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Title: Old-Time Makers of Medicine

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*** START OF THE PROJECT GUTENBERG EBOOK OLD-TIME
MAKERS OF MEDICINE ***

O l d - Ti m e
Makers of Medicine

THE STORY OF THE STUDENTS AND TEACHERS
OF THE SCIENCES RELATED TO MEDICINE
DURING THE MIDDLE AGES

BY

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 1911

JAMES J. WALSH

THE QUINN & GODEN CO. PRESS
RAHWAY, N. J.

TO
REVEREND DANIEL J. QUINN, S.J.
The historical material here presented was gathered for my
classes at Fordham University School of Medicine 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 patronage 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 contemporary
science it is time to turn to past science; nothing fortifies the
judgment more than this comparative 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."—Littré: Œuvres
d'Hippocrate, T. I, p. 477.

"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."—
Littré: Introduction to the Works of Hippocrates.

"How true it is that in reading this history one finds
modern discoveries that are anything but discoveries, 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 Geschichte 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 Encyclopedia. Some of it
was developed for a series of addresses at commencements of medical
schools and before medical societies, on 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 usually thought quite sterile in medical
science proved, indeed, so astonishing, that I was tempted to connect the
details for a volume in the Fordham University 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 mentioned 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
distinguished 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 acknowledgments to them in the text as opportunity presented itself.
There is just one feature of the book that may commend it to present-day
readers, and that is that our medieval medical colleagues, when medicine
embraced most of science, faced the problems of medicine 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. 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 important 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 department 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 recent 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. Constantine Africanus 163
VIII. Medieval Women Physicians 177
IX. Mondino and the Medical School of Bologna 202
X. Great Surgeons of the Medieval Universities 234
XI. Guy de Chauliac 282
XII. Medieval Dentistry—Giovanni of Arcoli 313
Cusanus and the First Suggestion of Laboratory
XIII. 336
Methods in Medicine
Basil Valentine, Last of the Alchemists, First of the
XIV. 349
Chemists

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 Euthydemus
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 medicine, 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.R.S., Blakistons, 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 succeed them.

"There is one Science of Medicine which is concerned
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,
much more is known about Greek medical writers than those of any other
period except the last century or two. Our histories of medicine 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
consequence 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 Romans 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
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
impression 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 circumstances, 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 represents 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 headlands
that lie along the stream of medical thought during the somewhat more than
a thousand years from the fall of the Roman Empire under Augustulus (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, Columbus, Servetus,
Cæsalpinus, 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 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 education, in literature, in a word, in intellectual
accomplishment 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 attributed to what
has been called the inhibitory effect of Christianity on worldly interests.
Religion 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 Roman Empire had been the
guardian of letters and education and science. While the Romans 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 medicine. Galen's influence was due much more to the
prominence secured by him as the result of his stay in Rome than would
have been possible had he stayed in Asia. There are many other examples of
Roman patronage of literature and science that might be mentioned. As we
shall see, Rome drained Greece and Asia Minor of their best, and

appropriated to herself the genius products of the Spanish Peninsula. Rome
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 imperial 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 accustomed 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,
decadence 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 decadence 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, 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 Rome 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 manifestations
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 officials of the
Empire, the educated thinking classes of Rome, had become Christians.
After the conversion of the Emperor opportunities began to be afforded, 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 Empire decadent, crept in
on it, and though much more of the invasion was peaceful than we have
been accustomed to think, the Romans simply disappearing because family
life had been destroyed, children had become infrequent, and divorce had
become extremely common, it was not long before they replaced the
Romans almost entirely. These new peoples 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
Christianity had to perform. That it succeeded in accomplishing it is one of
the marvels of history.
The Church's first grave duty was the preservation 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 situated 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 excerpts 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
literary traditions was due to the one stable element in all these centuries—
the Church. Far from Christianity 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 regard to which our documents are comparatively scanty, and during
which the disturbed conditions made medical developments impossible, and

