attention rather early in the Eenaissance, and was deemed worthy of print. It was edited at the beginning of the sixteenth century by Dr. Schott at Strasburg, under the title, " Physica S. Hildegardis. ' ' Another manuscript of this part was found in the library of Wolfenbut- tel, in 1858, by Dr. Jessen. This gave him an in- terest in Hildegarde 's contributions to medicine, and, in 1859, he noted in the library at Copenhagen a manuscript with the title " Hildegardi Curae et Causae." On examination, he was sure that it was the " Liber Composite Medicinae " of the saint. The first work consists of nine books, treating of plants, elements, trees, stones, fishes, birds, quadrupeds, reptiles, and metals, and is printed in Migne's " Patrologia," under the title " Subtilita- tum Diversarum Naturarum Libri Novem." The second, in five books, treats of the general diseases of created things, of the human body and its ail- MEDIEVAL WOMEN PHYSICIANS 195 ments, of the causes, symptoms, and treatment of diseases. It would be very easy to think that these are small volumes and that they contain very little. We are so apt to think of old-fashioned so-called books as scarcely more than chapters, that it may be interest- ing to give some idea of the contents and extent of the first of these works. The first book on Plants has 230 chapters, the second on the Elements has 13 chapters, the third on Trees has 36 chapters, the fourth on various kinds of Minerals, including pre- cious stones, has 228 chapters, the fifth on Fishes has 36 chapters, the sixth on Birds has 68 chapters, the seventh on Quadrupeds has 43 chapters, the eighth on Reptiles has 18 chapters, the ninth on Metals has 8 chapters. Each chapter begins with a description of the species in question, and then defines its value for man and its therapeutic sig- nificance. Modern scientists have not hesitated to declare that the descriptions abound in observa- tions worthy of a scientific inquiring spirit. We are, of course, not absolutely sure that all the con- tents of the books come from Hildegarde. Subse- quent students often made notes in these manuscript books, and then other copyists copied these into the texts. Unfortunately we have not a number of codices to collate and correct such errors. Most of what Hildegarde wrote comes to us in a single copy, of none are there more than four copies, show- ing how near we came to missing all knowledge of her entirely. Dr. Melanie Lipinska, in her " Histoire des Femmes Medeaus," a thesis presented for the doc- 196 OLD-TIME MAKERS OF MEDICINE torate in medicine at the University of Paris in 1900, subsequently awarded a special prize by the French Academy, reviews Hildegarde's work critically from the medical standpoint. She says that the saint distinguishes a double mode of action of different substances, one chemical, the other phys- ical, or what we would very probably call magnetic. She discusses all the ailments of the various organs, the brain, the eyes, the teeth, the heart, the spleen, the stomach, the liver. She has special chapters on redness and paleness of the face, on asthma, on cough, on fetid breath, on bilious indigestion, on gout. Besides, she has other chapters on nervous affections, on icterus, on fevers, on intestinal worms, on infections due to swamp exhalations, on dysen- tery, and a number of forms of pulmonary diseases. Nearly all of our methods of diagnosis are to be found, hinted at at least, in her book. She dis- cusses the redness of the blood as a sign of health, the characteristics of various excrementitious mate- rial as signs of disease, the degrees of fever, and the changes in the pulse. Of course, it was changes in the humors of the body that constituted the main causes for disease in her opinion, but it is well to remind ourselves that our frequent dis- cussion of auto-intoxication in recent years is a dis- tinct return to this. Some of Hildegarde's anticipations of modern ideas are, indeed, surprising enough. For instance, in talking about the stars and describing their course through the firmament, she makes use of a comparison that is rather startling. She says: " Just as the blood moves in the veins which causes MEDIEVAL WOMEN PHYSICIANS 197 them to vibrate and pulsate, so the stars move in the firmament and send out sparks as it were of light like the vibrations of the veins.' ' This is, of course, not an anticipation of the discovery of the circulation of the blood, but it shows how close were men's ideas to some such thought five centuries be- fore Harvey's discovery. For Hildegarde the brain was the regulator of all the vital qualities, the centre of life. She connects the nerves in their passage from the brain and the spinal cord through the body with manifestations of life. She has a series of chapters with regard to psychology normal and morbid. She talks about frenzy, insanity, despair, dread, obsession, anger, idiocy, and innocency. She says very strongly in one place that " when headache and migraine and vertigo attack a patient simultaneously they render a man foolish and up- set his reason. This makes many people think that he is possessed of a demon, but that is not true." These are the exact words of the saint as quoted in Mile. Lipinska's thesis. It is no wonder that Mile. Lipinska thinks St. Hildegarde the most important medical writer of her time. Eeuss, the editor of the edition of Hilde- garde published in Migne's " Patrology," says: " Among all the saintly religious who have prac- tised medicine or written about it in the Middle Ages, the most important is without any doubt St. Hildegarde. . . . " With regard to her book he says : ' ' All those who wish to write the history of the medical and natural sciences must read this work in which this religious woman, evidently well grounded in all that was known at that time in the 198 OLD-TIME MAKERS OF MEDICINE secrets of nature, discusses and examines carefully all the knowledge of the time." He adds, " It is certain that St. Hildegarde knew many things that were unknown to the physicians of her time. ' ' When such books were read and widely copied, it shows that there was an interest in practical and scientific medicine among women in Germany much greater than is usually thought to have existed at this time. Such writers, though geniuses, and standing above their contemporaries, usually repre- sent the spirit of their times and make it clear that definite knowledge of things medical was consid- ered of value. The convents and monasteries of this time are often thought of by those who know least about them as little interested in anything except their own ease and certain superstitious prac- tices. As a matter of fact, they cared for their estates, and especially for the peasantry on them, they provided lodging and food for travellers, they took care of the ailing of their neighborhood, and, besides, occupied themselves with many phases of the intellectual life. It was a well-known tradition that country people who lived in the neighborhood of convents and monasteries, and especially those who had monks and nuns for their landlords, were much happier and were much better taken care of than the tenantry of other estates. For this a cultiva- tion of medical knowledge was necessary in certain, at least, of the members of the religious orders, and such books as Hildegarde's are the evidence that not only the knowledge existed, but that it was col- lected and written down, and widely disseminated. Nicaise, in the introduction to his edition of MEDIEVAL WOMEN PHYSICIANS 199 Guy de Chauliac's " Grande Chirurgie," reviews briefly the history of women in medicine, and con- cludes : " Women continued to practise medicine in Italy for centuries, and the names of some who attained great renown have been preserved for us. Their works are still quoted from in the fifteenth century. " There was none of them in France who became distinguished, but women could practise medicine in certain towns at least on condition of passing an examination before regularly appointed masters. An edict of 1311, at the same time that it interdicts unauthorized women from practising surgery, recog- nizes their right to practise the art if they have undergone an examination before the regularly ap- pointed master surgeons of the corporation of Paris. An edict of King John, April, 1352, contains the same expressions as the previous edict. Du Bouley, in his ' History of the University of Paris, ' gives another edict by the same King, also published in the year 1352, as a result of the complaints of the faculties at Paris, in which there is also question of women physicians. This responded to the peti- tion : ' Having heard the petition of the Dean and the Masters of the Faculty of Medicine at the Uni- versity of Paris, who declare that there are very many of both sexes, some of the women with legal title to practise and some of them merely old pre- tenders to a knowledge of medicine, who come to Paris in order to practise, be it enacted/ etc. (The edict then proceeds to repeat the terms of previous legislation in this matter.) " Guy de Chauliac speaks also of women who practised surgery. They formed the fifth and last class of operators in his time. He complains that they are accustomed to too great an extent to give over patients suffering from all kinds of maladies 200 OLD-TIME MAKERS OF MEDICINE to the will of Heaven, founding their practice on the maxim ' The Lord has given as he has pleased; the Lord will take away when he pleases; may the name of the Lord be blessed.' " In the sixteenth century, according to Pasquier, the practice of medicine by women almost entirely disappeared. The number of women physicians be- comes more and more rare in the following centuries just in proportion as we approach our own time. Pasquier says that we find a certain number of them anxious for knowledge and with a special penchant for the study of the natural sciences and even of medicine, but very few of them take up practice. ' ' Just how the lack of interest in medical education for women gradually deepened, until there was al- most a negative phase of it, only a few women in Italy devoting themselves to medicine, is hard to say. It is one of the mysteries of the vicissitudes of human affairs that ups and downs of interest in things practical as well as intellectual keep con- stantly occurring. The number of discoveries and inventions in medicine and surgery that we have neglected until they were forgotten, and then had to make again, is so well illustrated in chapters of this book, that I need only recall them here in gen- eral. It may seem a little harder to understand that so important a manifestation of interest in human affairs as the education and licensure of women physicians should not only cease, but pass entirely out of men's memory, yet such apparently was the case. It would not be hard to illustrate, as I have shown in " Cycles of Feminine Education and Influence ' ' in " Education, How Old the New ' f (Fordham University Press, 1910), that corre- MEDIEVAL WOMEN PHYSICIANS 201 sponding ups and downs of interest may be traced in the history of feminine education of every kind. In that chapter I have discussed the possible rea- sons for these vicissitudes, which have no place here, but I may refer those who are interested in the subject to that treatment of it. IX MONDINO AND THE MEDICAL SCHOOL OF BOLOGNA The most important contributions to medical sci- ence made by the Medical School of Salerno at the height of its development were in surgery. The text-books written by men trained in her halls or inspired by her teachers were to influence many succeeding generations of surgeons for centuries. Salerno's greatest legacy to Bologna was the group of distinguished surgical teachers whose text-books we have reviewed in the chapter, " Great Surgeons of the Medieval Universities.' ' Bologna herself was to win a place in medical history, however, mainly in connection with anatomy, and it was in this depart- ment that she was to provide incentive especially for her sister universities of north Italy, though also for "Western Europe generally. The first manual of dissection, that is, the first handy volume giving explicit directions for the dissection of human cadavers, was written at Bologna. This was scat- tered in thousands of copies in manuscript all over the medical world of the fourteenth and early fif- teenth centuries. Even after the invention of print- ing, many editions of it were printed. Down to the sixteenth century it continued to be the most used text-book of anatomy, as well as manual of dissec- tion, which students of every university had in hand 202 MONDINO AND MEDICAL SCHOOL OF BOLOGNA 203 when they made their dissection, or wished to pre- pare for making it, or desired to review it after the body had been taken away, for with lack of proper preservative preparation, bodies had to be removed in a comparatively short time. Probably no man more influenced the medical teaching of the four- teenth and fifteen centuries than Mundinus, or, as he was called in the Italian fashion, Mondino, who wrote this manual of dissection. Mundinus quern omnis studentium universitas colit ut deum (Mundinus, whom all the world of stu- dents cultivated as a god), is the expression by which the German scholar who edited, about 1500, the Leipzig edition of Mundinus' well-known manual, the Anathomia, introduces it to his readers. The expression is well worth noting, because it shows what was still the reputation of Mundinus in the medical educational world nearly two centuries after his death. 1 Until the time of Vesalius, whose influence was exerted about the middle of the sixteenth century, Mondino was looked up to by all teachers as the most important contributor to the science of 1 It is probably interesting to note that the word universitas as used here has no reference to our word university, but refers to the whole world of students as it were. In the Middle Ages universities were called studia generalia, general studies — that is, places where everything could be studied and where everyone from any part of the world could study. Our use of the word university in the special modern sense of the term comes from the formal mode of address to the faculty of a university when Popes or rulers sent them authoritative documents. Such documents began with the expression Universitas vestra, all of you (in the old-time English, as preserved in the Irish expression, " the whole of ye"), referring to all the members of the faculty. The transfer to our term and signification university was not difficult. 204 OLD-TIME MAKERS OF MEDICINE anatomy in European medicine since the Greeks. He owed his reputation to two things : his book, of which we have already spoken, and then, the fact that he reintroduced dissection demonstrations as a regular practice in the medical schools. His book is really a manual of making anatomical prepara- tions for demonstration purposes. These demon- strations had to be hurried, owing to the rapid de- composition of material consequent upon the lack of preservatives. The various chapters were pre- pared with the idea of supplying explicit directions and practical help during the anatomical demonstra- tions, so that these might be made as speedily as possible. The book does not comprise much that was new at that time, but it is a good compendium of previous knowledge, and contains some original ob- servations. It was entirely owing to its form as a handy manual of anatomical knowledge and, besides, because it was an incentive to the practice of human dissection, that it attained and maintained its pop- ularity. Mondino followed Galen, of course, and so did every other teacher in medicine and its allied sci- ences, until Vesalius' time. Even Vesalius permit- ted himself to be influenced overmuch by Galen at points where we wonder that he did not make his observations for himself, since, apparently, they were so obvious. The more we know of Galen, however, the less surprised are we at his hold over the minds of men. Only those who are ignorant of Galen's immense knowledge, his practical common sense, and the frequent marvellous anticipations of what we think most modern, affect to despise him. MONDINO AND MEDICAL SCHOOL OF BOLOGNA 205 His works have never been translated into any modern language except piecemeal, there is no com- plete translation, and one must be ready to delve into some large Latin, if not Greek, volumes to know what a marvel of medical knowledge he was, and how wise were the men who followed him closely, though, being human, there are times when necessarily he failed them. For those who know even a little at first hand of Galen, it is only what might be expected, then, that Mondino, trying to break away from the anatomy of the pig, which had been before this the basis of all anatomical teaching in the medical schools (Copho's book, used at Salerno and Bologna before Mondino 's was founded on dissections of the pig), should have clung somewhat too closely to this old Greek teacher and Greek master. The incentive furnished by Mondino 's book helped to break the tradition of Galen's unquestioned authority. Besides this, the group of men around Mondino, his master, Taddeo Alderotti, with his disciples and assistants, form the initial chapter in the history of the medical school of Bologna, which gradually assumed the place of Salerno at this time. There is no better way of getting a definite idea of what was being done in medicine, and how it was being done, than by knowing some of the details of the life of this group of medical workers. Mondino di Liucci, or Luzzi, is usually said to have been born about 1275. His first name is a diminutive for Eaimondo. It used to be said of him that, like many of the great men of history, many cities claimed to be his birthplace. Five were 206 OLD-TIME MAKERS OF MEDICINE particularly mentioned — Florence, Milan, Bologna, Forli, and Friuli. There is, however, another Mon- dino, a distinguished physician, who was born and lived at Friuli, and it is because of confusion with him that the claim for Friuli has been set up. Florence and Milan are considered out of the ques- tion. Mondino was probably born in or near Bo- logna. The fact that there should have been this multiple set of claims shows how much was thought of him. Indeed, his was the best known name in the medical schools of Europe for nearly two centuries and a half. He seems to have been a particularly brilliant student, for tradition records that he had obtained his degree of doctor of medicine when he was scarcely more than twenty. This seems quite out of the question for us at the present time, but we have taken to pushing back the time of gradua- tion, and it is not sure whether this is, beyond peradventure, so beneficial as is usually thought. That his early graduation did not hamper his in- tellectual development, the fact that, in 1306, when he was about thirty-one years of age, he was offered the professorial chair in anatomy, which he con- tinued to occupy with such distinction for the next twenty years, would seem to prove. His public dis- sections of human bodies, probably the first thus regularly made, attracted widespread attention, and students came to him not only from all over Italy, but also from Europe generally. In this, after all, Mondino was only continuing the tradition of world teaching that Bologna had acquired under her great surgeons in the preceding century. (See " Great Surgeons of the Medieval Universities.") MONDINO AND MEDICAL SCHOOL OF BOLOGNA 207 Mondino came from a family that had already dis- tinguished itself in medicine at Bologna. His uncle was a professor of physic at the university. His father, Albizzo di Luzzi, seems to have come from Florence not long after the middle of the thirteenth century, for the records show that, about 1270, he formed a partnership with one Bartolommeo Eaineri for the establishment of a pharmacy at Bologna. Later this passed entirely under the control of the Mondino family, and came to be known as the Spezieria del Mondino. In it were sold, besides Eastern perfumes, spices, condiments, probably all sorts of toilet articles, and even rugs and silks and feminine ornaments. The stricter pharmacy of the earlier times developed into a sort of department store, something like our own. The Mondini, how- ever, insisted always on the pharmacy feature as a specialty, and the fact was made patent to the gen- eral public by a sign with the picture of a doctor on it. This drug shop of the Mondini continued to be maintained as such, according to Dr. Pilcher, until the beginning of the nineteenth century. 1 One of the fellow students of Mondino at the Uni- versity of Bologna had been Mondeville. He came from distant France to take a course in surgery with 1 Physicians wore a particular garb consisting of a cloak and often a mask, supposed to protect them from infections at this time, so that it was not difficult to make a characteristic picture as a sign for a pharmacy. These symbolic signs were much commoner and very necessary when people generally were not able to read. It is from that period that we have the mortar and pestle as also the colored lights in the windows of the drug stores, and the many-colored barber-pole. Also the big boot, key, watch, hat, bonnet, and the like, the last symbolic sign invention apparently being the wooden Indian for the tobacco store. 208 OLD-TIME MAKERS OF MEDICINE Theodoric, whose high reputation in the olden time, vague with us half a century ago, is now amply justified by what we know of him from such ardent students and admirers as Pagel and Nicaise. Not long after Mondino's death, Guy de Chauliac came from France to reap similar opportunities to these, which had proved so fruitful for Mondeville. The more that we learn about this time the more do we find to make it clear how deeply interested the gen- eration was in education in every form, artistic, philosophic, but, also, though this is often not realized, scientific. The long distances, so much longer in that time than in ours, to which men were willing, and even anxious, to go, in order to obtain opportunities for research, and to get in touch with a special master, the associations with stimulating fellow pupils of other lands, the scientific correspondences, almost necessarily initiated by such circumstances, all in- dicate an enthusiasm for knowledge such as we have not been accustomed to attribute to this period. On the contrary, we have been rather inclined to think them neglectful of all education, and have, above all, listened acquiescently while men deprecated the lack of interest in things scientific displayed by these generations. Indeed, many writers have gone out of their way to find a reason for the supposed lack of interest in science at this time, and have proclaimed the Church's opposition to scientific edu- cation and study as the cause. At this time Italy was the home of the graduate teaching for all Europe. The Italian Peninsula con- tinued to be the foster-mother of the higher educa- MONDINO AND MEDICAL SCHOOL OF BOLOGNA 209 tion in letters and art, but also, though this is less generally known, in science, for the next five cen- turies. Germany has come to be the place of pil- grimage for those who want higher opportunities in science than can be afforded in their own coun- try only during the latter half of the nineteenth century. France occupied it during the first half of the nineteenth century. Except for short inter- vals, when political troubles disturbed Italy, as about the middle of the fourteenth century, when the removal of the Popes to Avignon brought their influence for education over to France and a short period at the beginning of the eighteenth century, when the Netherlands for a time came into educa- tional prominence, Italy has always been the European Mecca for advanced students. Prac- tically all our great discoverers in medicine, until the last century, were either Italians, or else had studied in Italy. Mondino, Bertrucci, Salicet, Lan- franc, Baverius, Berengarius, John De Vigo, who first wrote on gun-shot wounds ; John of Arcoli, first to mention gold filling and other anticipations of modern dentistry; Varolius, Eustachius, Caesal- pinus, Columbus, Malpighi, Lancisi, Morgagni, Spal- lanzani, Galvani, Volta, were all Italians. Monde- ville, Guy de Chauliac, Linacre, Vesalius, Harvey, Steno, and many others who might be named, all studied in Italy, and secured their best opportunities to do their great work there. It would be amusing, if it were not amazing, to have serious writers of history in the light of this plain story of graduate teaching of science in Italy for over five centuries, write about the opposition of 210 OLD-TIME MAKEES OF MEDICINE the Church to science during the Medieval and Renaissance periods. It is particularly surprising to have them talk of Church opposition to the med- ical sciences. The universities of the world all had their charters from the Popes at this time, and were all ruled by ecclesiastics, and most of the students and practically all of the professors down to the end of the sixteenth century belonged to the clerical order. The universities of Italy were all more di- rectly under the control of ecclesiastical authority than anywhere else, and nearly all of them were dominated by papal influence. Bologna, while do- ing much of the best graduate work in science, espe- cially in medicine, was, in