Lusitano's Rules for Physicians A. LEV I N SO X, .M.I). CHICAGO ted ] rum the Bulletin of the Society of Medical History of Chicago, April, W21, I'ol. II, pp. 260-263 RULES FOR PHYSICIANS* A. LEVINSON, M.D. CHICAGO The rules for physicians, authorship of which is credited to Lusi- tano, are contained in two Hebrew medical treatises. One of the treatises, Ozar Hachaim ("The Treasure of Life"), published in Venice in 1683, was written by Jacob Zaholon. The other, called Har- monia Wallichia Medico, published in Frankfort am Main, in 1700, was written by Abraham Wallich. 1 Zaholon's book is purely medical, while Wallich's treatise is a combination of medicine and religious philosopy, a type of literary fusion quite common in medical writings of the middle ages. The rules given in the two treatises differ somewhat, Wallich giving only fifty whereas Zaholon gives seventy-six. In the main, however, they are the same. Zaholon gives Lusitano's full name as Abram Zakuto Lusitanus, while Wallich speaks of him only as Zakuto Lusitanus. In the work of these two authors as well as in other Hebrew works his name is spelled Lusitanus with the "us" ending, while in the English translation of Graetz his name is spelled Lusitano. Neither of the authors tells when Lusitano lived. According to Graetz he was born in 1576 and died in 1642. He was the great- grandson of Zacuto, the historian and astronomer. He was one of the most celebrated physicians of his time and was honored by his professional brethren. It should be noted that the Lusitano under discussion is not Amatus Lusitano or Lusitanus, the Portuguese physician of the sixteenth cen- tury who was born in 1511 and died in 1568 and who was known for his seven books of case histories which appeared under the general title of "Centuries." Since Zaholon deals more exhaustively with the subject I shall quote his version of Lusitanus' rules for physicians. I shall present the rules in the exact numerical order in which they appear, although in many instances a rearrangement would make for more logical sequence. 1. The physician should he pious. 2. He should he dressed well. 3. He should not talk (too) much. 4. He should not be too economical (parsimonious). 5. He should not insist on his fee. * Read at a meeting of the Society of Medical History of Chicago. Dec. 10, 1920. 1. For permission to use the original Hebrew text I am indebted to Prof. Alexander Marx, librarian of the Jewish Theological Seminary of Xeu York 20694 P5 2 A. Levinson 6. He should not be envious. 7. He should not be vain. 8. He should not be willful toward his superiors. 9. He should admit his mistakes. 10. He should accept cheerfully the censure of his elders. 11. He should be well disposed. 12. He should have common sense. 13. He should study every subject thoroughly. 14. He should buy few books, but good ones for the study of medicine. 15. He should peruse the books of learned and practical men. 16. He should not undertake to cure the incurable. 17. He should refrain from making false promises. 18. He should not exaggerate a (slight) illness. 19. He should not make light of a serious illness. 20. He should be willing to consult with other physicians. 21. He should limit himself to but a few patients, for the care of too many breeds mistakes. 22. He should not pay much attention to the name of the disease, but to its character and treatment. 23. He should not make light of anything for even from small things one may be able to obtain a clue. 24. He should not be slow in giving the proper medication. 25. He should not do anything without reason. 26. He should be careful about giving a prognosis so that he may not be caught in a falsehood. 27. He should not make any promises. 28. He should do everything according to medical teachings (ethics). 29. He should combine experience and reasoning in his practice. 30. He should be quick in action and not sloth in time of need. 31. He should consider the value of the person he treats. (It is not clear whether he refers to the financial status of his patient or to the value of a human life in general.) 32. His principal aim should be the cure of his patient. 33. He should consider the difficulties and the dangers of the cure. 34. He should not fear the wrath (censure?) of people. 35. At times he should entertain the patient with pleasant conversation. 36. He should institute the cure quickly and unhesitatingly. 37. He should not deviate from the logical treatment even if the antici- pated cure is not obtained. 38. He should use common sense in purgation. 39. In giving counsel he should follow the rules of medicine and observe the working of Nature. 40. When Nature does not effect the physician should try to do so by means of medicine. 41. If Nature is bringing about a cure he should not do anything. 42. On the day that Nature is expected to work a change in the condi- tion the physician should not do anything. 43. He should be careful to administer medicine on the right day and at the right hour. 44. He should not give strong purgatives unless other remedies have not done any good. 45. Before giving a purgative he should prepare the body humors in order to make it easier to purge them. 46. He should always start with the lighter remedies. 47. He should select the proper time for purging. 48. He should keep in mind the signs of the astrologists as to which day is good and which is bad for purging or blood letting. Lusitano's Rules 3 49. In blood letting he should consider the nature of his patient whether he is warm or cold-blooded. 50. He should find out whether the patient can stand a strong purgative. 51. He should keep in mind the movements of the body fluid, the point from which it moves. 52. He should consider the character of the humors that need purging. 51. He should take into consideration the habits of the patient in purg- ing him. 54. He should also note the disposition of the fluids by the body whether they come from above or from below or through sweating. 55. He should not employ drugs in every illness, for at times if the ill- ness is slight and the patient is not strong, a change in diet may suffice. 56. A disposed body is preserved by a like remedy, a non-disposed body by its opposite. 57. Bad humors should not be removed from the diseased part of the body. 58. A chronic illness is sometimes cured by a change in the patient's surroundings. 59. The physician should assist Nature, for it is the most important factor in health. 