anything more than the preservation of the old authors out of the question.
The torch of medical illumination lighted at the great Greek fires passes
from people to people, never quenched, though often burning low because
of unfavorable conditions, but sometimes with new fuel added to its flame
by the contributions of genius. The early Christians took it up and kept it
lighted, and, with the Jewish physicians, 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 conditions 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 influence 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 popular, to impugn the tradition as to St. Luke
having been a physician, but this has all been undone, and 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 advantage 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
communities. There had been military hospitals before this, and places
where those who could afford to pay for service were kept during illness.
Our modern city hospital, however, is a Christian institution. Besides,
deformed and ailing children were cared for and homes for foundlings were
established. Before 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 Roman
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 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 opportunity for study, Christian interest in the
medical 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 speculative 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 description 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 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 literature. The first of these was Aëtius,
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 Ægina, 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 beginning of the Middle Ages, then, under
the fostering care of Christianity there is a period of considerable
importance in the history of medical literature. It is one of the best proofs
that we have not only that Christianity did not hamper medical
development, 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
intellectual 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 of St. Procopius the
martyr, was, according to Carptzovius, looked upon as an excellent
physician in Rome in the early part of the fourth century. She suffered
martyrdom under Diocletian. There was also a Nicerata who practised at
Constantinople under the Emperor Arcadius. It is said that to her St. John
Chrysostom owed the cure of a serious illness. From the very beginning
Christian women acted as nurses, and deaconesses were put in charge of
hospitals. Fabiola, at Rome, 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 knowledge 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
ecclesiastics selected Jewish physicians. Some of these made distinct
contributions to medicine, and a number of them deserve a place in any
account of medicine in the making during the Middle Ages. One of them,
Maimonides, to whom a special chapter is devoted, 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 Roman literature in other
departments, and had only the Greek traditions at second hand. During the
disturbance occasioned by the invasion of the barbarians there was little
opportunity for such leisure as would enable men to devote themselves with
tranquillity to medical study and writing. Medical traditions 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 tradition 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 Benedictines 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 professors 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 position to carry on medical traditions.
Their teachers were the Christian and Jewish physicians of the cities of Asia
Minor, but soon they themselves became 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 Roman Empire, providing 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 education on what had been
the highest development of Roman civilization.
The influence of the Arabs on Western civilization, 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 cultured. 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 accomplishment 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 little came from the Arabs that was good, while
not a little that was unfortunate in its influence was borrowed 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 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 practice began to creep in, a series of
laws were made creating a standard of medical education and regulating 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 professors,
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 Græcia, and that the stimulus of
Greek tradition has always been especially favorable to the development of
scientific medicine.
Salerno's influence on Bologna is not difficult to trace, and the precious
tradition of surgery particularly, which was carried to the northern
university, served to initiate a period of surgery lasting nearly two centuries,
during which we have some of the greatest contributions to this branch of
medical 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 education declined in Italy in the midst of political disturbances,
they advanced materially at the south of France.
For our generation undoubtedly the most interesting chapter in the
history of medieval medicine is that which tells of the marvellous
development of surgery that took place in the thirteenth and fourteenth
centuries. Considerable space has been devoted 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
illustrates exquisitely the possibility of important discoveries in medicine
being made, applied successfully 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 anæsthesia is
not new, and that at various times in the world's history men have invented
methods of producing states of sensibility in which more or less painless
operations were possible. Very few of us have realized, however, the
perfection to which anæsthesia was developed, and the possibility this
provided for the great surgeons of the later medieval centuries to do
operations 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 intervention 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 assurance that antisepsis and asepsis were entirely modern
developments of surgery. More knowledge, however, of the history of
surgery has given a serious set-back to this self-complacency, and now we
know that the later medieval surgeons understood practical antisepsis very