the Papal States, abso- lutely under the rule of the Popes. The university was, practically, a department of the Papal govern- ment. The medical school at the University of Rome itself was for several centuries, at the end of the Middle Ages, the teaching-place where were as- sembled the pick of the great medical investigators, who, having reached distinction by their discoveries elsewhere, were summoned to Rome in order to add prestige to the Papal University. All of them be- came special friends of the Popes, dedicated their books to them, and evidently looked to them as beneficent patrons and hearty encouragers of original scientific research. While this is so strikingly true of medical science as to make contrary declarations in the matter ut- terly ridiculous, and to suggest at once that there must be some motive for seeing things so different to the reality, the same story can be told of graduate science in other departments. It was to Italy that « i\ MONDINO AND MEDICAL SCHOOL OF BOLOGNA 211 men came for special higher studies in mathematics and astronomy, in botany, in mineralogy, and in ap- plied chemistry, so far as it related to the arts of painting, illuminating, stained-glass making, and the like. No student of science felt that he had quite exhausted the opportunities for study that were pos- sible for him until he had been down in Italy for some time. To meet the great professors in Italy was looked on as sure to be a source of special in- centive in any department of science. This is com- ing to be generally recognized just in proportion as our own interest in the arts and crafts, and in the history of science, leads us to go carefully into the details of these subjects at first hand. The editors of the " Cambridge Modern History," in their preface, declared ten years ago that we can no longer accept with confidence the declaration of any secondary writer on history. This is par- ticularly true of the medieval period. We must go back to the writers of those times. If it seems surprising that the University of Bo- logna should have come into such great prominence as an institute for higher education at this time, it would be well to recall some of the great work that is being done in this part of Italy in other depart- ments at this time. Cimabue laid the foundation of modern art towards the end of the thirteenth cen- tury, and during Mondino's life Giotto, his pupil, raised an artistic structure that is the admiration of all generations of artists since. Dante's years are almost exactly contemporary with those of Giotto and of Mondino. If men were doing such wondrous work in literature and in art, why should 212 OLD-TIME MAKERS OF MEDICINE not the same generation produce a man who will ac- complish for the practical science of medicine what his friends and contemporaries had done in other great intellectual departments. In recent years we have come to think much more of environment as an influence in human develop- ment and accomplishment than was the custom some- time ago. The broader general environment in Italy, with genius at work in other departments, was certainly enough to arouse in younger minds all their powers of original work. The narrower en- vironment at Bologna itself was quite as stimulat- ing, for a great clinical teacher, Taddeo Alderotti, had come, in 1260, from Florence to Bologna, to take up there the practice and teaching of medicine. It was under him that Mondino was to be trained for his life work. To understand the place of Mondino, and of the medical school of Bologna, in his time, and the repu- tation that came to them as world teachers of medi- cine, we must know, first, this great teacher of Mon- dino and the atmosphere of progressive medicine that enveloped the university in the latter half of the thirteenth century. In the chapter on " Great Surgeons of the Medieval Universities ' ' we call par- ticular attention to the series of distinguished men, the first four of whom were educated at Salerno, and who came to Bologna to teach surgery. They were doing the best surgery in the world, much better than was done in many centuries after their time; indeed, probably better than at any period down to our own day. Besides, they seem to have been mag- netic teachers who attracted and inspired pupils. MONDINO AND MEDICAL SCHOOL OF BOLOGNA 213 We have the surgical contributions of a series of men, written at Bologna, that serve to show what fine work was accomplished. At this time, however, the field of medicine was not neglected, thongh we have but a single great historical name in it that has lived. This was Taddeo Alderotti, a man who lifted the medical profession as high in the estimation of his fellow citizens at Florence as the great painters and literary men of his time did their depart- ments, and who then moved to Bologna, because of the opportunity to teach afforded him by the uni- versity. It is sometimes a little difficult for casual students of the time to understand the marvellous repu- tation acquired by this medieval physician. It should not be, however, when we recall the enthusi- astic reception and procession of welcome accorded to Cimabue's Madonna, and the almost universal acclaim of the greatness of Dante's work, even in his own time. In something of that same spirit Bo- logna came to appreciate Taddeo, as he is familiarly known, looked upon him as a benefactor of the com- munity, and voted to relieve him of the burden of paying taxes. He came to be considered as a pub- lic institution, whose presence was a blessing to his fellow citizens, and whose goodness to them should be recognized in this public way. One is not sur- prised to hear Villani, the well-known contemporary historian, speak of him as the greatest physician in Christendom. The feelings of the citizens of Bologna, it may well be confessed, were not entirely unselfish, or due solely to the desire to encourage a great sci- 214 OLD-TIME MAKEBS OF MEDICINE entific genius. Few men of his generation had done more for the city in a material way quite apart from whatever benefits he conferred upon the health of its citizens than Dr. Taddeo. It was he who or- ganized medical teaching in the city on such a plane that it attracted students from all over the world. Bologna had had a great law school before this, founded by Irnerius, to which students had come from all over the world. With the advent of Tad- deo from Florence, and his success as a medical practitioner, there began to flock to his lectures many students who spread his fame far and wide. The city council could scarcely do less than grant the same privileges to the medical students and teachers of Taddeo 's school as they had previously accorded to the faculty of law and its students. The city council recognized quite as clearly as any board of aldermen in the modern time how much, even of material benefit, a great university was to the build- ing up of a city, though their motives were prob- ably much higher than that, and their enlightened policy had its reward in the rapid growth of Bo- logna until, very probably at the end of the thir- teenth century, it had more students than any uni- versity of the modern time. The number was not less than fifteen thousand, and may have been twenty thousand. To this great university success Taddeo and his medical school contributed not a little. The espe- cially attractive feature of his teaching seems to have been its eminent practicalness. He himself had made an immense success of the practice of medicine, and accumulated a great fortune, so much MONDINO AND MEDICAL SCHOOL OF BOLOGNA 215 so that Dante, in his " Paradiso," when he wishes to find a figure that would represent exactly the op- posite to what St. Dominic, the founder of the Dominicans, did for the love of wisdom and hu- manity, he takes that of Taddeo, who had accom- plished so much for personal reputation and wealth. This might easily lead to the impression that Taddeo 's teaching was unscientific, or merely em- piric, or that he himself was a narrow-minded maker of money, intent only on his immediate influence, and hampered by exclusive devotion to practical medicine. Nothing could be farther from the truth than any such impression. Taddeo was not only the head of a great medical school, a great teacher whom his students almost worshipped, a physician to whom patients flocked because of his marvellous success, a fine citizen of a great city, whom his fellow citizens honored, but he was a broad-minded scholar, a philosopher, and even an author in branches apart from medicine. In that older time it was the custom to combine the study of philosophy and medicine. For cen- turies after that period in Italy it was the custom for men to take both degrees, the doctorate in philosophy and in medicine at the same time. In- deed, most of those whose work has made them famous, down to and including Galvani, did so. Taddeo wrote commentaries on the works of Hip- pocrates and Galen, but he also translated the ethics of Aristotle, and did much to make the learn- ing of the Arabs easily available for his students. His was a broad, liberal scholarship. Dr. Lewis 216 OLD-TIME MAKERS OF MEDICINE Pilcher, in his article on " The Mondino Myth," 1 does not hesitate to say that " to the spirit which, from his professorial chair, Taddeo infused into the teaching and study of medicine undoubtedly is due the high position which for many generations there- after the school of Bologna continued to maintain as a centre of medical teaching. ' ' Of course, erudition had its revenge, and carried Taddeo too far. The difficult thing in human nature is to stay in the mean and avoid exaggera- tion. His methods of illustrating medical truths from many literary and philosophical sources often caused the kernel of observation to be hidden be- neath a blanket of speculation or, at least, to be concealed to a great extent. Even the Germans, who have insisted most on this unfortunate tendency of Taddeo, have been compelled to confess that there is much that is valuable in what he accomplished, and that even his modes of expression were not without a certain vivacity which attracted atten- tion and doubtless added materially to his success as a teacher. Pagel, in Puschmann's " Handbuch," says : ' ' It cannot be denied [this is just after he has quoted a passage of Taddeo with regard to dreams] that Taddeo's expressions have a certain liveliness all their own that gives us some idea why he was looked upon as so good a teacher, a teacher who, as we know now, also gave instruction by the bedside of patients. ' ' Pagel adds, ' ' Taddeo 's greatest merit and his highest significance in medical education consist in the fact that a great many (zahlreiche) 1 The Medical Library and Historical Journal, Brooklyn, December, 1906. MONDINO AND MEDICAL SCHOOL OF BOLOGNA 217 physicians followed directly in his footsteps and were counted as his pupils. They were all men, as we know them, who as writers and practitioners of medicine succeeded in going far beyond the level of mediocrity in what they accomplished. ' ' This was the teacher who most influenced young Mondino when he came to the University of Bo- logna, for it seems not unlikely that as a medical student he was actually the pupil of Taddeo, then in a vigorous old age. If not, he was at least brought under the direct influence of the teaching tradition created during more than thirty years by that won- derful old man. Knowing what we do of Taddeo it is not surprising that his pupil should have accom- plished work that was to influence succeeding gen- erations more than any other of that wonderful thirteenth century. Dr. Pilcher in the article on * ' The Mondino Myth, ' ' so often placed under contri- bution in this sketch, says that " It needs no great stretch of the imagination to picture somewhat of the effect that contact with such a man as Taddeo di Alderotto 1 might have, in molding the character of his young neighbor and pupil, the chemist's son, who a few years later, by his devotion to the study of human anatomy, was to re-establish the practical 1 Taddeo, who was born in 1215, according to our usually accepted traditions in the matter, would have been seventy-five years of age when Mondino as a youth of scarcely more than fifteen went to the University. It might seem that so old a man would have very little influence over the young man. Taddeo, however, had, as we have said, a very strenuous old age. Everything in life had come to him late. He was well past thirty before he began to study philoso- phy and medicine, having been a seller of candles from necessity be- cause of poverty in his younger years. His great success in practice came when he was past forty. He first began to teach when he was 218 OLD-TIME MAKERS OF MEDICINE pursuit of study on the human cadaver as the com- mon privilege of the skilled physician, and was to engrave his own name deeply on the records of medicine. ' ' Under this worthy compatriot and contemporary of the great Florentines, Mondino was inspired to be the teacher that did so much for Bologna. Until recent years it has usually been the custom to give too much significance to the work of the men whose names stand out most prominently in the early his- tory of departments of the intellectual life. Mon- dino J s reputation has shared in this exaggerative tendency to some extent, hence the necessity for realizing what was accomplished before his time and the fact that he only stands as the culmination of a progressive period. Carlyle spoke of Dante as the man in whom " ten silent centuries found a voice." The centuries, however, were only silent because the moderns did not know how to listen to their mes- sage. We know now that every country in Europe had a great contributor to literature in the century before Dante. The Cid, the Arthur Legends, the Nibelungen, the Troubadours, naturally led up to Dante. He was only the culmination of a great period forty-five, and he was nearly fifty-five before he began to write. According to tradition he married when he was nearly eighty — ■ whether for the first or second time is not said — and while this might be considered, and would in some cases be, an indication of weak- ness of character (it would probably depend on whether he married or was married ) , it seems in his case to have indicated a vigor of body and character which shows very clearly how great was the pos- sibility of his influence as a teacher having been maintained even up to this late time of life, and thus influencing a pupil who is to represent the most potent influence at the beginning of the next century. MONDINO AND MEDICAL SCHOOL OF BOLOGNA 219 of literature. We know now that men had worked in art before Cimabue and Giotto, and had done im- pressive work that made for the progress of art. These names, however, have come to represent in many minds the sort of solitary phenomena that Dante has seemed sometimes even to scholars. Because Mondino did such good work in medical teaching it is sometimes declared, even in rather seri- ous histories, that he was the first to accomplish any- thing in his department, and that before his time there is a blank. Some historians, for instance, have insisted that Mondino was the first to do human dis- sections, and that he did at most but two or three. Only those who are unacquainted with the magnifi- cent development of surgery that took place during the preceding century, the evidence for which is so abundantly given in modern historians of medicine and especially in Gnrlt's great work on the history of surgery, from which we have quoted enough to give a good idea of the extent to which the move- ment went, are likely to accept any such declaration. There could not have been all that successful sur- gery without much dissection not only of animals but also of human bodies. The teaching of dissec- tion was not regularly organized until Mondino 's time, but it seems very clear that even he must have dissected many more bodies than the number usually attributed to him. Professor Lewis Stephen Pilcher of Brooklyn, who made a special study of Mondino traditions in Bologna itself, and collected some of the early editions of his books, feels so acutely the ab- surdity of the ordinarily accepted tradition in this matter, that he has written a paper on the subject 220 OLD-TIME MAKEBS OF MEDICINE bearing the suggestive title, " The Mondino Myth." He says : x " We are accustomed to think cf the practice of dissection as having been re-created by Mondino, and at once fully developed, springing into acceptance. The year 1315 is the generally accepted date for the first public anatomical demonstration upon a human body made by Mondino, and yet it is true that among the laws promulgated by Frederick II, more than seventy-five years before (a.d. 1231), was included a decree that a human body should be dissected at Salernum at least once in five years in the presence of the assembled physicians and surgeons of the kingdom, and that in the regulations established for admission to the practice of medicine and surgery in the kingdom it was decreed that no surgeon should be admitted to practise unless he should bring testi- monials from the masters teaching in the medical faculty, that he was l learned in the anatomy of human bodies, and had become perfect in that part of medicine without which neither incisions could safely be made nor fractures cured.' " Salernum was notable in its legalization of the dissection of human bodies before the first public work of Mondino, for, according to a document of the Maggiore Consiglio of Venice of 1308, it appears that there was a college of medicine at Venice which was even then authorized to dissect a body every year. Common experience tells us that the embodi- ment of such regulations into formal law would occur only after a considerable preceding period of discussion, and in this particular field of clandestine practice. It is too much to ask us to believe that in all this period, from the date of the promulgation of Frederick's decree of 1231 to the first public dem- onstration by Mondino, at Bologna in 1315, the de- 1 Medical Library and Historical Journal, 1906. MONDINO AND MEDICAL SCHOOL OF BOLOGNA 221 cree had been a dead letter and no human body had been anatomized. It is true there is not, as far as I am aware, any record of any such work, and commentators and historians of a later date have, without exception, accepted the view that none was done, and thereby heightened the halo assigned to Mondino as the one who ushered in a new era. Such a view seems to me to be incredible. Be that as it may, it is undeniable that at the beginning of the 14th century the idea of dissecting the human body was not a novel one; the importance of a knowledge of the intimate structure of the body had already been appreciated by divers ruling bodies, and specific regulations prescribing its practice had been enacted. It is more reasonable to believe that in the era immediately preceding that of Mondino human bodies were being opened and after a fash- ion anatomized. All that we know of the work of Mondino suggests that it was not a new enterprise in which he was a pioneer, but rather that he brought to an old practice a new enthusiasm and better meth- ods, which, caught on the rising wave of interest in medical teaching at Bologna, and preserved by his own energy as a writer in the first original system- atic treatise written since the time of Galen, created for him in subsequent uncritical times the reputation of being the Kestorer of the practice of anatomizing the human body, the first one to demonstrate and teach such knowledge since the time of the Ptolemaic anatomists, Erasistratus and Herophilus. " The changes have been rung by medical his- torians upon a casual reference in Mondino 's chapter on the uterus to the bodies of two women and one sow which he had dissected, as if these were the first and the only cadavers dissected by him. The con- text involves no such construction. He is enforcing a statement that the size of the uterus may vary, and to illustrate it remarks that 'a woman whom I 222 OLD-TIME MAKERS OF MEDICINE anatomized in the month of January last year, viz., 1315 Anno Christi, had a larger uterus than one whom I anatomized in the month of March of the same year.' And further, he says that ' the uterus of a sow which I dissected in 1316 (the year in which he was writing) was a hundred times greater than any I have seen in the human female, for she was pregnant and contained thirteen pigs.' These hap- pen to be the only reference to specific bodies that he makes in his treatise. But it is a far cry to wring out of these references the conclusion that these are the only dissections he made. It is quite true that if we incline to enshroud his work in a cloud of mys- tery and to figure it as an unprecedented awe-inspir- ing feature to break down the prejudices of the ages, it is easy to think of him as having timidly profaned the human body by his anatomizing zeal in but one or two instances. His own language, however, throughout his book is that of a man who was fa- miliar with the differing conditions of the organs found in many different bodies; a man who was habitually dissecting. ' ' (Quotations from the work of Mundinus showing his familiarity with dissections. The leaf and line references are to the Dryander edition, Marburg, 1541.) "I do not consider separately the anatomy of component parts, because their anatomy does not appear clearly in the fresh subject, but rather in those macerated in water." (Leaf 2, lines 8-13.) 1 * . . . these differences are more noticeable in the cooked or perfectly dried body, and so you need not be concerned about them, and perhaps I will make an anatomy upon such a one at another time and will write what I shall observe with my own senses, as I have proposed from the beginning.' ' (Leaf 60, lines 14-17.) " What the members are to which these nerves MONDINO AND MEDICAL SCHOOL OF BOLOGNA 223 come cannot well be seen in such a dissection as this, but it should be liquefied with rain water, and this is not contemplated in the present body." (Leaf 60, lines 31-33.) " After the veins you will note many muscles and many large and strong cords, the complete anatomy of which you will not endeavor to find in such a body but in a body dried in the sun for three years, as I have demonstrated at another time; I also declared completely their number, and wrote the anatomy of the muscles of the arms, hands, and feet in a lecture which I gave over the first, second, third, and fourth subjects." (Leaf 61, lines 1-7.) Very probably the best evidence that we have of the comparative frequency at least of dissection at this time is to be found in the records of a trial for body-snatching that occurred in Bologna. The de- tails would remind one very much of what we know of the difficulties with regard to dissection in America a couple of generations ago, when no bodies were provided by law for dissection purposes. In the course of some studies for the history of the New York State Medical Society (New York, 1906) I found that nearly every one of the first half dozen presidents of the New York Academy of Medicine, which is not much more than sixty years old, had had body-snatching experiences when they were younger. Dr. Samuel Francis, the medico-historical writer, tells of a personal expedition across the ferry in the winter time, bringing a body from a Long Island graveyard. In order to avoid the constables on the Long Island side and the police on the New York side, because there had been a number of cases of body-snatching recently and the authorities were 224 OLD-TIME MAKERS OF MEDICINE on the lookout, the corpse was placed sitting beside the physician who drove the wagon, with a cloak wrapped around it, as if it were a living person specially protected against the cold. Similar experi- ences were not unusual. The lack of bodies for dis- section is sometimes attributed to religious scruples, but they have very little to do with it, as at all times men have refused to allow the bodies of their friends to be treated as anatomical material. This is the natural feeling of abhorrence and not at all religious. It is only when there are many unclaimed bodies of strangers and the poor, as happens in large cities, that there can be an abundance of anatomical material. The details of this body- snatching case are strangely familiar to those who know the history of similar cases before the middle of the nineteenth cen- tury. The case occurred in 1319 in Bologna, just four years after Mondino's public dissections. Four students were involved in the charge of body-snatch- ing, all of them from outside the city of Bologna it- self, three from Milan and one from Piacenza. In modern experience, too, as a rule, students from out- side of the town where the medical college was situ- ated, were always a little readier than natives to violate graveyards. These four students were ac- cused of having gone at night to the Cemetery of St. Barnabas, outside the gate of San Felice, — suburban graveyards were usually the scene of such exploits, — and to have dug up the body of a certain criminal named Pasino, who had been hanged a few days before. They carried the body to the school in the Parish of San Salvatore, where Alberto Zancari MONDINO AND MEDICAL SCHOOL OF BOLOGNA 225 was teaching. The resurrection had been accom- plished without witnesses, but there were several witnesses who testified that they recognized the body of Pasino in the school and students occupied with its dissection. If evidence for the zeal of the medi- cal students of that time for dissection were needed, surely we have it in the testimony at this trial. At a time when body-snatching has become a criminal offence usually there have been many repeated oc- currences of it before the parties are brought to trial, so that it seems not unlikely that a good many dis- sections of illegally secured bodies were being done at Bologna at this time. We know of a regulation of the University in force at this time, which required the teachers at the University to do an anatomy or dissection for students if they secured a body for that purpose. The students seem to have used all sorts of influ- ence, political, monetary, diplomatic, and ecclesiasti- cal, in order to secure the bodies of criminals. Some- times when they failed in their purpose they waited until after burial and then took the body without leave. When we recall the awfully deterrent condi- tion in which bodies must have been that were thus provided for dissecting purposes, it is easy to under- stand that the enthusiasm of the students for dis- section must have been at a very high pitch. Cer- tainly it was far higher than at the present day, when, in spite of the fact that our dissecting-rooms have very few of the old-time dangers and unpleas- antnesses, dissection is only practised with assiduity if special care is exercised in requiring attendance and superintending the work of the department. 