60. He should observe closely the strength of the patient, particularly the condition of his brain. 61. He should endeavor to discover what part of the body is diseased. 62. He should find out which is the primary disease and which the sec- ondary one. 63. If he does not diagnose the trouble he should treat the patient dietetically. 64. He should learn what is helpful to the patient and what injurious. 65. He should study the changes of locations (changes in climate or changes in location of disease?) for remedies must change accordingly. 66. He should direct the remedy to meet the most dangerous (symptom?) 67. He should not give a strong purgative at the beginning of the dis- ease before the humors are ripe for it. 08. He should not become alarmed if severe symptoms appear, for that marks the critical period. 09. Among the symptoms to be treated early is pain, for pain under- mines the patient's strength. 70. He should treat deep somnolence or persistent insomnia. 71. He should not administer a purgative from distant places in the body until the bowels have moved. 72. In administering drugs he should keep in mind the difference between a male whose nature is warm and strong and a female whose nature is cold and strong, for to her only few and light remedies should be given. 73. He should be careful in giving medicine to young and to very old both of whom are weak. 74. He should be very careful in treating infants. 75. He should know the anatomy of different parts of the body. 76. He should learn surgery. 77. He should learn the properties and the compounding of various drugs. Zaholon supplements the golden rules of Lusitano with some addi- tional advice. Whether the advice is his own or whether it is still a continuation of the counsel of Lusitano is not plain, but the suggestions are worth while irrespective of the source. In the translation that 4 A. Levinson follows I have tried to preserve the original uniqueness of the style as closely as possible: It is very good that at the beginning of his practice the physician should go around with an older (wise) physician to visit patients, and as soon as he comes home, he should mark down the remedies that he has heard from the older physician and he should also read up the case in different books to clear up any doubts he might have about it. When a doctor comes to a patient, he should not take the pulse immedi- ately but should rest up a bit, and should ask the patient or his relatives how the disease started, and should inquire first about his head, whether or not he has a headache, whether he sleeps well, whether he is thirsty, whether he has pain anywhere, whether he eats or drinks ; he should then look at his tongue and examine his urine and take the pulse. Then he should give orders what should be done, in the same manner that a king commands his subjects ; To poor people he should give effective but inexpensive remedies ; to rich people he should give pleasant and expensive remedies. It is also best that he write down the remedies in order that the people should not forget, as might happen if he gave verbal orders. It is also more impressive if the physician writes down his orders. At times it is well to explain the reasons for the remedies but not the nature of the remedy that people may not become disgusted with them. He should not make the disease hard in order not to worry the people, but he should put the matter in a doubtful manner giving good hopes : even if the disease should be severe he should tell the patient himself that the illness is slight, and that others who have had the same sickness recovered. If he hears of a good remedy from another physician, he should not make light of it. and if there is another physician with him, he should not belittle his words, whether they are good or bad. at least he should not give his opinion of them in the presence of others. If the patient has a bad disease, the physician should not come too close to him: likewise if the patient has a bad odor. When the patient gets well the doctor should excuse himself and should not call on him (the patient) too long if it is unnecessary. He should leave instructions as to how the patient should conduct himself after he gets well in order that the disease should not repeat itself, and he should thank God for curing the patient. If necessary he should visit the patient more than twice a day. The physician should not give out the medicine himself, but should send the patient to an apothecary. At times he should be present during the blood letting. He should not think of expense but of what is useful for the health of the patient, and before he orders the medicine he should pray to God to instruct him in giving the proper medicine. If he sees that the patient is dangerously ill. he should tell the relatives, so that if the patient should die they will not think ill of him; he should do this also so that they may be able to do everything they can for the patient without caring for expense. When a physician treats women, he should be modest. He should also inquire whether the patient menstruated or whether she is pregnant. He should not accept remuneration from poor people, from relatives, or from good friends, nor should he accept any money on the Sabbath or holi- days. If, however, he treats a friend who wants to pay him every day so that he should not have to give him an expensive present at the end, or that he may feel free to call on him. he should accept a fee, for though it is true that a physician does the work of God, and should not accept any money, still he can do the same as a teacher and accept remuneration for his time, also that he may be able to make a living in the profession, and also because as, the saying goes, "a physician who works for nothing is worth nothing." Once a week also he should say a prayer for physicians that I have written in my book, "Good Pearls," published in Venice. ERTER'S SATIRE ON DOCTORS* A. LEVINSON CHICAGO Among the interesting satires on doctors should be included one which appeared in the early nineties of the last century. It was written in Hebrew by Isaac Erter, a Galician physician. I shall present a translation and interpretation of a few of the most interesting por- tions of the book which, in addition to the satire, contains visions and revelations made to the author by a spirit. The spirit is made the mouthpiece of the author's criticisms all