well, and applied it successfully. 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 consequence 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 actually 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 anæsthesia, was marvellously anticipated by the
surgical forefathers of the medieval period.
It has always seemed to me that the story of Medieval Dentistry
presented an even better illustration 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
dentatores. 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 interesting, because if there is any department of medical
practice that we are sure is comparatively recent in origin, it is dentistry.
Here, however, we find that practically all our dental manipulations, the
filling of teeth, artificial dentures, even orthodontia, were anticipated by the
dentists of the Middle 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 heritage 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 discovery.
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 medicine, diagnosis and therapeutics, took definite
shape on the foundations that lie at the basis of our modern medical science.
We hear of percussion for abdominal 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 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 ascertained in order to get another definite datum in the
knowledge of disease. It was long before these suggestions were to bear
much fruit, but it is interesting 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 Renaissance period was
abroad. Valentine, however, owes little to anything except his own
investigations, and they were surprisingly successful, considering the
circumstances of time and place. His practical suggestions 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, however, 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 insisted, also that personal
observation, both of patients and drugs, was more important than book
knowledge. Indeed, he has some rather strong expressions with regard to
the utter valuelessness of book information in subjects where actual
experience and observation are necessary. It gives a conceit of knowledge
quite unjustified by what is really known.
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 accumulation of knowledge ever since.
It was very fortunate for the after time that in the period now known as
the Renaissance, after the invention of printing, there were a number of

serious, 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 possibility
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 scientific
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 learning and masterpieces of editorial work with
regard to medieval masters of medicine, were lying in libraries waiting to
be unearthed and restudied during 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 sympathetically 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
Renaissance. Without 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 EARLY 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 Introduction, 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
assistants to the clergy, the deaconesses, took care of them. As Christians
became more numerous, special hospitals were founded, and these became
public institutions just as soon as freedom from persecution 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 matter 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 best possible evidence of the liberal charity that inspired 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
Cæsarea. 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 separate
buildings for strangers, for the poor, and for the ailing, and comfortable

dwellings for the physicians and nurses. An important portion of the
institution 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 Emperor
Constantine, had built similar institutions around Jerusalem, and during this
same century nearly everywhere we have evidence of organization 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
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. Religion itself was spoken of as a medicine of the soul and the body.
Christianity was defined as the religion of healing. The word salvation had
a reference 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
medicine of the soul. It is not surprising to find, then, that Harnack has
found among the texts that illustrate 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 consider it her duty to keep
the Church officials informed 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
supposed to have the right of life and death over their children, and no one
questioned it. In every country in the world until the coming of Christianity
this had always been the case. Besides, there were institutions for the care
of the old. These are the classes of mankind who are especially liable to
suffer from disease, and the opportunity to study human ailments in such
institutions could scarcely help but provide facilities for clinical observation
such as had not existed before. Unfortunately the work of Christianity was

hampered, first by the Roman persecutions, and then later by the invasion
of the barbarians, who had to be educated 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 development.
Harnack, whose writings in the higher criticism of Scripture have
attracted so much attention in recent 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 distinction in the earliest days of Christianity. Some of these were
priests, some of them bishops, as Theodotos of Laodicea; Eusebius, Bishop
of Rome; 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. Organizations
of various kinds since, as the College of St. Come, and medical societies,
have been named after them.
Some idea of the interest of ecclesiastics in medical 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, evidently 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 people
generally twenty years ago. We have come back to recognize the place of
teleology. Clement of Alexandria was an early Christian temperance
advocate, who argued that the use of wine was only justified when it did
good as a medicine. The problems of embryology and of diseases of
childhood interested him as they did many other of the early Christian
writers.