226 OLD-TIME MAKEES OF MEDICINE In my book on " The Popes and Science " I have gathered the traditions relating to Mondino 's as- sistants in the chair of anatomy at Bologna. They furnish abundant evidence of the fact that dissec- tions, far from being uncommon, must have been not at all infrequent at the north Italian universities at this time. Curiously enough, one of these assistants was a young woman who, as was not infrequently the custom at this time in the Italian universities, was matriculated as a student at Bologna. She took up first philosophy, and afterwards anatomy, under Mondino. While it is not generally realized, co-educa- tion was quite common at the Italian universities of the thirteenth and fourteenth centuries, and at no time since the foundation of the universities has a century passed in Italy without distinguished women occupying professors' chairs at some of the Italian universities. This young woman, Alessandra Gili- ani, of Persiceto, a country district not far from Bologna, took up the study of anatomy with ardor and, strange as it may appear, became especially enthusiastic about dissection. She became so skilful that she was made the prosector of anatomy, that is, one who prepares bodies for demonstration by the professors. According to the " Cronaca Persicetana," quoted by Medici in his " History of the Anatomical School at Bologna ' ' : " She became most valuable to Mondino because she would cleanse most skilfully the smallest vein, the arteries, all ramifications of the vessels, without lacerating or dividing them, and to prepare them for MONDINO AND MEDICAL SCHOOL OF BOLOGNA 227 demonstration she would fill them with various colored liquids, which, after having been driven into the vessels, would harden without destroying the ves- sels. Again, she would paint these same vessels to their minute branches so perfectly and color them so naturally that, added to the wonderful explanations and teachings of the master, they brought him great fame and credit.' ' The whole passage shows a won- derful anticipation of our most modern methods — injection, painting, hardening — of making anatom- ical preparations for class and demonstration pur- poses. Some of the details of the story have been doubted, but her memorial tablet, erected at the time of her death in the Church of San Pietro e Marcellino of the Hospital of Santa Maria de Mareto, gives all the important facts, andiells the story of the grief of her fiance, who was himself Mondino's other assistant. 1 This was Otto Agenius, who had made for himself a name as an assistant to the chair of anatomy in Bologna, and of whom there were great hopes enter- tained because he had already shown signs of genius as an investigator in anatomy. These hopes were destined to grievous disappointment, however, for Otto died suddenly, before he had reached his thirti- eth year. The fact that both these assistants of Mon- dino died young and suddenly, would seem to point x Pilcher (loc. cit.) tells of her tomb. I venture to change his translation of the inscription in certain unimportant particulars. He says: "We know the very place where she was buried in front of the Madonna delle Lettre in the Church of San Pietro e Marcellino of the 228 OLD-TIME MAKERS OF MEDICINE to the fact that probably dissection wounds in those early days proved even more fatal than they occa- sionally did a century or more ago, when the proper precautions against them were not so well under- stood. The death of Mondino's two prosectors in early years would seem to hint at some such un- fortunate occurrence. As regards the evidence of what the young man had accomplished before his untimely death, prob- ably the following quotation, which Medici has taken Hospital of Santa Maria de Mareto, where her associate, Agenio, mourning and inconsolable, placed a tablet with this inscription: D . O . M . Vrceo . Contenti Alexandrae . Galinae . Pvellae . Persicetanae Penicillo . Egregiae . Ad . Anatomen . Exhibendam Et . Insignissimi . Medici . Mundini . Lucii Paucis . Comparandae . Discipulae . Cineres Carnis . Hie . Expectant . Resurrectionem Vixit . Ann . XIX . Obiit . Studio . Absunta Die XXVI Martii . A . S . MCCCXXVI Otto . Agenius . Lustrulanus . Ob . Earn . Demptam Sui . Potiori . Parte . Spoliatus . Sodali . Eximiae Ac . De . Se . Optime . Meritae . Inconsolabilis . M . P . This inscription may be translated as follows: In this urn enclosed The ashes of the body of Alexandra Giliani, a maiden of Periceto; Skilful with her brush in anatomical demonstrations And a disciple equalled by few, Of the most noted physician, Mundinus of Luzzi, Await the resurrection. She lived 19 years: she died consumed by her labors March 26, in the year of grace 1326. Otto Agenius Lustrulanus, by her taking away Deprived of his better part, his excellent companion, Deserving of the best, Has erected this tablet." MONDINO AND MEDICAL SCHOOL OF BOLOGNA 229 from one of the old chroniclers, will give the best idea : * ' What advantage indeed might not Bologna have had from Otto Agenius Lustrulanus, whom Mon- dino had used as an assiduous prosector, if he had not beeen taken away by a swift and lamentable death before he had completed the sixth lustrum of his life! ,? How well the tradition created by Mondino con- tinued at the university will be best understood from what we know of Guy de Chauliac's visit to the medi- cal school here about the middle of the century. The great French surgeon tells us that he came to Bo- logna to study anatomy under the direction of Mon- dino ? s successor, Bertruccius. When he wrote his preface to his great surgery he recalled this teaching of anatomy at Bologna and said, "It is necessary and useful to every physician to know, first of all, anatomy. For this purpose the study of books is indeed useful, but it is not sufficient to explain those things which can only be appreciated by the senses and which need to be seen in the dead body itself. ' ' He advises his students to consult Mundinus' treatise but to demonstrate its details for themselves on the dead body. He relates that he himself had often, multitoties, done this, especially under the direction of Bertruccius at Bologna. Curiously enough, as pointed out by Professor Pilcher, Mondino had used this same word multitotiens (the variant spelling makes no difference in the meaning) in speaking about his own work. In describing the hypogastric lesion he mentions that he had demonstrated cer- tain veins in it many times, multitotiens. 230 OLD-TIME MAKERS OF MEDICINE Mondino was just past fifty when he finished his little book and permitted copies of it to be made. Though the book occurs so early in the history of modern book-making the author offers his excuses to the public for writing it, and quotes the authority of Galen, to whom he turns in other difficult situ- ations, for justification. As prefaces go, Mondino 's is so like that of many an author of more recent date that his words have a bibliographic, as well as a personal, interest. He said: ' ' A work upon any science or art — as saith Galen — is issued for three reasons: first, that one may satisfy his friends. Second, that he may exercise his best mental powers. Third, that he may be saved from the oblivion incident to old age. Therefore, moved by these three causes, I have proposed to my pupils to compose a certain work on medicine. " And because a knowledge of the parts to be subjected to medicine (which is the human body, and the names of its various divisions) is a part of medical science, as saith Averrhoes in his first chapter, in the section on the definition of medicine, for this reason among others, I have set out to lay before you the knowledge of the parts of the human body which is derived from anatomy, not attempting to use a lofty style, but the rather that which is suitable to a manual of procedure. ' ' Some of the early editions of Mondinus , book are said, according to old writers, to have contained illus- trations. None of these copies have come down to us, but the assertion is made so definitely that it seems likely to have been the case. The editions that we have contain wood engravings of the method of making a dissection as frontispiece, so that it MONDINO AND MEDICAL SCHOOL OF BOLOGNA 231 would not be difficult to think of further such illus- trations having been employed in the book itself. As we note in the chapter on " Great Surgeons of the Medieval Universities," Mondeville, according to Guy de Chauliac, had pictures of anatomical prepara- tions which he used for teaching purposes. It is easy to understand that the value of such aids would be recognized at a time when the difficulty of preserv- ing bodies made it necessary to do dissections hur- riedly so as to get the rapidly decomposing material out of the way. Beyond his book and certain circumstances con- nected with it we know very little about Mondino. What we know, however, enables us to conclude that, like many another great teacher, he must have had the special faculty of inspiring his students with an ardent enthusiasm for the work that they were tak- ing under him. Hence the body- snatching and other stories. Mondino continued to be held in high esti- mation by the Bolognese for centuries after his death. Dr. Pilcher calls attention to the fact that his sepulchral tablet, which is in the portico of the Church of San Vitari in Bologna, and a replica of which he was allowed to have made in order to bring it to America, is the only one of the sepulchral tablets in the great churches of Florence, San Domenico, San Martino, the Cathedral and the Cloister of San Giacomo degli Ermitani, which has not been removed from its original location and placed in the halls of the Civic Museum. Their removal he considers " a kind of desecration which does violence to one's sense of sanctity and propriety." " Fortunately, thus far, the Mondino Tablet has escaped the spoiler." Very 232 OLD-TIME MAKERS OF MEDICINE probably Dr. Pilcher's replica of the tablet which he was required to deposit in the Civic Museum at the time when the copy was made to be brought to America may save the tablet to be seen in its original position for many generations. Mondino's career is of special interest because it foreshadows the life and accomplishment of many another maker of medicine of the after time. He did a great new thing in medicine in organizing regular public dissections, and then in making a manual that would facilitate the work. He waited patiently for years before completing his book in order that it might be the fruit of long experience, and so be more helpful to others. He was so modest as to require urging to secure the publication. He had the reward of his patience in the popularity of his little work for centuries after his time. The glimpse that we get of his relations to his young assistants, Agenius and Alessandra, seems to show us a teacher of distinct personal magnetism. Un- doubtedly the reputation of his book did much for not only the medical school of the University of Bologna, but also for the medical schools of other north Italian universities, and helped to bring to them the crowds of students that flocked there during the fourteenth and fifteenth centuries. Taddeo and Mondino turned the attention of the medical students of their generations Bolognawards. Before that time they had mainly gone to Salerno. After their time most of the ardent students of medi- cine felt that they must study for a time at least at Bologna. Other important medical schools of Italian universities at Padua, at Vicenza, at Piacenza, arose MONDINO AND MEDICAL SCHOOL OF BOLOGNA 233 and prospered. During the time when the political troubles of Italy reached a climax about the middle of the fourteenth century, while the Popes were at Avignon, there was a remission in the attendance at all the Italian universities, but with the Popes' re- turn to Eome and the coming of even comparative peace to Italy, Bologna once more became the term of medical pilgrimages for students from all over the world. In the meantime Mondino's book went forth to be the most used text-book of its kind until Vesalius , great work came to replace it. To have ruled in the world of anatomy for two centuries as the best known of teachers is of itself a distinction that shows us at once the teaching power and the scientific ability of this professor of anatomy of Bologna in the early fourteenth century. GREAT SURGEONS OF THE MEDIEVAL UNIVERSITIES Strange as it may appear to those who have not watched the development of our knowledge of the Middle Ages in recent years the most interesting feature in the medical departments and, indeed, of the post-graduate work generally of the medieval universities, is that in surgery. There is a very gen- eral impression that this department of medicine did not develop until quite recent years, and that par- ticularly it failed to develop to any extent in the Middle Ages. A good many of the historians of this period, indeed, though never the special historians of medicine, have even gone far afield in order to find some reason why surgery did not develop at this time. They have insisted that the Church by its prohibition of the shedding of blood, first to monks and friars, and then to the secular clergy, prevented the normal development of surgery. Besides they add that Church opposition to anatomy completely precluded all possibility of any genuine natural evo- lution of surgery as a science. There is probably no more amusing feature of quite a number of supposedly respectable and pre- sumably authoritative historical works written in English than this assumption with regard to the ab- sence of surgery during the later Middle Ages. Only 234 GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 235 the most complete ignorance of the actual history of medicine and surgery can account for it. The writers who make such assertions must never have opened an authoritative medical history. Nothing illustrates so well the expression of the editors of the ' ' Cambridge Modern History " referred to more than once in these pages that " in view of changes and of gains such as these [the printing of original documents] it has become impossible for historical writers of the present day to trust without reserve even to the most respected secondary authority. The honest student finds himself continually deserted, retarded, misled by the classics of historical literature. ' ' Fortunately for us this sweeping condemnation does not hold to any great extent for the medical historical classics. All of the classic historians of medicine tell us much of the surgery of the thirteenth and fourteenth cen- turies, and in recent years the republication of old texts and the further study of manuscript documents of various kinds have made it very clear that there is almost no period in the history of the world when surgery was so thoroughly and successfully culti- vated as during the rise and development of the uni- versities and their medical schools in the thirteenth and fourteenth centuries. It is interesting to trace the succession of great contributors to surgery during these two centuries. We know their teaching not from tradition, but from their text-books so faithfully preserved for us by their devoted students, who must have begrudged no time and spared no labor in copying, for many of the books are large, yet exist in many manuscript copies. 236 OLD-TIME MAKERS OF MEDICINE Modern surgery may be said to owe its origin to a school of surgeons, the leaders of whom were edu- cated at Salerno in the early part of the thirteenth century, and who, teaching at various north Italian universities, wrote out their surgical principles and experiences in a series of important contributions to that department of medical science. The fact that the origin of the school was at Salerno, where, as is well known, Arabian influence counted for much and for which Constantine's translations of Arabian works proved such a stimulus a century before, makes most students conclude that this later medie- val surgical development is simply a continuation of the Arabian surgery that, as we have seen, developed very interestingly during the earlier Middle Ages. Any such idea, however, is not founded on the reali- ties of the situation, but on an assumption with re- gard to the extent of Arabian influence. Gurlt in his " History of Surgery " (Vol. I, page 701) completely contradicts this idea, and says with regard to the first of the great Italian writers on surgery, Eogero, that " though Arabian works on surgery had been brought over to Italy by Constantine Africanus a hundred years before Roger's time, these exercised no influence over Italian surgery in the next century, and there is scarcely a trace of the surgical knowl- edge of the Arabs to be found in Roger's works.' ' It is in the history of medicine particularly that it is possible to trace the true influence of the Arabs on European thought in the later Middle Ages. We have already seen in the chapter on Salerno that Arabian influence did harm to Salernitan medical teaching. The school of Salerno itself had developed GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 237 simple, dietetic, hygienic, and general remedial meas- ures that included the use of only a comparatively small amount of drugs. Its teachers emphasized nature's curative powers. With Arabian influence came polypharmacy, distrust of nature, and attempts to cure disease rather than help nature. In surgery, which developed very wonderfully in the thirteenth and fourteenth centuries, Salerno must be credited with the incentive that led up to the marvellous de- velopment that came. With this, however, Arabian influence has nothing to do. Gurlt, besides calling attention to the fact that the author of the first great text-book on the subject not only did not draw his in- spiration from Arab sources, insisted that ' ' instead of any Arabisms being found in his [Roger's] writ- ings many Grsecisms occur.' ' The Salernitan school of surgery drank at the fountain-head of Greek sur- gery. Apart from Greek sources Roger's book rests entirely upon his own experiences, those of his teach- ers and his colleagues, and the tradition in surgery that had developed at Salerno. This tradition was entirely from the Greek. Roger himself says in one place, " We have resolved to write out deliberately our methods of operation such as they have been derived from our own experience and that of our colleagues and illustrious men." ROGEE, ROLAND, AND THE FOUR MASTERS Ruggero, or Rogero, who is also known as Rogerio and Rogerus with the adjective Parmensis, or Saler- nitanus, of Parma or of Salerno, and often in Ger- man and English history simply as Roger, lived at 238 OLD-TIME MAKERS OF MEDICINE the end of the twelfth or the beginning of the thir- teenth century and probably wrote his text-book about 1180. This text-book was, according to tradi- tion, originally drafted for his lessons in surgery at Salerno. It attracted much attention and after being commented on by his pupil Eolando, the work of both of them being subsequently annotated by the Four Masters, this combined work became the basis of modern surgery. Eoger was probably born either in Palermo or Parma. There are traditions of his having taught for a while at Paris and at the Uni- versity of Montpellier, though these are not substan- tiated. His book was printed at Venice in 1546, and has been lately reprinted by De Eenzi in his " Col- lectio Salernitana. ' ' Eoland was a pupil of Eoger's, and the two names that often occur in medieval romance became asso- ciated in a great historic reality as a consequence of Eoland 's commentary on his master's work, which was a favorite text-book in surgery for a good while in the thirteenth century at Salerno. Some space will be given to the consideration of their surgical teach- ing after a few words with regard to some disciples who made a second commentary, adding to the value of the original work. This is the well-known commentary of the Four Masters, a text-book of surgery written somewhat in the way that we now make text-books in various de- partments of medicine, that is, by asking men who have made specialties of certain subjects to write on that subject and then bind them all together in a single volume. It represents but another striking reminder that most of our methods are old, not new GBEAT SUEGEONS OF MEDIEVAL UNIVERSITIES 239 as we are likely to imagine them. The Four Masters took the works of Roger and Rolando, acknowledged their indebtedness much more completely than do our modern writers on all occasions, I fear, and added their commentaries. Gurlt says (" Geschichte der Chirurgie," Vol. I, p. 703) that " in spite of the fact that there is some doubt about the names of the authors, this volume constitutes one of the most important sources for the history of surgery of the later Middle Ages and makes it very clear that these writers drew their opinions from a rich experience. ' ' It is rather easy to illustrate from the quotations given in Gurlt or from the accounts of their teaching in Daremberg or De Renzi some features of this experience that can scarcely fail to be surprising to modern surgeons. For instance, what is to be found in this old text- book of surgery with regard to fractures of the skull is likely to be very interesting to surgeons at all times. One might be tempted to say that fewer men would die every year in prison cells who ought to be in hospitals, if the old-time teaching was taken to heart. For there are rather emphatic directions not to conclude because the scalp is unwoundedthat there can be no fracture of the skull. Where nothing can be felt care must be exercised in getting the history of the case. For instance, if a man is hit by a metal instrument shaped like the clapper of a bell or by a heavy key, or by a rounded instrument made of lead — this would remind one very much of the lead pipe of the modern time, so fruitful of mistakes of diag- nosis in head injuries — special care must be taken to look for symptoms in spite of the lack of an external 240 OLD-TIME MAKERS OF MEDICINE penetrating wound. Where there is good reason to suspect a fracture because of the severity of the in- jury, the scalp should be incised and a fracture of the cranium looked for carefully. That is carrying the exploratory incision pretty far. If a fracture is found the surgeon should trephine so as to relieve the brain of any pressure of blood that might be affect- ing it. There are many warnings, however, of the danger of opening the skull and of the necessity for defi- nitely deciding beforehand that there is good reason for so doing. How carefully their observations had been made and how well they had taken advantage of their opportunities, which were, of course, very frequent in those warlike times when firearms were unknown, hand-to-hand conflict common, and blunt weapons were often used, can be appreciated very well from some of the directions. For instance, they knew of the possibility of fracture by contrecoup. They say that ' ' quite frequently though the percus- sion comes in the anterior part of the cranium, the cranium is fractured on the opposite part." 1 They even seem to have known of accidents such as we now discuss in connection with the laceration of the mid- dle meningeal artery. They warn surgeons of the possibilities of these cases. They tell the story of " a youth who had a very small wound made by a thrown stone and there seemed no serious results or bad signs. He died the next day, however. His cranium was opened and a large amount of black ir rhis is so striking that I quote their actual words from Gurlt, p. 704: " Multoties fit percussio in anteriori parte cranei et craneum in parte frangitur contraria." GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 241 blood was found coagulated about bis dura mater. ' ' There are many interesting tbings said witb re- gard to depressed fractures and tbe necessity for elevating tbe bone. If tbe depressed portion is wedged tben an opening sbould be made witb tbe trephine and an elevating instrument called a spatu- men used to relieve tbe pressure. Great care sbould be taken, bowever, in carrying out this procedure lest tbe bone of tbe cranium itself, in being lifted, sbould injure tbe soft structures witbin. Tbe dura mater sbould be carefully protected from injury as well as tbe pia. Care sbould especially be exercised at tbe brow and tbe rear of tbe bead and at tbe com- missures (proram et pupim et commissural), since at tbese points tbe dura mater is likely to be ad- berent. Perbaps tbe most striking expression, tbe word infect being italicized by Gurlt, is : ' * In ele- vating tbe cranium be solicitous lest you sbould infect or injure tbe dura mater. ' ' For wounds of tbe scalp sutures of silk are recom- mended because tbis resists putrefaction and bolds tbe wound edges togetber. Interrupted sutures about a finger-breadtb apart are recommended. " Tbe lower part of tbe wound sbould be left open so tbat tbe cure may proceed properly.' ' Red pow- der was strewed over tbe wound and the leaf of a plant set above it. In tbe lower angle of tbe wound a pledget of lint for drainage purposes was inlaid. Hemorrhage was prevented by pressure, by the bind- ing on of burnt wool firmly, and by tbe ligature of veins and by tbe cautery. Tbere are rather interesting discussions of the 242 OLD-TIME MAKERS OF MEDICINE prognosis of wounds of the head, especially such as may be determined from general symptoms in this commentary of the Four Masters on Roger's and Rolando's treatises. If an acute febrile condition develops, the wound is mortal. If the patient loses the use of the hands and feet or if he loses his power of direction, or his sensation, the wound is mortal. If a universal paralysis comes on, the wound is mor- tal. For the treatment of all these wounds careful precautions are suggested. Cold was supposed to be particularly noxious to them. Operations on the head were not to be done in cold weather and, above all, not in cold places. The air where such operations were done must be warmed artificially. Hot plates should surround the patient's head while the opera- tion 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. These precautions are interesting as foreshadowing many ideas of much more modern time and especially indi- cating how old is the idea that cold may be taken in wounds. In popular medicine this still has its place. Whenever a wound does badly in the winter time pa- tients are sure that they have taken cold. Such popu- lar medical ideas are always derived from sup- posedly scientific medicine, and until we learned about microbes physicians used the same expressions. We have not got entirely away from them yet. These old surgeons must have had many experi- ences with fractures at the base of the skull. Hemor- rhages from the mouth and nose, for instance, and from the ears were considered bad signs. They were inclined to suggest that openings into the skull should GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 243 be discovered by efforts to demonstrate a connection between the mouth and nares and the brain cavity. For instance, in their commentary the Four Masters said: " Let the patient hold his mouth and nostrils tight shut and blow strongly." If there was any lessening of the pressure or any appearance of air in the wound in the scalp, then a connection between the mouth and nose was diagnosticated. This is in- genious but eminently dangerous because of the in- fectious material contained in the nasal and oral cavities, so likely to be forced by such pressure into the skull. They were particularly anxious to detect linear fractures. 