through the book. The author, who is critical of existing conditions, discusses the status of the physician of his day. In one of his chapters he tells of his encounter with a spirit who flew out of one of his patients at the time of his death. The spirit enters into a lengthy conversation with the physician, in the course of which he gives him some pointed advice on the art of his conduct as a physician. In what he designates as the ten golden chapters he lays down several practical rules by which the physician should guide himself in dealing with his patients : "The spirit said unto me," says Erter, "You are a physician ; you live among people, but you do not know the soul of the people. You do not know the rabble among them. People judge you by appearance only. Their measure of your knowledge depends on the beauty of your apartment, the bounty of your table, the number of servants in your household, the appearance of your clothes and furniture. If a donkey puts on nice clothes, and holds his head aloft, he is considered a wise and learned creature. I know all this and I have therefore become rich and mighty. Hippocrates wrote his aphorisms in books, and one who gets sick may become well by following his axioms. I have written chapters better than his in a book, chapters and rules which a doctor should follow if he desires to live. Pythagoras called his aphorisms the Golden Aphorisms, an improper name, for what have his aphorisms to do with gold. They are moral lessons, wise sayings, but not golden sayings. My chapters I properly call the Golden Chapters, for through them even a donkey who undertakes the task of healing can fill his bags with gold. A few of these chapters I shall let you read, and if you will be attentive and observe them, you too will succeed !" The author then quotes the Golden Chapters which the spirit entrusted to him. The translation follows : * Read at a meeting of the Society of Medical History of Chicago, Dec. 10, 1920. A. Levinson THE GOLDEN CHAPTERS A. Whiten your hair with dust, and put a camel's pillow on your stomach. You will then be considered wise by all who look upon you, for they will say, "Great problems turned his hair white, and his learning is within him." B. Put a human skull on your table, and a stillbirth without head or foot in a glass jar preserved in alcohol on your window. All who will visit you will look at them and will marvel at your wisdom. C. Buy countless numbers of books, dress them up in skin dresses (sheepskin), and cover their backs and their margins with gold. Then put them in a case and lock them up, never to be read ; but transparent glass should you put in the doors of your bookcase. People will see your beautiful books and will say, "There is no end to your wisdom." D. Pawn everything you have to buy yourself fine horses. Let the loan shark go after you, but buy yourself a carriage, for even though you kill all people like one man, if your horses and chariot stand in front of the door, all who pass by will say, "He cures everybody ; he is truly wonderful." E. When you come to the house of a patient, do not worry about his sickness, but look at the people who stand by his bed and bethink yourself what to say to them. On parting you should say, "I do not believe he will survive," so that if the patient dies, they will all say, "Did not the doctor say so? He understood it all." If on the other hand the patient gets well, they will not say he did not understand, but will exclaim with astonishment, "He returned soul to a corpse." F. Poor people usually look for medical aid only when they reach the gates of death. To cure a poor man is very hard. If he lives, he does not pay you for your work, and what reward is there if he dies, except that your name is connected with his death. Therefore, keep them away from you. Do that diplo- matically. When you talk to them, raise your voice, show them your superiority. They will be frightened, and will not come near you. G. Set aside a certain time for poor people to come to you for consultation. Let therp stand in the doorway of your house, and whoever passes by and sees them will say, "Behold, he is a great and renowned physician. People from all over rap at his doors." Pick out only the rich people who come at the same time, take them first, examine them, prescribe for them, talk to them, and take their money, and when the rich people leave, tell the poor people who stand outside to come tomorrow, today it is too late, they cannot come in any more. H. Your colleagues are robbing you of your bread. There- fore, belittle them. Throw mud at them. Speak only bad of them. Show up their faults. There is no such thing as another good doctor. If your rival happens to read journals and history, say that he occupies his time with other things. When he comes to a patient, report that he pays no heed to the sickness, that he is concerned at that moment with the politics of Great Britain, Erter's Satire or France or Spain. If your colleague is young, you should say, "He is too young, he has not had the experience I have had, he will have a great deal to learn before he will be a doctor." If, on the other hand, your colleague is older than you, you should say he is too old, his eyes do not serve him any more ; his mind does not work well any more. I. If your colleague calls you for consultation, and he tells you what he did for the patient until the time you came in, you should turn up your nose and your lips, your face should bespeak your dissatisfaction with what has been done, and if the bystanders do not understand your heart's thoughts, you should speak up and tell the doctor, in the presence of the others, "Why, you have done, the wrong thing for the patient; your ways are the ways of death." In such a manner your enemy will be doomed, and you will be up in the skies, for if the patient dies, it will be the fault of your enemy. If he gets well, you have done wonder- ful things by delivering him from death through your wisdom. J. When somebody calls another physician as a consultant in your case, do not heed the consultant's words, for if you do the patient may get well and you will be shown up. If you see, how- ever, that there is no hope for the patient, then listen to the consultant's words, and take his advice so that when the patient dies you will say, "I am not to blame; the patient died through the fault of my consultant," and the people will believe you. 000076 159