AËTIUS

The first great Christian physician whose works meant much for his own
time, and whose writings have become a classic in medicine, was Aëtius
Amidenus, that is, Aëtius 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 Christian physicians. There is no doubt
that Aëtius 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 medical
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 breadth of his scholarship, and the thoroughly practical
character of his teaching, show how medical science and medical art were
being developed and encouraged at this time.
Aëtius' 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 important operations and the chapters on fractures
and dislocations are lacking. Aëtius himself announces 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 extensively even than Paulus Æginetus, but most of his
work is devoted to therapeutics.
At times those who read these old books from certain 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 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 discrimination, 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 judgment or
on the special knowledge of his time, but are the index of his special
receptivity and teaching habit.
Aëtius' first and second books are taken up entirely 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 Aëtius 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 expression, 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 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 superficial. 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 purpose 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. Under this the question of tattooing and its removal
comes in. It is surprising how much Aëtius 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
received 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 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 usually 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.

Aëtius 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 inflammation of the mouth nor of the
fauces, but is complicated 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 vertebræ—retropharyngeal abscess—
that may be followed by luxation and is complicated by great difficulty of
respiration. All of these have as a common symptom difficulty of
swallowing. This is greater in one variety than in another at different times.
In certain affections even "drinks when taken are returned through the
nose."
Hypertrophy of the tonsils—Aëtius speaks of them as glands—is to be
treated by various astringent remedies, but 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, however, 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 excision a mixture of water and
vinegar should be kept in the mouth for some time. This should be
administered 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 foreign 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 sneezing. If the foreign body can be seen it
should be grasped with a pincers and removed. If it is in the esophagus,
Aëtius 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, Aëtius has some interesting 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 drawing of the breath being prevented or repressed during 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 Aëtius 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.
Aëtius' 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. First, simple section of the skin
lying above the dilated vessel is made, and with the hook it is separated
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 Aëtius, 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.
Aëtius' chapters on obstetrics and gynæcology are of special interest,
because, while we are prone to think that gynæcology particularly is a
comparatively 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) devoted 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. Aëtius
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 prevents
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 become
prominent and become attached to surrounding 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 conditions, 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 cannot
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 Aëtius
gives a description of operation for cancer of the breast, in which he insists
particularly on the extensive 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 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 amputation of such
a portion down to the healthy parts may suffice." Aëtius quotes this with
approval.

Others before Aëtius had suggested the connection between hypertrophy
of the clitoris and certain exaggerated manifestations of the sexual instinct,
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 Aëtius 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 injury. 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 operation a sponge wet with astringent wine
should be applied, 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 conditions 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 removal of the new growth
whenever possible. He 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.
Aëtius 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,"[2] calls attention to the fact that the earliest reference to the use of
drying oil for varnish is made by the physician Aëtius.
Aëtius, or Aëtios, 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 Renaissance he was one of the first of the early writers on medicine
accorded 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 Aëtius had as much importance for physicians as
had the Pandects of Justinian for lawyers. This high estimation had survived
almost from the time of the Renaissance, 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 extended, and the whole of Paulus (of Ægina) amplified, if he
would have all the special remedies of the old physicians as well in
pharmacy as in surgery boiled down to a summa for all affections, he will
find it in Aëtius." Naturally enough, this exaggerated estimation was
followed by a reaction, in which Aëtius 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 observations 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 Aëtius 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 careful attention in the Renaissance
period and in our own, and who must be considered one of the great
independent thinkers in medicine. While it is usually 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
procedure, and weighing them by his own experience and observation, turn
out work that was valuable for all succeeding generations. The modern
German school of medical historians have agreed in declaring him an
independent thinker and physician, 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 physician,
and it is probable that there were physicians in preceding generations, and
one of his brothers, Dioscoros, was also a successful physician. Altogether
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 understand 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 Constantinople, as we have come to call it. A third brother was a
prominent jurist, also in Constantinople. The fourth brother, Dioscoros, like
Alexander, 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 gathering medical knowledge
and medical experience. Then he settled down at Rome, probably in an
official 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 relations of the rest of the family to the nobility of the
time, it is easy to understand, especially in connection 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 Aëtius' 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 observation as to the pathology of internal diseases. A shorter treatise
of Alexander is with regard to intestinal parasites. There are many printed