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, how- ever, adds to this " sed hoc aliquando fallit — but this sign sometimes fails. ' ' Split or crack fractures were also diagnosticated by the method suggested by Hip- pocrates of pouring some colored fluid over the skull after the bone was exposed, when the linear fracture would show by coloration. The Four Masters sug- gest a sort of red ink for this purpose. While they have so much to say about fractures of the skull and insist, over and over again, that though all depressed fractures need treatment and many fissure fractures require trepanation, still great care must be exercised in the selection of cases. They say, for instance, that surgeons who in every serious wound of the head have recourse to the trephine must be looked upon as ' ' fools and idiots ' ' (idioti et stolidi). In the light of what we now know % 244 OLD-TIME MAKERS OF MEDICINE about the necessity for absolute cleanliness, — asep- sis as we have come to call it, — it is rather startling to note the directions that are given to a surgeon to be observed on the day when he is to do a trepana- tion. For obvious reasons I prefer to quote it in the Latin: " Et nota quod die ilia cavendum est medico a coitu et malis cibis aera corrumpentibus, ut sunt allia, cepe, et hujusmodi, et colloquio mulieris men- struosce, et mcmus ejus debent esse mundce, etc." My quotation is from Gurlt, Vol. I, p. 707. The direc- tions are most interesting. The surgeon 's hands must be clean, he must avoid the taking of food that may corrupt the air, such as onions, leeks, and the like; must avoid menstruating and other women, and in general must keep himself in a state of absolute cleanliness. To read a passage like this separated from its context and without knowing anything about the wonderful powers of observation of the men from whom it comes, it would be very easy to think that it is merely a set of general directions which they had made on some general principle, perhaps quite foolish in itself. We know, however, that these men had by observation detected nearly every feature of importance in fractures of the skull, their indications and contra-indications for operation and their prog- nosis. They had anticipated nearly everything of importance that has come to be insisted on even in our own time in the handling of these difficult cases. It is not unlikely, therefore, that they had also ar- rived at the recognition by observations on many patients that the satisfactory after-course of these cases which were operated on by the surgeon after GBEAT SURGEONS OF MEDIEVAL UNIVERSITIES 245 due regard to such meticulous cleanliness as is sug- gested in the paragraph I have quoted, made it very clear that these aseptic precautions, as we would call them, were extremely important for the outcome of the case and, therefore, were well worth the sur- geon's attention, though they must have required very careful precautions and considerable self-denial. Indeed this whole subject, the virtual anticipation of our nineteenth-century principles of aseptic surgery in the thirteenth century, is not a dream nor a far- fetched explanation when one knows enough about the directions that were laid down in the surgical text-books of that time. THE NOKTH ITALIAN SUEGEONS After Roger and Rolando and the Four Masters, who owe the inspiration for their work to Salerno and the south of Italy, comes a group of north Italian surgeons: Bruno da Longoburgo, usually called simply Bruno ; Theodoric and his father, Hugo of Lucca, and William of Salicet. Immediately fol- lowing them come two names that belong, one almost feels, to a more modern period : Mondino, the author of the first text-book on dissection, and Lanfranc (the disciple of William of Salicet), who taught at Paris and i l gave that primacy to French surgery which it maintained all the centuries down to the nineteenth " (Pagel). It might very well be thought that /this group of Italian surgeons had very little in their writings that would be of any more than antiquarian interest for the modern time. It needs but a little knowledge of their writings as they have come down 246 OLD-TIME MAKERS OF MEDICINE to us to show how utterly false any such opinion is. To Hugo da Lucca and his son Theodoric we owe the introduction and the gradual bringing into prac- tical use of various methods of anaesthesia. They used opium and mandragora for this purpose and later employed an inhalant mixture, the composition of which is not absolutely known. They seem, how- ever, to have been very successful in producing in- sensibility to pain for even rather serious and com- plicated and somewhat lengthy operations. Indeed it is to this that must be attributed most of their surprising success as surgeons at this early date. We are so accustomed to think that anaesthesia was discovered about the middle of the nineteenth cen- tury in America that we forget that literature is full of references in Tom Middleton's (seventeenth century) phrase to " the mercies of old surgeons who put their patients to sleep before they cut them." Anaesthetics were experimented with almost as zeal- ously, during the latter half of the thirteenth century at least, as during the latter half of the nineteenth century. They were probably not as successful as we are, but they did succeed in producing insensibility to pain, otherwise they could never have operated to the extent they did. Moreover the traditions show that the Da Luccas particularly had invented a method that left very little to be desired in this matter of anaesthesia. A reference to the sketch of Guy de Chauliac in this volume will show how practical the method was in his time. Nearly the same story as with regard to anaesthet- ics has to be repeated for what are deemed so surely modern developments, — asepsis and antisepsis. I GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 247 have already suggested that Roger seems to have known how extremely important it was to approach operations upon the skull with the most absolute cleanliness. There are many hints of the same kind in other writers which show that this was no mere accidental remark, but was a definite conclusion de- rived from experience and careful observation of results. We find much more with regard to this same subject in the writings of the group of northern Ital- ian surgeons and especially in the group of those associated with William of Salicet. Professor Clif- ford Allbutt, Regius Professor of Medicine at the University of Cambridge, England, in his address before the St. Louis World's Fair Congress of Arts and Science in 1904, did not hesitate to declare that William discussed the causes for union by first in- tention and the modes by which it might be obtained. He, too, insisted on cleanliness as the most impor- tant factor in having good surgical results, and all of this group of men, in operating upon septic cases, used stronger wine as a dressing. This exerted, as will be readily understood, a very definite antiseptic quality. Evidently some details of the teaching of this group of great surgeons in northern Italy in the second half of the thirteenth century will make clearer to us how much the rising universities of the time were accomplishing in medicine and surgery as well as in their other departments. The dates of the origin of some of these universities should per- haps be recalled so as to remind readers how closely related they are to this great group of surgical teach- ers. Salerno was founded very early, probably in 248 OLD-TIME MAKERS OF MEDICINE the tenth century; Bologna, Reggio, and Modena came into existence toward the end of the twelfth century; Vicenza, Padua, Naples, Vercelli, and Pi- acenza, as well as Arezzo, during the first half of the thirteenth century; Rome, Perugia, Trevizo, Pisa, Florence, Sienna, Lucca, Pavia, and Ferrara during the next century. The thirteenth century was the special flourishing period of the universities, and the medical departments, far from being behind, were leaders in accomplishment. (See my " The Thirteenth Greatest of Centuries," N. Y., 1908.) BRUNO DA LONGOBURGO The first of this important group of north Italian surgeons who taught at these universities was Bruno of Longoburgo. While he was born in Calabria, and probably studied in Salerno, his work was done at Vicenza, Padua, and Verona. His text-book, the " Chirurgia Magna/ ' dedicated to his friend An- drew of Piacenza, was completed at Padua in Jan- uary, 1252. Gurlt notes that he is the first of the Italian surgeons who quotes, besides the Greeks, the Arabian writers on surgery. Eclecticism had defi- nitely come into vogue to replace exclusive devotion to the Greek authors, and men were taking what was good wherever they found it. Gurlt tells us that Bruno owed much of what he wrote to his own ex- perience and observation. He 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 medi- cine to be used only when the other two instruments, GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 249 diet and potions, have failed. He insists that sur- geons 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. ' ' In his second chapter on healing he talks about healing by first and second intention. Wounds must be more carefully looked to in summer than in win- ter, because putref 'actio est major in aestate quam in hyeme, putrefaction is greater in summer than in winter. For 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 indis- pensable, and recommends for this a fine, square needle. The preferable suture material in his experi- ence was silk or linen. The end of the wound was to remain open in order that lint might be placed therein in order to draw off any objectionable material. He is particularly insistent on the necessity for drainage. In deep 250 OLD-TIME MAKERS OP MEDICINE wounds special provision must be made, and in wounds of extremities the limb must be so placed as to encourage drainage. If drainage does not take place, then either the wound must be thoroughly opened, or if necessary a counter opening must be made to provide drainage. All his treatment of wounds is dry, however. Water, he considered, al- ways did harm. We can readily understand that the water generally available and especially as surgeons saw it in camps and on the battlefield, was likely to do much more harm than good. In penetrating wounds of the belly cavity, 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 sug- gested, 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 developments 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 treat- GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 251 ment 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 pro- hibiting wrestling and loud crying and violent mo- tion. 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 considera- ble 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 fistulas into penetrating and non- penetrating, and suggests salves for the non-pene- trating and the actual cautery for those that pene- trate. He warns against the possibility of producing incontinence by the incision of deep fistulas, for this would leave the patient in a worse state than before. HUGH OF LUCCA Bruno brought up with him the methods and prin- ciples of surgery from the south of Italy, but there seems to have been already in the north at least one distinguished surgeon who had made his mark. This was Ugo da Lucca or Ugo Luccanus, sometimes known in the modern times in German histories of medicine as Hugo da Lucca and in English, Hugh of Lucca. He flourished early in the thirteenth cen- tury. In 1214 he was called to Bologna to become the city physician, and joined the Bolognese volun- teers in the crusade in 1218, being present at the 252 OLD-TIME MAKEES OF MEDICINE siege of Damietta. He returned to Bologna in 1221 and was given the post of legal physician to the city. The civic statutes of Bologna are, according to G-urlt, the oldest monument of legal medicine in the Middle Ages. Ugo died not long after the middle of the century, and is said to have been nearly one hundred years old. Of his five sons, three became physicians. The most celebrated of these was Theodoric, who wrote a text -book of surgery in which are set down the traditions of surgery that had been practised in his father 's life. Theodoric is especially enthusiastic in praise of his father, because he succeeded in bring- ing about such perfect healing of wounds with only wine and water and the ligature and without the employment of any ointments. Ugo seems to have occupied himself much with chemistry. To him we owe a series of discoveries with regard to anodyne and anaesthetizing drugs. He is said to have been the first who taught the sublimation of arsenic. Unfortunately he left no writings after him, and all that we know of him we owe to the filial devotion of his son Theodoric. THEODORIC This son, after having completed his medical studies at the age of about twenty-three, en- tered the Dominican Order, then only recently established, but continued his practice of medi- cine undisturbed. His ecclesiastical preferment was rapid. He attracted the attention of the Bishop of Valencia, and became his chaplain in Eome. At the age of about fifty he was made GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 253 a bishop in South Italy and later transferred to the Bishopric of Cervia, not far from Ravenna. Most of his life seems to have been passed in Bo- logna however, and he continued to practise medi- cine, devoting his fees, however, entirely to charity. His text-book of surgery was written about 1266 and is signed with his full name and title as Bishop of Cervia. Even at this time however, he still re- tained the custom of designating himself as a mem- ber of the Dominican Order. The most interesting thing in the first book of his surgery is undoubtedly his declaration that all wounds should be treated only with wine and ban- daging. Wine he insists on as the best possible dressing for wounds. It was the most readily availa- ble antiseptic that they had at that time, and un- doubtedly both his father's recommendation of it and his own favorable experience with it were due to this quality. It must have acted as an excellent in- hibitive agent of many of the simple forms of pus formation. At the conclusion of this first book he emphasizes that it is extremely important for the healing of wounds that the patient should have good blood, and this can only be obtained from suitable nutrition. It is essential therefore for the physician to be familiar with the foods which produce good blood in order that his wounded patients may be fed appropriately. He suggests, then, a number of arti- cles of diet which are particularly useful in produc- ing such a favorable state of the tissues as will bring about the rebirth of flesh and the adhesion of wound surfaces. Shortly before he emphasizes the neces- sity for not injuring nerves, though if nerves have 254: OLD-TIME MAKERS OF MEDICINE been cut they should be brought together as carefully as possible, the wound edges being then approxi- mated. Probably the most interesting feature for our gen- eration of the great text-books of the surgeons of the medieval universities is the occurrence in them of definite directions for securing union in surgical wounds, at least by first intention and their insist- ence on keeping wounds clear. The expression union by first intention comes to us from the olden time. They even boasted that the scars left after their incisions were often so small as to be scarcely noticeable. Such expressions of course could only have come from men who had succeeded in solving some of the problems of antisepsis that were solved once more in the generation preceding our own. With regard to their treatment of wounds, Professor Clifford Allbutt says : * i ' They washed the wound with wine, scrupulously removing every foreign particle ; then they brought the edges together, not allowing wine nor anything else to remain within — dry adhesive surfaces were their desire. Nature, they said, produces the means of union in a viscous exudation, or natural balm, as it was afterwards called by Paracelsus, Pare, and Wurtz. In older wounds they did their best to ob- tain union by cleansing, desiccation, and refreshing of the edges. Upon the outer surface they laid only lint steeped in wine. Powders they regarded as too desiccating, for powder shuts in decomposing mat- ters ; wine after washing, purifying, and drying the raw surfaces evaporates. >? J " Historical Relations of Medicine and Surgery Down to the Six- teenth Century," London, 1904. GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 255 Theodoric comes nearest to us^efsall these old sur- Cgeons. The surgeon who in d26§JwYote : ' ' For it is not necessary, as Roger and Roland have written, as many of their disciples teach, and as all modern surgeons profess, that pus should be generated in wounds. No error can be greater than this. Such a practice is indeed to hinder nature, to prolong the disease, and to prevent the conglutination and con- solidation of the wound ' ' was more than half a mil- lennium ahead of his time. The italics in the word modern are mine, but might well have been used by some early advocate of antisepsis or even by Lord Lister himself. Just six centuries almost to the year would separate the two declarations, yet they would be just as true at one time as at another. When we learn that Theodoric was proud of the beautiful cicatrices which he obtained without the use of any ointment, pulcherrimas cicatrices sine unguento attquo inducebat, then further that he im- pugned the use of poultices and of oils on wounds, while powders were too drying and besides had a tendency to prevent drainage, the literal meaning of the Latin words saniem incarcerare is to " in- carcerate sanious material," it is easy to understand that the claim that antiseptic surgery was antici- pated six centuries ago is no exaggeration and no far-fetched explanation with modern ideas in mind of certain clever modes of dressing hit upon acci- dentally by medieval surgeons. Theodoric's treatment of many practical problems is interesting for the modern time. For instance, in his discussion of cancer he says that there are two forms of the affection. One of them is due to a 256 OLD-TIME MAKERS OF MEDICINE melancholy humor, a constitutional tendency as it were, and occurs especially in the breasts of women or latent in the womb. This is difficult of treatment and usually fatal. The other class consists of a deep ulcer with undermined edges, occurring partic- ularly on the legs, difficult to cure and ready of re- lapse, but for which the outlook is not so bad. His description of noli me tang ere and of lupus is rather practical. Lupus is ' i eating herpes, ' ' occurs mainly on the nose, or around the mouth, slowly increases, and either follows a preceding erysipelas or comes from some internal cause. Noli me tangere is a cor- roding ulcer, so called perhaps because irritation of it causes it to spread more rapidly. He thinks that deep cauterization of it is the best treatment. Since these are in the department of skin diseases this seems the place to mention that Theodoric describes salivation as occurring after the use of mercury for certain skin diseases. He has already shown that he knows of certain genital ulcers and sores on the genital regions and of distinctions between them. WILLIAM OF SALICET The third of the great surgeons in northern Italy was William of Salicet. He was a pupil of Bruno's and the master of Lanfranc. The first part of his life was passed at Bologna and the latter part as the municipal and hospital physician of Verona. He probably died about 1280. He was a physician as well as a surgeon and was one of those who insisted that the two modes of practising medicine should not be separated, or if they were both medicine and GBEAT SURGEONS OF MEDIEVAL UNIVERSITIES 257 surgery would suffer. He thought that the physician learned much by seeing the interior of the body dur- ing life, while the surgeon was more conservative if he were a physician. It is curiously interesting to find that the Regius Professors at both Oxford and Cambridge in our time have expressed them- selves somewhat similarly. Professor Clifford All- butt is quite emphatic in this matter and Professor Osier is on record to the same effect. Following Theodoric, William of Salicet did much to get away from the Arabic abuse of the cautery and brought the knife back to its proper place again as the ideal surgical instrument. Unlike those who had written before him, William quoted very little from preced- ing writers. Whenever he quotes his contemporaries it is in order to criticise them. He depended on his own experience and considered that it was only what he had actually learned from experience that he should publish for the benefit of others. A very good idea of the sort of surgery that Wil- liam of Salicet practised may be obtained even from the beginning of the first chapter of his first book. This is all with regard to surgery of the head. He begins with the treatment of hydrocephalus or, as he calls it, ' ' water collected in the heads of children newly born." He rejects opening of the head by an incision because of the danger of it. In a number of cases, however, he had had success by puncturing the scalp and membranes with a cautery, though but a very small opening was made and the fluid was al- lowed to escape only drop by drop. He then takes up eye diseases, a department of surgery rather well developed at that time, as can be seen from our 258 OLD-TIME MAKERS OF MEDICINE account of the work of Pope John XXI as an