editions of these books, and many manuscript copies are in existence.
Alexander was often quoted during 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.
Alexander's first book of pathology and therapeutics treats of head and
brain diseases. For baldness, 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 formation of small flake-like scales, he recommends
rubbing with wine, with certain salves, and washing with salt water.
He gives a good deal of attention to diseases of the nervous system. He
has a rather interesting chapter on headache. The affection occurs in
connection with fevers, after excess in drinking, and as a consequence of
injury to the skull. Besides, it 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 inflammation 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, Alexander considered
venesection the best remedy. Massage, rubbings, baths, and warm
applications 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 occasionally
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 necessity for careful attention to the gastro-intestinal tract in
many cases of epilepsy. Planned diet and regular bowels are very helpful.
He rejects treatment of the condition by surgery of the head, either by

trephining or by incisions, or cauterization. Regular exercise, baths, sexual
abstinence are the foundation of any successful treatment. It is probable that
we have returned to Alexander's treatment of epilepsy much more nearly
than is generally thought. There are those who still think that remedies of
various kinds do good, but in the large epileptic colonies regular exercise,
bland diet, regulation 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 phrenitis, 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 patient must be avoided, and visitors must be forbidden.
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 nineteenth
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 melancholy 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 laxatives and purgatives, of baths and stimulant remedies.
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
recommends as gargles at the beginning light astringents; later stronger
astringents, as alum and soda dissolved 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 dyscrasias. Opium

preparations carefully used are the best remedies. The breathing in of steam
impregnated with various ethereal resins, was also recommended.
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 watering-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
influence 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. For hemoptysis, especially 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
circulation. 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 agreeable 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 of the
membrane covering the ribs, and its symptoms 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 expectoration
in liver cases, though it also may be absent 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 lemonade. 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.
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 compresses, and a cooling diet, were his favorite remedies. 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 remedies of all kinds. He did
not believe in strong purgatives, nor in profuse and sudden blood-lettings.
He opposed arteriotomy for this reason, and refused to employ extensive
cauterization. His diagnosis is thorough and careful. He insisted particularly
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 administered 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 encouraged 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 abstracted 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 interesting. Gurlt declares that this chapter alone provides
striking evidence for Alexander's practical experience and power of
observation, as well as for his knowledge of the literature of medicine. He
considers 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
head leant toward the affected side, bring about a dislodgment of the
foreign body. If these means do not succeed, gentle injections of warm oil
or washing 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 differential diagnostic signs.

One of the most surprising chapters of Alexander's knowledge of
pathology and therapeutics is to be found in his treatment of the subject of
intestinal worms, which is contained in a letter sent by him to his friend,
Theodore, whose child was suffering from them. He describes the oxyuris
vermicularis 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 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 describes the roundworms as existing in the intestines,
but occasionally wandering into the stomach to be vomited. His vermifuges
were the flowers and the seeds of the pomegranate, the seeds of the
heliotrope, castor-oil, and certain herbs that are still used, by country
people, at least, as worm medicines. For roundworms he recommended
especially a decoction of artemisia maritima, coriander seeds, and
decoctions of thyme. Our return to thymol for intestinal 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 Alexander's time.

PAUL OF ÆGINA

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 Ægina. He
was born on the island of Ægina, hence the name Æginetus, 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 educated at the University of
Alexandria. As that institution was broken up at the time of the capture of
the city by the Arabs, he cannot have been there later than during the first
half of the seventh century. An Arabian writer, Abul Farag, in "The Story of
the Reign of the Emperor Heraclius," who died 641, says that "among the
celebrated physicians who flourished at this time was Paulus Æginetus." In

his works Paul quotes from Alexander 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 results 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 fishbones 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 designed 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 circumference to which a string is attached be swallowed,
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 indications 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
immediately, a treatment calculated to encourage granulations 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 Surgery" 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
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 incision
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 Obstetrician."
Perhaps the term should be translated the man-midwife, for it was rather
unusual for men to have much knowledge of this subject. His knowledge 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 suggested ligature of

the limbs, and it is easy to understand 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 affection. Paul's description of the
use of the speculum is as complete as that in any modern text-book of
gynæcology.