oph- thalmologist during the thirteenth century. See Ophthalmology (January, 1909), reprinted in " Catholic Churchmen in Science," Philadelphia, The Dolphin Press, 1909. William devotes six chapters to the diseases of the eyes and the eyelids. Then there are two chap- ters on affections of the ears. Foreign bodies and an accumulation of ear wax are removed by means of instruments. A polyp is either cut off or its pedi- cle bound with a ligature, and it is allowed to shrivel. The next chapter is on the nose. Nasal polyps were to be grasped with a sharp tenaculum, cum tenacillis acutis, and either wholly or partially extracted. Eanula was treated by being lifted well forward by means of a sharp iron hook and then split with a razor. It is evident that the tendency of these to fill up again was recognized, and accordingly it was recommended that vitriol powder, or alum with salt, be placed in the cavity for a time after evacuation in order to produce adhesive inflammation. In the same chapter on the mouth one finds that William did not hesitate to perform what cannot but be considered rather extensive operations within the oral cavity. For instance, he tells of removing a large epulis and gives an account in detail of the case. To quote his own words : ' ■ I cured a certain woman from Piacenza who was suffering from fleshy tumor on the gums of the upper jaw, the tumor hav- ing grown to such a size above the teeth and the gums that it was as large or perhaps larger than a hen's egg. I removed it at four operations by means of heated iron instruments. At the last GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 259 operation I removed the teeth that were loose with certain parts of the jawbone.' ' In the next chapter there is an account of the treat- ment of a remarkable case of abscess of the uvula. In the following chapter the swelling of cervical glands is taken up. In his experience expectant treatment of these was best. He advises internal medication with the building up of the general health, or suggests allowing the inflamed glands to empty themselves after pustulation. After much meddlesome surgery we are almost back to his meth- ods again. He did not hesitate to treat goitre sur- gically, though he considered there were certain in- ternal remedies that would benefit it. In obstinate cases he suggests the complete extirpation of cystic goitre, but if the sac is allowed to remain it should be thoroughly rubbed over on the inside with green ointment. He warns about the necessity for avoid- ing the veins and arteries in this operation, and says that ' ' in this affection many large veins make their appearance and they find their way everywhere through the fleshy mass." What I have given here is to be found in a little more than half a page of G-urlt's abstract of the first twenty chapters of Salicet's first book. Alto- gether Gurlt has more than ten pages of rather small print with regard to William ; most of it is as inter- esting and as practical and as representative of an- ticipations of what is done in the modern time as what I have here quoted. William, as I have said, depended much more upon his own experience than upon what was to be found in text-books. He knew the old text-books very well however, but as a rule 260 OLD-TIME MAKERS OF MEDICINE did not quote from them unless he had tried the recommendations for himself, or unless similar cases to these mentioned had come under his own observa- tion. He was evidently a thoroughly observant phy- sician, a skilled surgeon who was practical enough to see the simplest way to do things, and he proceeded to do them. It is no wonder that he influenced suc- ceeding generations so much, nor that his great pupil, Lanfranc, continuing his tradition, founded a school of surgery in Paris, the influence of which was to endure almost down to our time, and give France a primacy in surgery until the nineteenth century. LANFRANC After Salicet's lifetime the focus of interest in surgery changes from Italy to France, and what is still more complimentary to William, it is through a favorite disciple of his that the change takes place. This was Lanfranchi, or Lanfranco, sometimes spoken of as Alanfrancus, who practised as phy- sician and surgeon in Milan until banished from there by Matteo Visconti about 1290. He then went to Lyons, where in the course of his practice he attracted so much attention that he was offered the opportunity to teach surgery in Paris. He attracted what Gurlt calls an almost incredible number of scholars to his lessons in Paris, and by hundreds they accompanied him to the bedside of his patients and attended his operations. The dean of the med- ical faculty, Jean de Pas savant, urged him to write a text-book of surgery, not only for the benefit of GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 261 his students at Paris but for the sake of the prestige which this would confer on the medical school. Deans still urge the same reasons for writing. Lan- franc completed his surgery, called " Chirurgia •Magna, ' ' in 1296, and dedicated it to Philippe le Bel, the then reigning French King. Ten years later he died, but in the meantime he had transferred Italian prestige in surgery from Italy to France and laid the foundations in Paris of a thoroughly scientific as well as a practical surgery, though this depart- ment of the medical school had been in a sadly backward state when he came. In the second chapter of this text-book, the first containing the definition of surgery and general in- troduction, Lanfranc describes the qualities that in his opinion a surgeon should possess. He says, " It is necessary that a surgeon should have a temperate and moderate disposition. That he should have well- formed hands, long slender fingers, a strong body, not inclined to tremble and with all his members trained to the capable fulfilment of the wishes of his mind. He should be of deep intelligence and of a simple, humble, brave, but not audacious dis- position. He should be well grounded in natural science, and should know not only medicine but every part of philosophy ; should know logic well, so as to be able to understand what is written, to talk prop- erly, and to support what he has to say by good rea- sons." He suggests that it would be well for the surgeon to have spent some time teaching grammar and dialectics and rhetoric, especially if he is to teach others in surgery, for this practice will add greatly to his teaching power. Some of his expres- 262 OLD-TIME MAKERS OF MEDICINE » sions might well be repeated to young surgeons in the modern time. " The surgeon should not love difficult cases and should not allow himself to be tempted to undertake those that are desperate. He should help the poor as far as he can, but he should not hesitate to ask for good fees from the rich. ' ' Many generations since Lanfranc 's time have used the word nerves for tendons. Lanfranc, how- ever, made no such mistake. He says that the wounds of nerves, since the nerve is an instrument of sense arTd motion, are, on account of the greater sensitiveness which these structures possess, likely to involve much pain. Wounds along the length of the nerves are less dangerous than those across them. When a nerve is completely divided by a cross wound Lanfranc is of the opinion, though Theodoric and some others are opposed to it, that the nerve ends should be stitched together. He says that this suture insures the redintegration of the nerve much better. After this operation the restora- tion of the usefulness of the member is more com- plete and assured. His description of the treatment of the bite of a rabid dog is interesting. A large cupping glass should be applied over the wound so as to draw out as much blood as possible. After this the wound should be dilated and thoroughly cauterized to its depths with a hot iron. It should then be covered with various substances that were supposed to draw, in order as far as possible to remove the poison. His description of how one may recognize a rabid animal is rather striking in the light of our present GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 263 knowledge, for he seems to have realized that the main diagnostic element is a change in the disposi- tion of the animal, but above all a definite tendency to lack playfulness. Lanfranc had seen a number of cases of true rabies, and describes and suggests treatment for them, though evidently without very much confidence in the success of the treat- ment. The treatment of snake bites and the bites of other poisonous animals was supposed to follow the prin- ciples laid down for the bite of a mad dog, especially as regards the encouragement of free bleeding and the use of the cautery. Lanfranc has many other expressions that one is tempted to quote, because they show a thinking sur- geon of the old time, anticipating many supposedly modern ideas and conclusions. He is a particular favorite of Gurlt 's, who has more than twenty-five large octavo, closely printed pages with regard to him. There is scarcely any development in our mod- ern surgery that Lanfranc has not at least a hint of, certainly nothing in the surgery of a generation ago that does not find a mention in his book. On most subjects he has practical observations from his own experience to add to what was in surgical literature before his time. He quotes altogether more than a score of writers on surgery who had preceded him and evidently was thoroughly familiar with gen- eral surgical literature. There is scarcely an impor- tant surgical topic on which Gurlt does not find some interesting and personal remarks made by Lanfranc. All that we can do here is refer those who are inter- ested in Lanfranc to his own works or Gurlt. 264 OLD-TIME MAKERS OF MEDICINE MONDEVILLE The next of the important surgeons who were to bring such distinction to French surgery for five centuries was Henri de Mondeville. Writers usu- ally quote him as Henricus. His latter name is only the place of his birth, which was probably not far from Caen in Normandy. It is spelled in so many different ways, however, by different writers that it is well to realize that almost anything that looks like Mondeville probably refers to him. Such vari- ants as Mundeville, Hermondaville, Amondaville, Amundaville, Amandaville, Mandeville, Armanda- ville, Armendaville, Amandavilla occur. We owe a large amount of our information with re- gard to him to Professor Pagel, who issued the first edition of his book ever published (Berlin, 1892). It may seem surprising that Mondeville 's work should have been left thus long without publica- tion, but unfortunately he did not live long enough to finish it. He was one of the victims that tuberculosis claimed among physicians in the midst of their work. Though there are a great number of manuscript copies of his book, somehow Eenaissance interest in it in its incompleted state was never aroused suf- ficiently to bring about a printed edition. Certainly it was not because of any lack of interest on the part of his contemporaries or any lack of significance in the work itself, for its printing has been one of the surprises afforded us in the modern time as showing how thoroughly a great writer on surgery did his work at the beginning of the fourteenth century. GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 265 Gurlt, in his " History of Surgery/ ' has given over forty pages, much of it small type, with regard to Mondeville, because of the special interest there is in his writing. 1 His life is of particular interest for other reasons besides his subsequent success as a surgeon. He was another of the university men of this time who wan- dered far for opportunities in education. Though born in the north of France and receiving his pre- liminary education there, he made his medical stud- ies towards the end of the thirteenth century under Theodoric in Italy. Afterwards he studied medicine in Montpellier and surgery in Paris. Later he gave at least one course of lectures at Montpellier himself and a series of lectures in Paris, attracting to both universities during his professorship a crowd of students from every part of Europe. One of his teachers at Paris had been his compatriot, Jean Pitard, the surgeon of Philippe le Bel, of whom he speaks as " most skilful and expert in the art of surgery,' ' and it was doubtless to Pitard 's friend- ship that he owed his appointment as one of the four surgeons and three physicians who accompanied the King into Flanders. Besides his lectures, Mondeville had a large con- sultant practice and also had to accompany the King on his campaigns. This made it extremely difficult J Of course, for any extended knowledge of Mondeville, a modern reader must turn to Nicaise's translation of his "Chirurgia," which, with an introduction and a biography, was published at Paris in 1893. Nicaise's publication of this and of Guy de Chauliac's treatise has worked a revolution in medical history and, above all, has made these old authors available for those who hesitate to take up a work written entirely in Latin. 266 OLD-TIME MAKERS OF MEDICINE for him to keep continuously at the writing of his book. It was delayed in spite of his good intentions, and we have the picture that is so familiar in the modern time of a busy man trying to steal or make time for his writing. Unfortunately, in addition to other obstacles, Mondeville showed probably before he was forty the first symptoms of a serious pulmonary disease, presumably tuberculosis. He bravely fought it and went on with his work. As his end approached he sketched in lightly what he had hoped to treat much more formally, and then turned to what was to have been the last chapter of his book, the Antidotarium or suggestions of practical remedies against diseases of various kinds because his students and physician friends were urging him to complete this portion for them. We of the modern time are much less interested in that than we would have been in some of the portions of the work that Mondeville neglected in order to provide therapeutic hints for his disciples. But then the students and young physicians have always clamored for the practical — which so far at least in medical history has always proved of only passing interest. It is often said that at this time surgery was mainly in the hands of barbers and the ignorant. Henri de Mondeville, however, is a striking example in contradiction of this. He must have had a fine preliminary education and his book shows very wide reading. There is almost no one of any importance who seriously touched upon medicine or surgery be- fore his time whom Mondeville does not quote. Hip- pocrates, Aristotle, Dioscorides, Pliny, Galen, Rhazes, Ali Abbas, Abulcasis, Avicenna, Constan- GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 267 tine Africanus, Averroes, Maimonides, Albertus Magnus, Hugo of Lucca, Theodoric, William of Sa- licet, Lanfranc are all quoted, and not once or twice but many times. Besides lie has quotations from the poets and philosophers, Cato, Diogenes, Horace, Ovid, Plato, Seneca, and others. He was a learned man, devoting himself to surgery. It is no wonder, then, that he thought that a sur- geon should be a scholar, and that he needed to know much more than a physician. One of his char- acteristic passages is that in which he declares " it is impossible that a surgeon should be expert who does not know not only the principles, but every- thing worth while knowing about medicine," and then he added, " just as it is impossible for a man to be a good physician who is entirely ignorant of the art of surgery. ' ' He says further : ' ' This our art of surgery, which is the third part of medicine (the other two parts were diet and drugs), is, with all due reverence to physicians, considered by us surgeons ourselves and by the non-medical as a more certain, nobler, securer, more perfect, more necessary, and more lucrative art than the other parts of medicine." Surgeons have always been prone to glory in their specialty. Mondeville had a high idea of the training that a surgeon should possess. He says: " A surgeon who wishes to operate regularly ought first for a long time to frequent places in which skilled sur- geons operate often, and he ought to pay careful attention to their operations and commit their tech- nique to memory. Then he ought to associate him- self with them in doing operations. A man cannot 268 OLD-TIME MAKEBS OF MEDICINE be a good surgeon unless he knows both the art and science of medicine and especially anatomy. The characteristics of a good surgeon are that he should be moderately bold, not given to disputations before those who do not know medicine, operate with fore- sight and wisdom, not beginning dangerous opera- tions until he has provided himself with everything necessary for lessening the danger. He should have well-shaped members, especially hands with long, slender fingers, mobile and not tremulous, and with all his members strong and healthy so that he may perform all the good operations without disturb- ance of mind. He must be highly moral, should care for the poor for Grod's sake, see that he makes him- self well paid by the rich, should comfort his pa- tients by pleasant discourse, and should always ac- cede to their requests if these do not interfere with the cure of the disease.' ' " It follows from this," he says, ' ' that the perfect surgeon is more than the perfect physician, and that while he must know medi- cine he must in addition know his handicraft. ' ' Thinking thus, it is no wonder that he places his book under as noble patronage as possible. He says in the preface that he " began to write it for the honor and praise of Christ Jesus, of the Virgin Mary, of the Saints and Martyrs, Cosmas and Damian, and of King Philip of France as well as his four chil- dren, and on the proposal and request of Master William of Briscia, distinguished professor in the science of medicine and formerly physician to Pope Boniface IV and Benedict and Clement, the present Pope." His first book on anatomy he proposed to found on that of Avicenna and ' ' on his personal ex- GBEAT SURGEONS OF MEDIEVAL UNIVERSITIES 269 perience as lie has seen it." The second tractate on the treatments of wounds, contusions, and ulcers was founded on the second book of Theodoric i ' with whatever by recent study has been newly acquired and brought to light through the experience of mod- ern physicians." He then confesses his obligations to his great master, John Pitard, and adds that all the experience that he has gained while operating, studying, and lecturing for many years on surgery will be made use of in order to enhance the value of the work. He hopes, however, to accomplish all this " briefly, quietly, and above all, charitably." There are many things in the preface that show us the reason for Mondeville's popularity, for they ex- hibit him as very sympathetically human in his in- terests. While Mondeville is devoted to the principle that authority is of great value, he said that there was nothing perfect in things human, and successive gen- erations of younger men often made important addi- tions to what their ancestors had left them. While his work is largely a compilation, nearly everywhere it shows signs of the modification of his predecessors' opinions by the results of his own experience. His method of writing is, as Pagel declares, i ' always in- teresting, lively, and often full of meat. ' ' He had a teacher 's instinct, for in several of the earlier manu- scripts his special teaching is put in larger letters in order to attract students ' attention. . . He seems to have introduced or re-introduced into practice the idea of the use of a large magnet in order to extract portions of iron from the tissues. He made several modifications in needles and thread holders and in- 270 OLD-TIME MAKERS OF MEDICINE vented a kind of small derrick for the extraction of arrows with barbs. Besides, lie suggested the sur- rounding of the barbs of the arrows with tubes, to facilitate extraction. In his treatment of wounds, Pagel considers that as a writer and teacher he is far ahead of his predecessors and even of those who came after him in immediately subsequent genera- tions. One of his great merits undoubtedly is that Guy de Chauliac, the father of modern surgery, in his text-book turned to him with a confidence that proclaims his admiration and how much he felt that he had gained from him. One of the most interesting features of Monde- ville's work is his insistence on the influence of the mind on the body and the importance of using this influence to the best advantage. It is especially im- portant in Mondeville's opinion to keep a surgical patient from being moody. ' ' Let the surgeon, ' ' says he, ' ' take care to regulate the whole regimen of the patient's life for joy and happiness by promising that he will soon be well, by allowing his relatives and special friends to cheer him and by having some- one to tell him jokes, and let him be solaced also by music on the viol or psaltery. The surgeon must forbid anger, hatred, and sadness in the patient, and remind him that the body grows fat from joy and thin from sadness. He must insist on the patient obeying him faithfully in all things. He repeats with approval the expression of Avicenna that " often the confidence of the patient in his physician does more for the cure of his disease than the physician with all his remedies.' ' Obstinate and conceited patients prone to object to nearly everything that the sur- GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 271 geon wants to do, and who often seem to think that they surpass Galen and Hippocrates in science and wisdom, are likely to delay their cure very much, and they represent the cases with which the surgeon has much difficulty. Mondeville thought that nursing was extremely important and that without it surgery often failed of its purpose. He says, i ' For if the assistants are not solicitous and faithful, and obedient to the sur- geons in each and every thing which may make for the cure of the disease, they put obstacles and diffi- culties in the way of the surgeon.' ' It is especially important that the patient's nutrition should be cared for and that the bandages should be managed exactly as the surgeon directs. He has no use for garrulous, talkative nurses, and does not hesitate to say that sometimes near relatives are particularly likely to disturb patients. " Especially are they prone to let drop some hint of bad news which the surgeon may have revealed to them in secret, or even the reports that they may hear from others, friends or enemies, and this provokes the patient to anger or anxiety and is likely to give him fever. If the as- sistants quarrel among themselves, or are heard mur- muring, or if they draw long faces, all of these things will disturb the patients and produce worry and anxiety or fear. The surgeon therefore must be careful in the selection of his nurses, for some of them obey very well while he is present, but do as they like and often just exactly the opposite of what he has directed when he is away. ' ' We do not know enough of the details of Monde- ville 's life to be sure whether he was married or not. 272 OLD-TIME MAKERS OF MEDICINE It is probable that he was not, for all of these sur- geons of the thirteenth century before Mondeville 's time, Theodoric, William of Salicet, Lanfranc, and Guy de Chauliac, after him belonged to the clerical order; Theodoric was a bishop; the others, how- ever, seem only to have been in minor orders. It is therefore from the standpoint of a man who views married life from without that Mondeville makes his remarks as to the difficulty often encountered when wives nurse their husbands. He says that the sur- geon has difficulty oftener when husbands or wives care for their spouses than at other times. This is much more likely to take place when the wives are caring for the husbands. " In our days," he says, " in this Gallican part of the world, wives rule their husbands, and the men for the most part permit themselves to be ruled. Whatever a surgeon may order for the cure of a husband then will often seem to the wives to be a waste of good material, though the men seem to be quite willing to get anything that may be ordered for the cure of their wives. The whole cause of this seems to be that every woman seems to think that her husband is not as good as those of other women whom she sees around her." It would be interesting to know how Mondeville was brought to a conclusion so different from modern experience in the matter. For those who are particularly interested in med- ical history one of the sections of Henry's book has a special appeal, because he gives in it a sketch of the history of surgery. We are little likely to think, as a rule, that at this time, full two centuries before the close of the Middle Ages, men were interested GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 273 enough in the doings of those who had gone before them to try to trace the history of the development of their specialty. It is characteristic of the way that the scholarly Mondeville views his own life work that he should have wanted to know something about his predecessors and teach others with regard to them. He begins with Galen, and as Galen divides the famous physicians of the world into three sects, the Methodists, the Empirics, and the Eationalists, so Mondeville divides modern surgery into three sects: first, that of the Salernitans, with Roger, Roland, and the Four Masters ; second, that of Wil- liam of Salicet and Lanfranc; and third, that of Hugo de Lucca and his brother Theodoric and their modern disciples. He states briefly the characteris- tics of these three sects. The first limited patients' diet, used no stimulants, dilated all wounds, and got union only after pus formation. The second allowed a liberal diet to weak patients, though not to the strong, but generally interfered with wounds too much. The third believed in a liberal diet, never di- lated wounds, never inserted tents, and its members were extremely careful not to complicate wounds of the head by unwise interference. His critical dis- cussion of the three schools is extremely interesting. Another phase of Mondeville 's work that is sym- pathetic to the moderns is his discussion of the ir- regular practice of medicine and surgery as it existed in his time. Most of our modern medicine and sur- gery was anticipated in the olden time; but it may be said that all of the modes of the quack are as old as humanity. Galen's description of the travelling charlatan who settled down in his front yard, not 274 OLD-TIME MAKERS OF MEDICINE knowing that it belonged to a physician, shows this very well. There were evidently as many of them and as many different kinds in Mondeville's time as in our own. In discussing the opposition that had arisen between physicians and surgeons in his time and their failure to realize that they were both mem- bers of a great profession, he enumerates the many different kinds of opponents that the medical profes- sion had. There were " barbers, soothsayers, loan agents, falsifiers, alchemists, meretrices, midwives, old women, converted Jews, Saracens, and indeed most of those who, having wasted their substance foolishly, now proceed to make physicians or sur- geons of themselves in order to make their living under the cloak of healing. ' ' What surprises Mondeville however, as it has al- ways surprised every physician who knows the sit- uation, is that so many educated, or at least sup- posedly well-informed people of the better classes, indeed even of the so-called best classes, allow them- selves to be influenced by these quacks. And it is even more surprising to him that so many well-to-do, intelligent people should, for no reason, though with- out knowledge, presume to give advice in medical matters and especially in even dangerous surgical diseases, and in such delicate affections as diseases of the eyes. " It thus often happens that diseases in themselves curable grow to be simply incurable or are made much worse than they were before.' ' He says that some of the clergymen of his time seemed to think that a knowledge of medicine is infused into them with the sacrament of Holy Orders. He was himself probably a clergyman, and I have in the GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 275 modern time more than once known of teachers in the clerical seminaries emphasizing this same idea for the clerical students. It is very evident that the world has not changed very much, and that to know any time reasonably well is to find in it comments on the morning paper. We are in the midst of just such a series of interferences with medicine on the part of the clergy as this wise, common-sense sur- geon of the thirteenth century deprecated. In every way Mondeville had the instincts of a teacher. He took advantage of every aid. He was probably the first to use illustrations in teaching anatomy. Guy de Chauliac, whose teacher in anat- omy for some time Mondeville was, says in the first chapter of his " Chirurgia Magna " that pictures do not suffice for the teaching of anatomy and that actual dissection is necessary. The passage runs as follows : ' i In the bodies of men, of apes, and of pigs, and of many other animals, tissues should be studied by dissections and not by pictures, as did Henricus, who was seen to demonstrate anatomy with thirteen pictures.' ' x What Chauliac blames is the attempt to replace dissections by pictorial de- monstrations. Hyrtl, however, suggests that this in- vention of Mondeville 's was probably very helpful, and was brought about by the impossibility of pre- 1 In the very first book containing some account of human anatomy, a German volume by Conradus Mengenberger, called " Puch der Na- tur," the date of printing of which is about 1478, — that is, less than ten years after the printing of the very first book, the "Bibliapauperum," which appeared in 1470,— there are, according to Haller in his "Biblio- theca Anatomica," a series of illustrations. This is the first illustrated medical work ever published. 276 OLD-TIME MAKERS OF MEDICINE serving bodies for long periods as well as the dif- ficulty of obtaining them. YPERMAN" One of the maxims of the old Greek philosophers was that good is diffusive of itself. As the scholas- tics put it, bonum est diffusivum sui. This proved to be eminently true of the old universities also, and especially of their training in medicine and in sur- gery. We have the accounts of men from many na- tions who went to the universities and returned to benefit their own people. Early in the thirteenth cen- tury Richard the Englishman was in Italy, having previously been in Paris and probably atMontpellier. Bernard Gordon, probably also an Englishman, was one of the great lights in medicine down at Mont- pellier, and his book, ' ' Lilium De Medicina, ' ' is well known. Two distinguished surgeons whose names have come down to us, having studied in Paris after Lanfranc had created the tradition of great surgical teaching there, came to their homes to be centres of beneficent influence among their people in this mat- ter. One was Yperman, of the town of Ypres in Belgium; the other Ardern of England. Ypermann was sent by his fellow-townsmen to Paris in order to study surgery, because they wanted to have a good surgeon in their town and Paris seemed the best school at that time. Ypres was at this period one of the greatest commercial cities of Europe, and probably had a couple of hundred thousand inhab- itants. The great hall of the cloth gild, which has been such an attraction for visitors ever since, was GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 277 built shortly before the town determined upon the very sensible procedure of securing good surgery beyond all doubt by having a townsman specially educated for that purpose. Yperman 's work was practically unknown to us until Broeck, the Belgian historian, discovered man- uscript copies of his book on surgery and gath- ered some details of his life. After his return from Paris, Yperman obtained great renown, which maintained itself in the custom extant in that part of the country even yet of calling an expert surgeon an Yperman. He is the author of two works in Flemish. One of these is a smaller com- pendium of internal medicine, which is very inter- esting, however, because it shows the many subjects that were occupying physicians ' minds at that time. He treats of dropsy, rheumatism, under which occur the terms coryza and catarrh (the flowing diseases), icterus, phthisis (he calls the tuberculosis, tysiken), apoplexy, epilepsy, frenzy, lethargy, fallen palate, cough, shortness of breath, lung abscess, hemor- rhage, blood-spitting, liver abscess, hardening of the spleen, affections of the kidney, bloody urine, dia- betes, incontinence of urine, dysuria, strangury, gonorrhea, and involuntary seminal emissions — all these terms are quoted directly from PagePs ac- count of his work; the original is not available in this country. JOHN AKDEEN In English-speaking countries of course we are in- terested in what was done by Englishmen at this 278 OLD-TIME MAKERS OF MEDICINE time. Fortunately we have the record of one great English surgeon of the period worthy to be placed beside even the writers already mentioned. This is John Ardern, whose name is probably a modifica- tion of the more familiar Arden, whose career well deserves attention. I have given a sketch of his work in " The Popes and Science.' ' x He was edu- cated at Montpellier, and practised surgery for a time in France. About the middle of the century how- ever, according to Pagel, he went back to his native land and settled for some twenty years at Newark, in Nottinghamshire, and then for nearly thirty years longer, until about the end of the century, was in London. He is the chief representative of English surgery during the Middle Ages. His " Practica," as yet unprinted, contains, according to Pagel, a short sketch of internal medicine, but is mainly de- voted to surgery. Contrary to the usual impression with regard to works in medicine and surgery at this time, the book abounds in references to case his- tories which Ardern had gathered, partly from his own and partly from others' experience. The thera- peutic measures that he suggests are usually very simple, in the majority of cases quite rational, though, of course, there are many superstitions among them; but Ardern always furnished a num- ber of suggestions from which to choose. He must have been an expert operator, and had excellent suc- cess in the treatment of diseases of the rectum. He seems to have been the first operator who made careful statistics of his cases, and was quite as proud 1 Fordham University Press, New York, 1908. GREAT SURGEONS OF MEDIEVAL UNIVERSITIES 279 as any modern surgeon of the large numbers that he had operated on, which he gives very exactly. He was the inventor of a new clyster apparatus. Fortunately we possess here in America, in the Surgeon General's Library at Washington, a very interesting manuscript containing Ardern's surgical writings, though it has not yet been published. Even a little study of this and of the notes on it prepared by an English bibliophile before its purchase by the Surgeon General 's Library, serves to show how val- uable the work is in the history of surgery. There are illustrations scarcely less interesting than the text. Some of these illustrations were inserted by the original writer or copyist, and some of them later. In general, however, they show a rather high devel- opment of the mechanics of surgery at that time. Some of the pages have spaces for illustrations left unfilled, so that evidently the copyist did not com- plete his work. The titles of certain of the chapters are interesting, as illustrating the fact that our medical and surgical problems were stated clearly in the olden time, and thinking physicians, even six centuries ago, met them quite rationally. There is, for instance, a chapter headed " Against Colic and the Iliac Passion,' ' immediately followed by the sub- heading, " Method of Administering Clysters." The iliac passion, passio iliaca of the old Latin, is usually taken to signify some obstruction of the in- testines causing severe pain, vomiting, and eventu- ally fecal vomiting. A good many different forms of severe painful conditions, especially all those com- plicated by peritonitis, were included under the term, and the modern student of surgery is likely to won- 280 OLD-TIME MAKEMS OF MEDICINE der whether these old observers had not noted that the right iliac region was particularly psone to be the source of fatal conditions. There is a chapter entitled " Against Pain in the Loins and the Kid- neys/ ' followed by the chapter subheading, ' ' Against Stone in the Kidneys. ' ' There is a chap- ter with the title, ' * Against Ulceration of the Blad- der or the Kidneys.' ' Another one, with the title " Against Burning of the Urine and Excoriation of the Lower Part of the Yard. ' ' Gonorrhea is frankly treated under the name Shawdepisse, evidently an English alliteration of the corresponding French word. As to the instrumentation of such conditions and for probing in general, Ardern suggests the use of a lead probe, because it may readily be made to bend any way and not injure the tissues. MEDIEVAL SURGERY Even this brief account of the surgeons who taught and studied at the medieval universities demon- strates what fine work they did. It is surely not too much to say that the chapter on university educa- tion mainly concerned with them is one of the most interesting in the whole history of the universities. Their story alone is quite enough to refute most of the prevalent impressions and patronizing expres- sions with regard to medieval education. Their careers serve to show how interested were the men of many nations in the development of an extremely important application of science for the benefit of sutler ing humanity. Their work utterly contradicts the idea so frequently emphasized that the great GBEAT SURGEONS OF MEDIEVAL UNIVERSITIES 281 students of the Middle Ages were lacking in prac- ticalness. Besides, they make very clear that we have been prone to judge the Middle Ages too much from its speculative philosophies. It has been the custom to say that speculation ruled men's minds and prevented them from making observations, de- veloping science, or applying scientific principles. There was much speculation during the Middle Ages, but probably not any more in proportion than exists at the present day. We were either not acquainted with, or failed to appreciate properly, until com- paratively recent years, the other side of medieval accomplishment. Our ignorance led us into misun- derstanding of what these generations really did. It was our own fault, because during the Kenaissance practically all of these books were edited and printed under the direction cf the great scholars of the time in fine editions, but during the eighteenth century nearly all interest was lost in them, and we are only now beginning to get back a certain amount of the precious knowledge that they had in the Kenaissance period of this other side of medieval life. We have learned so much about surgery because distinguished scholars devoted themselves to this phase of the his- tory of science. Doubtless there are many other phases of the history of science which suffered the same fate of neglect and with regard to which the future will bring us equally startling revelations. For this reason this marvellous chapter in the his- tory of surgery is a warning as well as a startling record of a marvellous epoch of human progress. XI GUY DE CHAULIAC One of the most interesting characters in the his- tory of medieval medicine, and undoubtedly the most important and significant of these Old-Time Makers of Medicine, is Guy de Chauliac. Most of the false no- tions so commonly accepted with regard to the Mid- dle Ages at once disappear after a careful study of his career. The idea of the careful application of scientific principles in a great practical way is far removed from the ordinary notion of medieval pro- cedure. Some observations we may concede that they did make, but we are inclined to think that these were not regularly ordered and the lessons of them not drawn so as to make them valuable as experi- ences. Great art men may have had, but science and, above all, applied science, is a later development of humanity. Particularly is this supposed to be true with regard to the science and practice of surgery, which is assumed to be of comparatively recent origin. Nothing could well be less true, and if the thoroughly practical development of surgery may be taken as a symbol of how capable men were of apply- ing science and scientific principles, then it is com- paratively easy to show that the men of the later Middle Ages were occupied very much as have been our recent generations with science and its practical applications. 282 GUT DE CHAULIAC 283 The immediate evidence of the value of old-time surgery is to be found in the fact that Guy de Chauliac, who is commonly spoken of in the history of medicine as the Father of Modern Surgery, lived his seventy-odd years of life during the fourteenth century and accomplished the best of his work, therefore, some five centuries before surgery in our modern sense of the term is supposed to have de- veloped. A glance at his career, however, will show how old are most of the important developments of surgery, as also in what a thoroughly scientific temper of mind this subject was approached more than a century before the close of the Middle Ages. The life of this French surgeon, indeed, who was a cleric and occupied the position of chamberlain and physician-in-ordinary to three of the Avignon Popes, is not only a contradiction of many of the tradi- tions as to the backwardness of our medieval for- bears in medicine, that are readily accepted by many presumably educated people, but it is the best pos- sible antidote for that insistent misunderstanding of the Middle Ages which attributes profound igno- rance of science, almost complete failure of observa- tion, and an absolute lack of initiative in applica- tions of science to the men of those times. Guy de Chauliac 's life is modern in nearly every phase. He was educated in a little town of the south of France, made his medical studies at Mont- pellier, and then went on a journey of hundreds of miles into Italy, in order to make his post-graduate studies. Italy occupied the place in science at that time that Germany has taken during the nineteenth century. A young man who wanted to get into touch 284 OLD-TIME MAKERS OF MEDICINE with the great masters in medicine naturally went down into the Peninsula. Traditions as to the atti- tude of the Church to science notwithstanding, Italy where education was more completely under the influence of the Popes and ecclesiastics than in any other country in Europe, continued to be the home of post-graduate work in science for the next four centuries. Almost needless to say, the journey to Italy was more difficult of accomplishment and in- volved more expense and time than would even the voyage from America to Europe in our time. Chau- liac realized, however, that both time and expense would be well rewarded, and his ardor for the round- ing out of his education was amply recompensed by the event. Nor have we any reason for thinking that what he did was very rare, much less unique, in his time. Many a student from France, Germany, and England made the long journey to Italy for post-graduate opportunities during the later Middle Ages. Even this post-graduate experience in Italy did not satisfy Chauliac, however, for, after having studied several years with the most distinguished Italian teachers of anatomy and surgery, he spent some time in Paris, apparently so as to be sure that he would be acquainted with the best that was being done in his specialty in every part of the world. He then settled down to his own life work, carrying his Italian and French masters' teachings well beyond the point where he received them, and after years of personal experience he gathered together his masters' ideas, tested by his own observations, into his " Chirurgia Magna," a great text-book of sur- GUY BE CHAULIAC 285 gery which sums up the whole subject succinctly, yet completely, for succeeding generations. When we talk about what he accomplished for surgery, we are not dependent on traditions nor vague informa- tion gleaned from contemporaries and successors, who might perhaps have been so much impressed by his personality as to be made over-enthusiastic in their critical judgment of him. We know the man in his surgical works, and they have continued to be classics in surgery ever since. It is an honorable distinction for the medicine of the later fourteenth, the fifteenth, and sixteenth centuries that Guy de Chauliac 's book was the most read volume of the time in medicine. Evidently the career of such a man is of import, not alone to physicians, but to all who are interested in the history of education. Chauliac derives his name from the little town of Chauliac in the diocese of Mende, almost in the centre of what is now the department of Lozere. The records of births and deaths were not consid- ered so important in the fourteenth century as they are now, and so we are not sure of either in the case of Chauliac. It is usually considered that he was born some time during the last decade of the thir- teenth century, probably toward the end of it, and that he died about 1370. Of his early education we know nothing, but it must have been reasonably efficient, since it gave him a good working knowledge of Latin, which was the universal language of science and especially of medicine at that time ; and though his own style, as must be expected, is no better than that of his contemporaries, he knew how to express his thoughts clearly in straightforward Latin, with 286 OLD-TIME MAKERS OF MEDICINE only such a mixture of foreign terms as his studies suggested and the exigencies of a new development of science almost required. Later in life he seems to have known Arabic very well, for he is evidently familiar with Arabian books and does not depend merely on translations of them. Pagel, in the first volume of Puschmann's " Hand- book of the History of Medicine,' ' says, on the authority of Nicaise and others, that Chauliac re- ceived his early education from the village clergy- man. His parents were poor, and but for ecclesi- astical interest in him it would have been difficult for him to obtain his education. The Church sup- plied at that time to a great extent for the founda- tions and scholarships, home and travelling, of our day, and Chauliac was amongst the favored ones. How well he deserved the favor his subsequent career shows, as it completely justifies the judg- ment of his patrons. He went first to Toulouse, as we know from his affectionate mention of one of his teachers there. Toulouse was more famous for law, however, than for medicine, and after a time Chau- liac sought Montpellier to complete his medical studies. For English-speaking people an added interest in Guy de Chauliac will be the fact that one of his teachers at Montpellier was Bernard Gordon, very probably a Scotchman, who taught for some thirty- five years at this famous university in the south of France, and died near the end of the first quarter of the fourteenth century. One of Chauliac 's fellow- students at Montpellier was John of Gaddesden, the first English Eoyal Physician by official appoint- GUT BE CHAULIAC 287 ment of whom we have any account. John is men- tioned by Chaucer in his " Doctor of Physic,'' and is usually looked upon as one of the fathers of Eng- lish medicine. Chauliac did not think much of him, though his reason for his dislike of him will prob- ably be somewhat startling to those who assumejthat the men of the Middle Ages always clung servilely to authority. Chauliac 's objection to Gaddesden's book is that he merely repeats his masters and does not dare to think for himself. It is not hard to understand that such an independent thinker as Chauliac should have been utterly dissatisfied with a book that did not go beyond the forefathers in medicine that the author quotes. This is the ex- planation of his well-known expression, " Last of all arose the scentless rose of England [' Eosa An- giise ' was the name of John of Gaddesden's book], in which, on its being sent to me, I hoped to find the odor of sweet originality, but instead of that I en- countered only the fictions of Hispanus, of Gilbert, and of Theodoric." The presence of a Scotch professor and an Eng- lish fellow-student, afterwards a royal physician, at Montpellier, at the beginning of the fourteenth cen- tury, shows how much more cosmopolitan was uni- versity life in those times than we are prone to think, and what attraction a great university medical school possessed even for men from long distances. After receiving his degree of Doctor of Medicine at Montpellier Chauliac went, as we have said, to Bologna. Here he attracted the attention and re- ceived the special instruction of Bertruccio, who was attracting students from all over Europe at 288 OLD-TIME MAKERS OF MEDICINE this time and was making some excellent demonstra- tions in anatomy, employing human dissections very freely. Chauliac tells of the methods that Bertruc- cio used in order that bodies might be in as good condition as possible for demonstration purposes, and mentions the fact that he saw him do many dis- sections in different ways. In Both's life of Vesalius, which is usually con- sidered one of our most authoritative medical his- torical works not only with regard to the details of Vesalius' life, but also in all that concerns anatomy about that time and for some centuries before, there is a passage quoted from Chauliac himself which shows how freely dissection was practised at the Italian universities in the fourteenth century. This passage deserves to be quoted at some length be- cause there are even serious historians who still cite a Bull of Pope Boniface VIII, issued in 1300, forbidding the boiling and dismembering of bodies in order to transport them to long distances for burial in their own country, as being, either rightly or wrongly, interpreted as a prohibition of dissec- tion and, therefore, preventing the development of anatomy. In the notes to his history of dissection during this period in Bologna Koth says : ' ' Without doubt the passage in Guy de Chauliac which tells of having frequently seen dissections, must be con- sidered as referring to Bologna. This passage runs as follows : ' My master Bertruccius conducted the dissection very often after the following manner: the dead body having been placed upon a bench, he used to make four lessons on it. In the first the nutritional portions were treated, because they are GUY DE CHAULIAC 289 so likely to become putrefied. In the second, he demonstrated the spiritual members; in the third, the animate members; in the fourth, the extrem- ities. ' " (Both, " Andreas Vesalius." Basel, 1896.) Bertruccio 's master, Mondino, is hailed in the his- tory of medicine as the father of dissection. His book on dissection was for the next three centuries in the hands of nearly every medical scholar in Europe who was trying to do good work in anatomy. It was not displaced until Vesalius came, the father of modern anatomy, who revolutionized the science in the Eenaissance time. Mondino had devoted him- self to the subject with unfailing ardor and enthusi- asm, and from everywhere in Europe the students came to receive inspiration in his dissecting-room. Within a few years such was the enthusiasm for dis- section aroused by him in Bologna that there were many legal prosecutions for body-snatching, the con- sequence doubtless of a regulation of the Medical Department of the University of Bologna, that if the students brought a body to any of their teachers he was bound to dissect it for them. Bertruccio, Mondino's disciple and successor, continued this great work, and now Chauliac, the third in the tradi- tion, was to carry the Bolognese methods back to France, and his position as chamberlain to the Pope was to give them a wide vogue throughout the world. The great French surgeon's attitude toward anat- omy and dissection can be judged from his famous expression that " the surgeon ignorant of anatomy carves the human body as a blind man carves wood." The whole subject of dissection at this time has been fully discussed in the first three chapters 290 OLD-TIME MAKERS OF MEDICINE of my " Popes and Science," where those who are interested in the matter may follow it to their satis- faction. 1 After his Bologna experience Chauliac went to Paris. Evidently his indefatigable desire to know all that there was to be known would not be satisfied until he had spent some time at the great French university where Lanfranc, after having studied under William of Salicet in Italy, had gone to estab- lish that tradition of French surgery which, carried on so well by Mondeville his great successor, was to maintain Frenchmen as the leading surgeons of the world until the nineteenth century (Pagel). Lanfranc, himself an Italian, had been exiled from his native country, apparently because of political troubles, but was welcomed at Paris because the faculty realized that they needed the inspiration of the Italian medical movement in surgery for the es- tablishment of a good school of surgery in connec- tion with the university. The teaching so well begun by Lanfranc was magnificently continued by Monde- ville and Arnold of Villanova and their disciples. Chauliac was fortunate enough to come under the influence of Petrus de Argentaria, who was worthily maintaining the tradition of practical teaching in anatomy and surgery so well founded by his great predecessors of the thirteenth century. After this grand tour Chauliac was himself prepared to do work of the highest order, for he had been in touch with all that was best in the medicine and surgery of his time. 1 Fordham University Press, New York, 1908. GUT BE CHAULIAC 291 Like many another distinguished member of his profession, Chauliac did not settle down in the scene of his ultimate labors at once, but was something of a wanderer. His own words are, " Et per multa tempora operatus fui in multis partibus." Perhaps out of gratitude to the clerical patrons of his native town to whom he owed so much, or because of the obligations he considered that he owed them for his education, he practised first in his native diocese of Mende ; thence he removed to Lyons, where we know that he lived for several years, for in 1344 he took part as a canon in a chapter that met in the Church of St. Just in that city. Just when he was called to Avignon we do not know, though when the black death ravaged that city in 1348 he was the body- physician of Pope Clement VI, for he is spoken of in a Papal document as " venerabilis et circum- spectus vir, dominus Guido de Cauliaco, canonicus et propositus ecclesice Sancti Justi Lugduni, medi- cusque domini Nostri Papce." All the rest of his life was passed in the Papal capital, which Avignon was for some seventy years of the fourteenth cen- tury. He served as chamberlain-physician to three Popes, Clement VI, Innocent VI, and Urban V. We do not know the exact date of his death, but when Pope Urban V went to Rome in 1367, Chauliac was putting the finishing touches on his " Chirurgia Magna,' ' which, as he tells us, was undertaken as a solatium senectutis — a solace in old age. When Urban returned to Avignon for a time in 1370 Chauliac was dead. His life work is summed up for us in this great treatise on surgery, full of anticipa- 292 OLD-TIME MAKERS OF MEDICINE tions in surgical procedures that we are prone to think much more modern. Nicaise has emphasized the principles which guided Guy de Chauliac in the choice and interpreta- tion of his authorities by a quotation from Guy himself, which is so different in its tone from what is usually supposed to have been the attitude of mind of the men of science of the time that it would be well for all those who want to understand the Mid- dle Ages better to have it near them. Speaking of the surgeons of his own and immediately preceding generations, Guy says: " One thing particularly is a source of annoyance to me in what these surgeons have written, and it is that they follow one another like so many cranes. For one always says what the other says. I do not know whether it is from fear or from love that they do not deign to listen except to such things as they are accustomed to and as have been proved by authorities. They have to my mind understood very badly Aristotle's second book of metaphysics where he shows that these two things, fear and love, are the greatest obstacles on the road to the knowledge of the truth. Let them give up such friendships and fears. ' Because while Socrates or Plato may be a friend, truth is a greater friend.' Truth is a holy thing and worthy to be honored above everything else. Let them fol- low the doctrine of Galen, which is entirely made up of experience and reason, and in which one in- vestigates things and despises words." After all, this is what great authorities in medi- cine have always insisted on. Once every hundred years or so one finds a really great observer who GUY DE CHAULIAC 293 makes new observations and wakes the world up. He is surprised that men should not have used their powers of observation for themselves, but should have been following old-time masters. His corn- temporaries often refuse to listen to him at first. His observations, however, eventually make their way. We blame the Middle Ages for following au- thority, but what have we been always doing but following authority, except for the geniuses who come and lift us out of the rut and illuminate a new portion of the realm of medicine. After they have come, however, and done their work, their disciples proceed to see with their eyes and to think that they are making observations for themselves when they are merely following authority. When the next mas- ter in medicine comes along his discovery is neg- lected because men have not found it in the old books, and usually he has to suffer for daring to have opinions of his own. The fact of the matter is that at any time there is only a very limited num- ber of men who think for themselves. The rest think other people's thoughts and think they are thinking and doing things. As for observation, John Buskin once said, i l Nothing is harder than to see something and tell it simply as you saw it. ' ' This is as true in science as in art, and only genius succeeds in doing it well. Chauliac's book is confessedly a compilation. He has taken the good wherever he found it, though he adds, modestly enough, that ' ' his work also contains whatever his own measure of intelligence enabled him to find useful (quce juxta modicitatem mei in- genii utilia reputavi). Indeed it is the critical judg- 294 OLD-TIME MAKERS OF MEDICINE inent displayed by Chauliac in selecting from his predecessors that best illustrates at once the prac- tical character of his intellect and his discerning spirit. What the men of his time are said to have lacked is the critical faculty. They were encyclo- pedic in intellect and gathered all kinds of informa- tion without discrimination, is a very common criti- cism of medieval writers. No one can say this of Chauliac, however, and, above all, he was no re- specter of authority, merely for the sake of author- ity. His criticism of John of Gaddesden's book shows that the blind following of those who had gone before was his special bete noir. His bitterest reproach for many of his predecessors was that " they follow one another like cranes, whether for love or fear, I cannot say." Chauliac 's right to the title of father of surgery will perhaps be best appreciated from the brief ac- count of his recommendations as to the value of sur- gical intervention for conditions in the three most important cavities of the body, the skull, the thorax, and the abdomen. These cavities have usually been the dread of surgeons. Chauliac not only used the trephine, but laid down very exact indications for its application. Expectant treatment was to be the rule in wounds of the head, yet when necessary, in- terference was counselled as of great value. His prognosis of brain injuries was much better than that of his predecessors. He says that he had seen injuries of the brain followed by some loss of brain substance, yet with complete recovery of the patient. In one case that he notes a considerable amount of brain substance was lost, yet the patient recovered GUY BE CHAULIAC 295 with only a slight defect of memory, and even this disappeared after a time. He lays down exact indi- cations for the opening of the thorax, that noli me tang ere of surgeons at all times, even our own, and points out the relations of the rihs and the dia- phragm, so as to show just where the opening should be made in order to remove fluid of any kind. In abdominal conditions, however, Chauliac's an- ticipation of modern views is most surprising. He recognized that wounds of the intestines were surely fatal unless leakage could be prevented. Accord- ingly he suggested the opening of the abdomen and the sewing up of such intestinal wounds as could be located. He describes a method of suture for these cases and seems, like many another abdominal sur- geon, even to have invented a special needleholder. To most people it would seem absolutely out of the question that such surgical procedures could be prac- tised in the fourteenth century. We have the definite record of them, however, in a text-book that was the most read volume on the subject for several cen- turies. Most of the surprise with regard to these operations will vanish when it is recalled that in Italy during the thirteenth century, as we have al- ready seen, methods of anaesthesia by means of opium and mandragora were in common use, having been invented in the twelfth century and perfected by Ugo da Lucca, and Chauliac must not only have known but must have frequently employed various methods of anaesthesia. In discussing amputations he has described in general certain methods of anaesthesia in use in his time, and especially the method by means of inhala- 296 OLD-TIME MAKERS OF MEDICINE tion. It would not seem to us in the modern time that this method would be very successful, but there is an enthusiastic accord of authorities attesting that operations were done at this time with the help of this inhalant without the infliction of pain. Chauliac says: " Some prescribe medicaments which send the pa- tient to sleep, so that the incision may not be felt, such as opium, the juice of the morel, hyoscyamus, mandrake, ivy, hemlock, lettuce. A new sponge is soaked by them in these juices and left to dry in the sun; and when they have need of it they put this sponge into warm water and then hold it under the nostrils of the patient until he goes to sleep. Then they perform the operation. ' ' Many people might be prone to think that the hospitals of Chauliac 's time would not be suitable for such surgical work as he describes. It is, how- ever, only another amusing assumption of this self- complacent age of ours to think that we were the first who ever made hospitals worthy of the name and of the great humanitarian purpose they sub- serve. As a matter of fact, the old-time hospitals were even better than ours or, as a rule, better than any we had until the present generation. In " The Popes and Science,' ' in the chapter on " The Foun- dation of City Hospitals,' ' I call attention to the fact that architects of the present day go back to the hospitals of the Middle Ages in order to find the models for hospitals for the modern times. Mr. Arthur Dillon, a well-known New York architect, writing of a hospital built at Tonnerre in France, to- ward the end of the thirteenth century (1292), says: GUY DE CHAULIAC 297 ' i It was an admirable hospital in every way, and it is doubtful if we to-day surpass it. It was iso- lated ; the ward was separated from the other build- ings ; it had the advantage we so often lose of being but one story high, and more space was given to each patient than we can now afford. " The ventilation by the great windows and ven- tilators in the ceiling was excellent ; it was cheerfully lighted ; and the arrangement of the gallery shielded the patients from dazzling light and from draughts from the windows and afforded an easy means of supervision, while the division by the roofless low partitions isolated the sick and obviated the depres- sion that comes from sight of others in pain. ' ' It was, moreover, in great contrast to the cheer- less white wards of to-day. The vaulted ceiling was very beautiful; the woodwork was richly carved, and the great windows over the altars were filled with colored glass. Altogether it was one of the best examples of the best period of Gothic Archi- tecture." 1 The fine hospital thus described was but one of many. Virchow, in his article on hospitals quoted in the same chapter, called attention to the fact that in the thirteenth and fourteenth centuries every town of five thousand or more inhabitants had its hospital, founded on the model of the great Santo Spirito Hospital in Eome, and all of them did good work. The surgeons of Guy de Chauliac's time would in- deed find hospitals wherever they might be called in consultation, even in small towns. They were more numerous in proportion to population than our own x See picture of the hospital ward at Tonnerre, in " The Thirteenth Greatest of Centuries," 3rd edit., New York, 1911. 298 OLD-TIME MAKERS OF MEDICINE and, as a rule, at least as well organized as ours were until the last few years. It is no wonder that with such a good hospital organization excellent surgery was accomplished. Hernia was Chauliac's specialty, and in it his sur- gical judgment is admirable Mondeville before his time did not hesitate to say that many operations for hernia were done not for the benefit of the pa- tient, but for the benefit of the surgeon, — a very striking anticipation of remarks that one sometimes hears even at the present time. Chauliac discussed operations for hernia very conservatively. His rule was that a truss should be worn, and no operation attempted unless the patient's life was endangered by the hernia. It is to him that we owe the inven- tion of a well-developed method of taxis, or manipu- lation of a hernia, to bring about its reduction, which was in use until the end of the nineteenth century. He suggested that trusses could not be made accord- ing to rule, but must be adapted to each individual case. He invented several forms of truss himself, and in general it may be said that his manipulative skill and his power to apply his mechanical prin- ciples to his work are the most characteristic of his qualities. This is particularly noteworthy in his chapters on fractures and dislocations, in which he suggests various methods of reduction and realizes very practically the mechanical difficulties that were to be encountered in the correction of the deform- ities due to these pathological conditions. In a word, we have a picture of the skilled surgeon of the mod- ern time in this treatise of a fourteenth-century teacher of surgery. GUY BE CHAULIAC 299 Chauliac discusses six different operations for the radical cure of hernia. As Gurlt points out, he criticises them from the same standpoint as that of recent surgeons. The object of radical operations for hernia is to produce a strong, firm tissue support over the ring through which the cord passes, so that the intestines cannot descend through it. It is rather interesting to find that the surgeons of this time tried to obliterate the canal by means of the cautery, or inflammation producing agents, arsenic and the like, a practice that recalls some methods still used more or less irregularly. They also used gold wire, which was to be left in the tissues and is supposed to protect and strengthen the closure of the ring. At this time all these operations for the radical cure of hernia involved the sacrifice of the testicle because the old surgeons wanted to obliterate the ring completely, and thought this the easiest way. Chauliac discusses the operation in this re- spect and says that he has seen many cases in which men possessed of but one testicle have procreated, and this is a case where the lesser of two evils is to be chosen. Of course Guy de Chauliac would not have been able to operate so freely on hernia and suggest, fol- lowing his own experience, methods of treatment of penetrating wounds of the abdomen only that he had learned the lessons of antiseptic surgery which had been gradually developed among the great surgeons of Italy during the preceding century. The use of the stronger wines as a dressing together with in- sistence on the most absolute cleanliness of the sur- geon before the operation, and careful details of 300 OLD-TIME MAKERS OF MEDICINE cleanliness during the operation, made possible the performance of many methods of surgical interven- tion that would otherwise surely have been fatal. Probably nothing is harder to understand than that after these practical discoveries men should have lost sight of their significance, and after having carefully studied the viscous exudation which pro- duces healthy natural union, should have come to the thought of the necessity for the formation of laud- able pus before union might be expected. The mys- tery is really no greater than that of many another similar incident in human history, but it strikes us more forcibly because the discovery and gradual de- velopment of antiseptic surgery in our own time has meant so much for us. Already even in Chauliac's practice, however, some of the finer elements of the technique that made surgery antiseptic to a marked degree, if not positively aseptic in many cases, were not being emphasized as they were by his predeces- sors, and there was a beginning of surgical meddle- someness reasserting itself. It must not be thought, however, that it was only with the coarse applications of surgery that Chau- liac concerned himself. He was very much inter- ested in the surgical treatment of eye diseases and wrote a monograph on cataract, in which he gathers what was known before his time and discusses it in the light of his own experience. The writing of such a book is not so surprising at this time if we recall that in the preceding century the famous Pope John XXI, who had been a physician before he be- came Pope, and under the name of Peter of Spain was looked up to as one of the distinguished sci- GUY DE CHAULIAC 301 entists of his time, had written a book on eye dis- eases that has recently been the subject of much attention. Pope John had much to say of cataract, dividing it into traumatic and spontaneous, and suggesting the needling of cataract, a gold needle being used for the purpose. Chauliac 's method of treating cataract was by depression. His care in the selec- tion of patients may be appreciated from his treat- ment of John of Luxembourg, King of Bavaria, blind from cataract, who consulted Chauliac in 1336 while on a visit to Avignon with the King of France. Chauliac refused to operate, however, and put off the King with dietary regulations. In the chapter on John of Arcoli and Medieval Dentistry we call attention to the fact that Chauliac discussed dental surgery briefly, yet with such prac- tical detail as to show very clearly how much more was known about this specialty in his time than we have had any idea of until recent years. He recog- nized the dentists as specialists, calls them denta- tores, but thinks that they should operate under the direction of a physician — hence the physician should know much about teeth and especially about their preservation. He enumerates instruments that dentists should have and shows very clearly that the specialty had reached a high state of development. A typical example of Chauliac's common sense and dependence on observation and not tradition is to be found in what he has to say with regard to methods of removing the teeth without the use of extracting instruments. It is characteristic of his method of dealing with traditional remedies, even 302 OLD-TIME MAKERS OF MEDICINE though of long standing, that he brushes them aside with some impatience if they have not proved them- selves in his experience. " The ancients mention many medicaments, which draw out the teeth without iron instruments or which make them more easy to draw out ; such as the milky juice of the tithymal with pyrethrum, the roots of the mulberry and caper, citrine arsenic, aqua fortis, the fat of forest frogs. But these remedies promise much and accomplish but little — mais Us donnent beaucoup de promesses, et peu d' operations." It is no wonder that Chauliao has been enthusi- astically praised. Nicaise has devoutly gathered many of these praises into a sheaf of eulogies at the end of his biography of the great French surgeon. He tells us that Fallopius compared him to Hippoc- rates. John Calvo of Valencia, who translated the " Great Surgery " into Spanish, looks upon him as the first law-giver of surgery. Freind, the great English physician, in 1725 called him the Prince of Surgeons. Ackermann said that Guy de Chau- liac's text-book will take the place of all that has been written on the subject down to his time, so that even if all the other works had been lost his would replace them. Dezimeris, commenting on this, says that " if one should take this appreciation literally, this surgeon of the fourteenth century would be the first and, up to the present time, the only author who ever merited such an eulogy. ' ' "At least, ' ' he adds, ' ' we cannot refuse him the distinction of hav- ing made a work infinitely superior to all those which appeared up to this time and even for a long time afterwards. Posterity rendered him this justice, for GUY BE CHAULIAC 303 he was for three centuries the classic par excellence. He rendered the stndy easy and profitable, and all the foreign nations the tributaries of our country." Peyrihle considered Guy's " Surgery " as the most valuable and complete work of all those of the same kind that had been published since Hippocrates and added that the reading of it was still useful in his time in 1784. Begin, in his work on Ambroise Pare, says " that Guy has written an immortal book to which are attached the destinies of French surgeons." Malgaigne, in his " History of Surgery," does not hesitate to say, U I do not fear to say that, Hip- pocrates alone excepted, there is not a single treatise on surgery, — Greek, Latin, or Arabic, — which I place above, or even on the same level with, this magnificent work, ' The Surgery of Guy de Chau- liac' " Daremberg said, " Guy seems to us a sur- geon above all erudite, yet expert and without ever being rash. He knows, above all, how to choose what is best in everything." Verneuil, in his " Con- ference sur Les Chirurgiens Erudits," says, " The services rendered by the ' Great Surgery ' were im- mense; by it there commenced for France an era of splendor. It is with justice, then, that posterity has decreed to Guy de Chauliac the title of Father of French surgery." The more one reads of Chauliac's work the less is one surprised at the estimation in which he has been held wherever known. It would not be hard to add a further sheaf of compliments to those col- lected by Nicaise. Modern writers on the history of medicine have all been enthusiastic in their ad- miration of him, just in proportion to the thorough- 304 OLD-TIME MAKERS OF MEDICINE ness of their acquaintance with him. Portal, in his " History of Anatomy and Surgery,' ' says, " Finally, it may be averred that Guy de Chauliac said nearly everything which modern surgeons say, and that his work is of infinite price but unfortu- nately too little read, too little pondered." Mal- gaigne declares Chauliac's " Chirurgia Magna " to be " a masterpiece of learned and luminous writ- ing." Professor Clifford Allbutt, the Eegius Pro- fessor of Physic at the University of Cambridge, says of Chauliac's treatise: " This great work I have studied carefully and not without prejudice; yet I cannot wonder