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 that for some two centuries, in quite modern times, it was used as a
text-book of anatomy at the University 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 delightfully 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 Emperor 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
abdominal dilatation: "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 Christianity came into existence in Italy will
not be surprised at that. The Arabs in the East were in contact with Greek
thought, and that is eminently prolific and inspiring. At the most, the
Christians in Italy got their inspiration at second hand through the Romans.
The Romans themselves, in spite of intimate contact with Greek physicians,
never made any important contributions to medical science, nor to science
of any kind. Their successors, the Christians of Rome and Italy, then could
scarcely be expected to do better, hampered especially, as they were, by the
trying social conditions created by the invasion of the barbarians from the
North. Whenever the Christians were in contact with Greek thought and
Greek medicine, above all, as at Alexandria, or in certain of the cities of the
near East, we have distinguished contributions from them.

ARABIAN CHRISTIAN 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 Christians. 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 acquiring fame elsewhere, was
called to Bagdad by the Caliph El-Mansur, where, because of his medical
skill, he reached the highest honors. His son became the body-physician of
Harun al-Raschid. In the third generation Gabriel (Dschibril) acquired fame
and did much, as had his father and grandfather, 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 themselves among the Arabs. Of

these the most prominent was Messui the elder, who is also known as Janus
Damascenus. Both he and his father practised medicine with great success
in Bagdad, and his son became the body-physician to Harun al-Raschid
either after or in conjunction with Gabriel Bachtischua. Like his colleague
or predecessor in official 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 "Breviarium," or "Practica Medicinæ," which appeared in
many printed editions within the century after the invention of printing.
During the ninth century, 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, and also certain of the Greek philosophic and
mathematical works. The accuracy of his translations became a proverb. His
compendium of Galen was the text-book of medicine in the West for many
centuries. 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
everything, however, and so came to be called the philosopher. He is said
altogether to have written and translated about two hundred works, of
which twenty-two treat of medicine. He was a contemporary of Honein Ben
Ischak in the ninth century. Another of the great ninth-century Christian
physicians 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 generations attracted attention as scholars. He became
the astronomer and physician of the Caliph Motadhid. His translations in
medical literature were mainly excerpts from Hippocrates and Galen meant
for popular use. These Christian translators, thoroughly scientific as far as
their times permitted them to be, were wonderfully industrious in their work

as translators, great teachers in every sense 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, occupied so much with
translations, and intent on the re-introduction of Greek medicine, might
have depended very little on their own observations, and been very
impractical. All that is needed to counteract any such false impression,
however, is to know something definite about their books. Gurlt, in his
"History of Surgery," has some quotations from Serapion the elder, who is
often quoted by Rhazes. In the treatment of hemorrhoids Serapion 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, however. 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 considers the operation very
dangerous, however, but seems to think the removal of a stone from the
bladder a rather simple procedure. His description 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 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 Roman
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 conservators 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 medical 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 writings 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 accidents
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.