that Fallopius compared the author to Hippocrates or that John Freind calls him the Prince of Surgeons. It is rich, aphoristic, orderly, and precise. ' ' * If to this account of his professional career it be added that Chauliac 's personality is, if possible, more interesting than his surgical accomplishment, some idea of the significance of the life of the great father of modern surgery will be realized. We have already quoted the distinguished words of praise accorded him by Pope Clement VI. That they were well deserved, Chauliac's conduct during the black death which ravaged Avignon in 1348, shortly after his arrival in the Papal City, would have been suffi- cient of itself to attest. The occurrence of the plague in a city usually gave rise to an exhibition of the most arrant cowardice, and all who could, fled. In many of the European cities the physicians joined the fugitives, and the ailing were left to care ^'The Historical Relations of Medicine and Surgery," by T. Clifford Allbutt, M.A., M.D. London: Macmillan & Co., Ltd., 1905. GUY DE CHAULIAC 305 for themselves. With a few notable exceptions, this was the case at Avignon, but Guy was among those who remained faithful to his duty and took on him- self the self-sacrificing labor of caring for the sick, doubly harassing because so many of his brother physicians were absent. He denounces their con- duct as shameful, yet does not boast of his own courage, but on the contrary says that he was in constant fear of the disease. Toward the end of the epidemic he was attacked by the plague and for a time his life was despaired of. Fortunately he recovered, to become the most influential among his colleagues, the most highly admired of the physi- cians of his generation, and the close personal friend of all the high ecclesiastics, who had witnessed his magnificent display of courage and of helpfulness for the plague-stricken during the epidemic. He wrote a very clear account of the epidemic, which leaves no doubt that it was true bubonic plague. After this fine example, Chauliac's advice to brother physicians in the specialty of surgery car- ried added weight. In the Introductory chapter of his ' ' Chirurgia Magna ' ' he said : " The surgeon should be learned, skilled, in- genious, and of good morals. Be bold in things that are sure, cautious in dangers; avoid evil cures and practices; be gracious to the sick, obliging to his colleagues, wise in his predictions. Be chaste, sober, pitiful, and merciful; not covetous nor extortionate of money; but let the recompense be moderate, ac- cording to the work, the means of the sick, the char- acter of the issue or event, and its dignity.' ' 306 OLD-TIME MAKERS OF MEDICINE No wonder that Malgaigne says of him, " Never since Hippocrates has medicine heard snch language filled with so much nobility and so full of matter in so few words." Chauliac was in every way worthy of his great contemporaries and the period in which his lot was cast. Ordinarily we are not apt to think of the early fourteenth century as an especially productive period in human history, but such it is. Dante's Divine Comedy was entirely written during Chau- liac 's life. Petrarch was born within a few years of Chauliac himself; Boccaccio in Italy, and Chaucer in England, wrote while Chauliac was still alive. Giotto did his great painting, and his pupils were laying the deep, firm foundations of modern art. Many of the great cathedrals were being finished. Most of the universities were in the first flush of their success as moulders of the human mind. There are few centuries in history that can show the exist- ence of so many men whose work was to have an enduring influence for all the after time as this upon which Chauliac's career shed so bright a light. The preceding century had seen the origin of the universities and the rise of such supremely great men as Albertus Magnus, Eoger Bacon, Thomas Aquinas, and the other famous scholars of the early days of the mendicant orders, and had made the in- tellectual mould of university training in which men's minds for seven centuries were to be formed, so that Chauliac, instead of being an unusual phe- nomenon is only a fitting expression of the interest of this time in everything, including the physical sciences and, above all, medicine and surgery. GUT DE CHAULIAC 307 For some people it may be a source of surprise that Chauliac should have had the intellectual train- ing to enable him to accomplish such judicious work in his specialty. Many people will be apt to assume that he accomplished what he did in spite of his training, genius succeeding even in an unfavorable environment, and notwithstanding educational dis- advantages. Those who would be satisfied with any such explanation, however, know nothing of the edu- cational opportunities provided in the period of which Chauliac was the fruit. He is a typical uni- versity man of the beginning o£ the fourteenth cen- tury, and the universities must be given due credit for him. It is ordinarily assumed that the univer- sities paid very little attention to science and that scientists would find practically nothing to satisfy in their curricula. Professor Huxley in his address on " Universities, Actual and Ideal," delivered as the Eectorial Address at Aberdeen University in 1874, declared that they were probably educating in the real sense of the word better than we do now. (See quotation in " The Medical School at Salerno.") In the light of Chauliac 's life it is indeed amusing to read the excursions of certain historians into the relationship of the Popes and the Church to science during the Middle Ages. Chauliac is typically rep- resentative of medieval science, a man who gave due weight to authority, yet tried everything by his own experience, and who sums up in himself such wonderful advance in surgery that during the last twenty years the students of the history of medicine 308 OLD-TIME MAKERS OF MEDICINE have been more interested in him than in anyone who comes during the intervening six centuries. Chauliac, however, instead of meeting with any op- position, encountered encouragement, liberal patron- age, generous interest, and even enjoyed the inti- mate friendship of the highest ecclesiastics and the Popes of his time. In every way his life may be taken as a type of what we have come to know about the Middle Ages, when we know them as we should, in the lives of the men who counted for most in them, and do not accept merely the broad general- izations which are always likely to be deceptive and which in the past have led men into the most absurd and ridiculous notions with regard to a wonderful period in human history. That Guy de Chauliac was no narrow specialist is abundantly evident from his book, for while the " Great Surgery " treats of the science and art of surgery as its principal subject, there are remarks about nearly everything else relating to medicine, and most of them show a deep interest, a thorough familiarity, and an excellent judgment. Besides we have certain expressions with regard to intellectual matters generally which serve to show Guy as a pro- found thinker, who thoroughly appreciated just how accumulations of knowledge came to men and how far each generation or member of a generation should go and yet how limited must, after all, be the knowledge obtained by any one person. With regard to books, for instance, he said, " for every- one cannot have all the books, and even if he did have them it would be too tiresome to read them all GUT DE CHAULIAC 309 and completely, and it would require a godlike memory to retain them all." He realized, however, that each generation, provided it took the oppor- tunities offered it, was able to see a little bit farther than its predecessor, and the figure that he employs to express this is rather striking. " Sciences," he said, " are made by additions. It is quite impossible that the man who begins a science should finish it. We are like infants, clinging to the neck of a giant ; for we can see all the giant sees and a little more." One of the most interesting features of the history of Guy de Chauliac is the bibliography of his works which has been written by Nicaise. This is ad- mirably complete, labored over with the devotion that characterized Nicaise 's attitude of unstinted admiration for the subject. Altogether he has some sixty pages of a quarto volume with regard to the various editions of Guy's works. The first manuscript edition of Guy de Chauliac was issued in 1363, the first printed edition in 1478. Even in the fourteenth century Guy's great work was translated into all the languages generally used in Europe. Nicaise succeeded in placing 34 com- plete manuscripts of the ' ' Great Surgery " : 22 of these are in Latin, 4 are in French, 3 are in English, 2 only in Provencal, though that was the language spoken in the region where much of Chauliac 's life was passed, and one each in Italian, in Low Dutch, and in Hebrew. Of the English manuscripts, one is number twenty-five English of the Bibliotheque Nationale, Paris; a second is number 3666 English of the Sloane collection in the British Museum, and 310 OLD-TIME MAKERS OF MEDICINE a third is in the Library of the University of Cam- bridge. 1 Paulin Paris, probably one of the best of recent authorities on the age and significance of old manu- scripts, says in the third volume of his ' Manuscrits Frangais," page 346, " This manuscript [of Guy de Chauliac's " Great Surgery "] was made, if not during the life, then certainly very shortly after the death of the author. It is one of the oldest that can be cited, and the fact that an English translation was made so near to the time of the original com- position of the book attests the great reputation enjoyed by Guy de Chauliac at this time, and which posterity has fully confirmed. ' ' The Sloane copy in the British Museum contains 1 The beginning of the manuscript copy in the ' ' Bibliotheque Natio- nale " is extremely interesting as an example of the English of the period, and alongside of it it seems worth while to quote the closing sentence as Nicaise reproduces them ; "In godes name here bygyneth the inventarie of gadryng to gedre medecyne in the partye of cyrurgie compilede and fulfilled in the zere (yere?) of our Loord 1363 by Guide de Cauliaco cirurgene and doctor of physik in the f ulclere studye of Mountpylerz. " On page 191, verso.— Here endeth the cyrurgie of Maistre Guyd' de Cauliaco dottoure of phisik." The University of Cambridge copy has the title in the colophon. It runs as follows: "Ye inventory e of Guydo de Caulhiaco Doctor of Phisyk and Cirurgien in Ye Universitie of Mount Pessulanee of Mont- peleres." The fly-leaf contains the words, " Jesu Christ save ye soule of mien.' It is rather interesting to note how much closer to modern English is this copy, made probably not much more than half a century later than the first one and, above all, how much more nearly the spell- ing has come. At this time, however, and, indeed, for more than a century later, spelling had no fixed rule, and a man might spell the same word quite differently even on the same page. The difference between doctor spelled thus in the early edition, and doctours in the later one, probably means nothing more than personal peculiarities of the original translator or copyist. GUY BE CHAULIAC 311 some medical recipes at the end by Francis Verney. It was probably written in the fifteenth century. Its title is : " The inventorie or the collectorie in cirnrgicale parte of medicine compiled and complete in the yere of onr Lord 1363, with some additions of other doc- tours, necessary to the foresaid arte or crapte (crafte?)." 1 What we find in the period of manuscripts, how- ever, is as nothing compared to the prestige of Guy de Chauliac's work, once the age of printing began. Nicaise was able to find sixty different printed edi- tions of the ' ' Great Surgery. ? ' Nine others that are mentioned by authors have disappeared and ap- parently no copies of them are in existence. Besides there are sixty editions of portions of the work, of compendiums of it and commentaries on it. Alto- gether 129 editions are extant. Of these there are sixteen Latin editions, forty-three French, five Italian, four Low Dutch, five Catalan, and one Eng- lish. Fourteen appeared in the fifteenth century, thirty-eight in the sixteenth century, and seventeen in the seventeenth century. The fourteen editions belonging to the incunabula of printing, issued, that is, before the end of the fifteenth century, show what lively interest there was in the French surgeon of the preceding century, since printing presses at this precious time were occupied only with the books that 1 In Nicaise this last word is written crapte. I have ventured to suggest crafte, since a misreading between the two letters would be so easy. In the same way I have suggested tentatively a changing of the z in the title of the Bibliotheque Nationale copy to y, mak- ing the word yere instead of zere. 312 OLD-TIME MAKEBS OF MEDICINE were considered indispensable for scholars. The first edition of the ' ' Great Surgery ' ' was printed in 1478 at Lyons. Printing had only been introduced there five years before. This first edition, primus primarius or editio princeps, was a French transla- tion by Nicholas Panis. In 1480 an Italian edition was printed at Venice. The first Latin edition was printed also in Venice in 1490. It would be only natural to expect that the suc- cessors of Guy de Chauliac, and especially those who had come personally in contact with him, would take advantage of his thorough work to make still fur- ther advances in surgery. As matter of fact, de- cadence in surgery is noted immediately after his death. Three men taught at the University of Montpellier at the end of the fourteenth and the be- ginning of the fifteenth century, John de Tornamira, Valesco de Taranta, and John Faucon. They can- not be compared, Gurlt says, with Guy de Chauliac, though they were physicians of reputation in their time. Faucon made a compendium of Guy's work for students. Somehow there seemed to be the im- pression that surgery had now reached a point of development beyond which it could not advance. Unfortunate political conditions, wars, the with- drawal of the Popes from Avignon to Eome, and other disturbances, distracted men's minds, and surgery deteriorated to a considerable extent, until the new spirit at the time of the Eenaissance came to inject fresh life into it. XII MEDIEVAL DENTISTRY— GIOVANNI OF AECOLL If there is one phase of our present-day medicine and surgery that most of us are likely to be quite sure is of very recent development it is dentistry. Probably most people would declare at once that they had every reason to think that the science and art of dentistry, as we have it now, developed for the first time in the world's history during the last generation or two. It is extremely interesting to realize then, in the light of this almost universal persuasion, founded to a great extent on the con- viction that man is in process of evolution and that as a consequence we must surely be doing things now that men never did before, to find that dentistry, both as an art and science, is old ; that it has devel- oped at a number of times in the world's history, and that as fortunately for history its work was done mainly in indestructible materials, the teeth themselves and metal prosthetic apparatus, we have actual specimens of what was accomplished at a num- ber of periods in the olden times. Surprising as it will seem to those who hear of it for the first time, dentistry reached high perfection even in what we know as ancient history. It is rather easy to trace scientific and craftsmanlike interest in it during the 313 314 OLD-TIME MAKERS OF MEDICINE medieval period and in the magnificent development of surgery that came just at the end of the Middle Ages, dentistry shared to such degree that some of the text-books of the writers on surgery of this time furnish abundant evidence of anticipations of many of the supposedly most modern developments of den- tistry. There are a number of historical traditions with regard to dentistry and the treatment of the teeth in Egypt that can be traced back to good authorities in Egyptology of a generation or more ago, but it is rather hard to confirm the accounts we have by actual specimens; either none were found or for some reason those actually discovered are now not readily available for study. Among the Phenicians however, though we have good reasons to think that they learned their arts and crafts from the Egyp- tians, there is convincing evidence of a high develop- ment of dentistry. M. Ernest Eenan, during an ex- ploring expedition in Phenicia, found in the old necropolis at Sidon a set of teeth wired together, two of which were artificial. It was a striking example of bridgework, very well done, and may now be seen in the Louvre. It would be more than a little surpris- ing, from what we know of the lack of inventiveness on the part of the Phenicians and their tendency to acquire their arts by imitation, if they had reached such a climax of invention by themselves. Since they adapted and adopted most of their arts and crafts from Egypt, with which they were in close commercial relations, it has been argued with some plausibility that the Egyptians may have had many modes of dental prosthesis, but removed all artificial MEDIEVAL DENTISTRY— GIOVANNI OF ABCOLI 315 teeth and dental appliances from the month of corpses before embalming them, in preparation for the next world, because there was some reli- gious objection to snch human handiwork being left in place for the hereafter, as they hoped for it. There is a well-authenticated tradition of intimate intercourse in a commercial way between the old Etruscans who inhabited the Italian hill country and the Phenicians, so that it is no surprise to find that the oldest of Etruscan tombs contain some fine ex- amples of bridge work. An improvement has come over Phenician work however, and bands of gold instead of wire are used for holding artificial teeth in place. Guerini, whose " History of Dentistry " is the standard work on the subject, on a commission from the Italian government, carefully studied these specimens of Etruscan dental work in the museums of Italy, and has made some interesting observa- tions on them. In one specimen, which is espe- cially notable, two incisor teeth are replaced by a single tooth from a calf. This was grooved in such a way as to make it seem like two separate teeth. Guerini suggests a very interesting and quite unex- pected source for this. While examining the speci- men he wondered where the old Etruscan dentist had obtained a calf's tooth without a trace of wear on it. He came to the conclusion that he must have cut into the gums of a young calf before the per- manent tooth was erupted in order to get this struc- ture absolutely unworn for his purpose. A number of examples of bridgework have been found in the old Etruscan tombs. The dates of their construe- 316 OLD-TIME MAKERS OF MEDICINE tion are probably not later than 500 b.c., and some of them are perhaps earlier than 700 b.c. The Etruscans affected the old Eomans in the mat- ter of dentistry, so that it is easy to understand the passage in the " Laws of the Twelve Tables," issued about 450 b.c, which, while forbidding the burial of gold with corpses, made a special exception for such gold as was fastened to the teeth. Gold was rare at Eome, and care was exercised not to allow any unnecessary decrease of the visible supply almost in the same way as governments now protect their gold reserves. It may seem like comparing little things with great, but the underlying principle is the same. Hence this special law and its quite natural excep- tion. In Pope Julius' Museum in Eome there is a speci- men of a gold cap made of two plates of gold riveted together and also riveted to bands of metal which were fastened around the neighboring teeth in order to hold the cap in place. This is from later Eepub- lican times at Eome. At the end of the Eepublic and the beginning of the Empire there appear to have been many forms of dental appliances. Martial says that the reason why one lady's teeth — whose name he does not conceal— are white and another's — name also given — were dark, was that the first one bought hers and the second still had her own. In another satiric poem he describes an elderly woman as so much frightened that when she ran away her teeth fell out, while her friends lost their false hair. Fillings of many kinds were used, den- trifices of nearly every kind were invented, and den- tistry evidently reached a high stage of development, MEDIEVAL DENTISTRY— GIOVANNI OF ARCOLI 317 though we have nowhere a special name for dentist, and the work seems to have been done by physicians, who took this as a specialty. While in the Middle Ages there was, owing to con- ditions, a loss of much of this knowledge of antiquity with regard to dentistry, or an obscuration of it, it never disappeared completely, and whenever men have written seriously about medicine, above all about surgery in relation to the face and the mouth, the teeth have come in for their share of scientific and practical consideration. Aetius, the first impor- tant Christian writer on medicine and surgery, dis- cusses, as we have seen in the sketch of him, the nutrition of the teeth, their nerves, " which came from the third pair and entered the teeth by a small hole existing at the end of the root,'' and other in- teresting details of anatomy and physiology. He knows much about the hygiene of the teeth, discusses extraction and the cure of fistula and other details. Paul of iE'gina in the next century has much more, and while they both quote mainly from older authors there seems no doubt that they themselves had made not a few observations and had practical experience. It was from these men that the Arabian physicians and surgeons obtained their traditions of medicine, and so it is not surprising to find that they discuss dental diseases and their treatment rationally and in considerable detail. Abulcasis particularly has much that is of significance and interest. We have pictures of two score of dental instruments that were used by them. The Arabs not only treated and filled carious teeth and even replaced those that were lost, but they also corrected deformities of the mouth 318 OLD-TIME MAKERS OF MEDICINE and of the dental arches. Orthodontia is sometimes said to be of much later origin and to begin many centuries after Abulcasis' time, yet no one who knows of his work can speak of Orthodontia as an invention after him. In this, however, as in most of the departments of medicine and surgery, the Arabs were merely imitators, though probably they ex- panded somewhat the practical knowledge that had come to them. When the great revival in surgery came in the twelfth and thirteenth centuries it is not surprising that there should also have been an important re- newal of interest in dentistry. A detailed review of this would take us too far afield, but at least something may be said of two or three of the great representative surgical writers who touched on this specialty. About the middle of the fourteenth century that prince of surgeons, and model of surgical writers, Guy de Chauliac, wrote his great text-book of sur- gery, ' ' Le Grande Chirurgie. ' • An extremely inter- esting feature of this work is to be found in the chapters that treat of diseases of the teeth. These are not very comprehensive, and are evidently not so much the result of his experience, as the fruit of his reading, yet they contain many practical valua- ble ideas that are supposed to be ever so much later than the middle of the fourteenth century. His anatomy and physiology at least are not without many errors. His rules for the preservation of the teeth show that the ordinary causes of dental decay were well recognized even as early as this. Emphasis was laid on not taking foods too hot or too cold, and MEDIEVAL DENTISTRY— GIOVANNI OF ABCOLI 319 above all not to follow either hot or cold food by something very different from it in temperature. The breaking of hard things with the teeth was recognized as one of the most frequent causes of such deterioration of the enamel as gives oppor- tunity for the development of decay. The eating of sweets, and especially the sticky sweets — pre- serves and the like — was recognized as an important source of caries. The teeth were supposed to be cleaned frequently, and not to be cleaned too roughly, for this would do more harm than good. We find these rules repeated by succeeding writers on gen- eral surgery, who touch upon dentistry, or at least the care of the teeth, and they were not original with Guy de Chauliac, but part of the tradition of surgery. As noted by Ghierini in his " History of Den- tistry,' ' the translation of which was published under the auspices of the National Dental Association of the United States of America, 1 Chauliac recognized the dentists as specialists. Besides, it should be added, as is evident from his enumeration of the sur- gical instruments which he declares necessary for them, they were not as we might easily think in the modern time mere tooth pullers, but at least the best among them treated teeth as far as their limited knowledge and means at command enabled them to do so, and these means were much more elaborate than we have been led to think, and much more de- 1