III

GREAT JEWISH PHYSICIANS[3]
Any account of Old-Time Makers of Medicine without 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 (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 conditions probably rather favored than
hampered their intellectual accomplishments.
It is not unlikely that the difficult personal circumstances in which the
Jews were placed had a good deal to do at all times with stimulating their
ambitions and making them accomplish all that was in them. Certain it is
that at all times we find a wonderful power in the people to rise above their
conditions. With them, however, as with other peoples, luxury, riches,
comfort, bring a surfeit to initiative and the race does not accomplish so
much. At various times in the early Middle Ages, particularly, we find

Jewish physicians doing great work and obtaining precious
acknowledgment for it in spite of the most discouraging conditions. Later it
is not unusual 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 Mohammedan
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 surprise 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,
contain 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 prophylaxis and in diagnosis have always remained
valuable, and though at times they have been forgotten, 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 landmarks in the history of medicine as well as of
religion.
Baas, in his "Outlines of the History of Medicine," says: "It corresponds
to the reality in both the actual and chronological point of view to consider
the books of Moses as the foundation of sanitary 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 teachings of these old times on such subjects. Moses made a
masterly exposition of the knowledge necessary 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 Talmud during the earlier
Middle Ages, that also contains 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 Physicians 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 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
injurious, 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. Induration of the lungs (tuberculosis) was
regarded as incurable. Suppuration of the spinal cord had an early, grave meaning.
Rabies was known. The following is a description given of the dog's condition: '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 prognosis
as to hydrophobia in man has remained unaltered 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 practical
anatomy for its very early date is the procuring of the skeleton from the body of a
prostitute by the process of boiling, by Rabbi Ishmael, a physician, at the close of the
first century. He gives the number 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 œsophagus 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; described monstrosities and

congenital deformities; practised version, evisceration, and Cæsarian section upon the
dead and upon the living mother. A. H. Israels has clearly shown in his 'Dissertatio
Historico-Medica Inauguralis' that Cæsarian section, according 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, œsophagus, stomach, small intestines, and gall bladder;
wounds of the spinal cord, windpipe, 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
being 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, provided the
head is not attacked; all manner of evils, except it be a bad woman."
There are many other interesting suggestions in the Talmud. Sometimes
they have come to be generally 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 suggestion 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 encyclopedia 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 medicine with some reference to how
high the worth of science was valued in this much misunderstood work. In one place
we have the expression 'occupation with science means more than sacrifice.' In
another 'science is more than priesthood and kingly dignity.'"[4]

After all this of national tradition in medicine before and after Christ, it is
only what we might quite naturally expect to find, that there is scarcely a
century 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. Perhaps I should say that they were held in high
estimation 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
sixteenth and early seventeenth centuries accomplished successfully the
task of printing many of the books of these old-time physicians and secured
their publication in magnificent editions. These were bought eagerly by
scholars and libraries all over Europe in spite of the high price they
commanded in that era of slow, laborious printing. The Renaissance
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 disappeared 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
Rab or Raw and Samuel. Rab 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
generation, 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 Rab'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 reputation 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 successful 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 particularly to have been anxious
to make his services available to the scholars of his time. He looked upon
them as brothers in spirit, fellow-laborers whose investigations were as
important as his own and whose labors for mankind he hoped to extend by
the helpfulness 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 imposed upon, but that seems to have
made no difference to him, and he went on straightforwardly doing what he
thought he ought to do, regardless of the devious ways of men, even those
whom he was generously 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 prominence as teachers, and this is one of the first important 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 instruction 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 practitioners of medicine, once more
becomes manifest. The first of the race who comes into prominence is
Maser Djawah Ebn Djeldjal, of Basra. To him we owe probably more than
to anyone else the preservation of old scientific writings and the cultivation
of arts and sciences by the Mohammedans. He prevailed on Caliph Moawia
I, whose physician he had become, to cause 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 upon 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 translation 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 translation, but we
have fragments of the translation preserved by Rhazes, 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 Rhazes himself.
Rhazes quoted Maser Djawah freely and evidently trusted his declarations
implicitly.
The succeeding Caliphs of the first Arabian dynasty 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 influence of physicians so wise and learned as Maser Djawah.
More probably, however, they themselves lacked interest. Toward the end
of the seventh century they were succeeded by the Abbassides. Almansor,
the second Caliph of this dynasty, was attacked by a dangerous disease and
sent for a physician of the Nestorian school. After his restoration 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 himself 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 provided a translation of Ptolemy he also had
translations made of Aristotle and Galen.
It is not surprising, then, that the school of Bagdad 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 physician in consultation. Their
opinions were so widely in disaccord that Isaac refused to prescribe
anything, and when the Emir, who had great confidence in him, demanded
the reason, he replied, "disagreement 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 important members of the profession in
the eighth century. 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-Raschid, 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
particularly 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 degree. The
greatest teacher of this school at Bagdad was Joshua Ben Nun, sometimes
known as the Rabbi of Seleucia. His teaching attracted many students to
Bagdad and his fame as one of the great practitioners of medicine of this

time brought many patients. Among his disciples was John Masuée, whose
Arabian name is so different, Yahia Ben Masoviah, that in order to avoid
confusion in reading it is important to know both. Almost better known,
perhaps, at this time was Abu Joseph Jacob Ben Isaac Kendi. Fortunately
for the after time, these men devoted themselves not only to their own
observations 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
Constantinople was conquered in battle, one of the obligations 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 Arabian empire schools and academies sprang up. We have
records of them at Basra, Samarcand, Ispahan. 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, and were the teachers of the Arabs in medicine and science generally.
These Christian and Jewish physicians 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 beginning of the tenth, century that we begin to have important
contributors to medicine from among the Arabs themselves. Even at this
time they have distinguished rivals among Jewish physicians. Indeed these
acquired such a reputation that they became the physicians to monarchs and

even high ecclesiastics, and we find them nearly everywhere throughout
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 Zijadeth III. The
younger Isaac established a school, and it was with him that Israeli obtained
his introduction 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 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 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 physician by the power of nature." 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 carefully."
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
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 physicians 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 magician, 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, however, 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 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 Rhazes. The translation 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 Europe 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
additions made by Faradj himself, notably a glossary of Arabian names.

In Spain also Jewish physicians rose to distinction. The most
distinguished in the tenth century was Chasdai Ben Schaprut. Like many
other of the great physicians of this time, he had studied astronomy as well
as the medical sciences. He became the physician of the Caliph Abd-er-
Rahman III of Cordova. 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 characterized the next centuries, the eleventh
and twelfth, at Cordova in Spain, when such men as Avenzoar, Avicenna,
and Averroës attracted the attention of the educational world of the time.
Jewish writers have sometimes claimed one of the most distinguished 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 ancestors
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,
popular 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 ecclesiastical authorities
toward the Jews, and of Church decrees that either absolutely forbade their
practice of the medical profession and their devotion to scientific study, or
at least made these pursuits 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 legislation 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 kings and even of high ecclesiastical
dignitaries, as well indeed of the Popes themselves. This, it is usually

declared, must be attributed to the surpassing 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 sentiment
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. Religion often became a cloak for ill-will and persecution.
The state of affairs that has been presumed however, 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
investigation of the conditions and from its very appearance 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 influence of the Benedictines
was very strong and where the influence of the Popes and the ecclesiastical
authorities was always dominant, full liberty of studying and teaching was
from the earliest days allowed to the Jews. Down at Montpellier it seems
clear that Jewish physicians had a large part in the foundation of the
medical school, and continued for several centuries to be most important
factors in the maintenance 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 physician's hands was made the occasion for persecution. We 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 scornfully 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 Christianity, but on
defective human nature.
During the Middle Ages the best possible criterion of the attitude of the
Church authorities towards the Jews is to be found in the legislation of Pope
Innocent 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 Christian by violence compel them to come
dissenting or unwilling to Baptism. Further, let no Christian venture
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 countries. Alexander II, Gregory IX, and
Innocent IV all issued formal documents demanding the protection 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
scholars, 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 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
demonstrate this there is no need to quote Catholic historians, 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 Rome,
the Jews went forth in their holiday garments to meet them, bearing before them the
'thora,' 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 instance, 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."
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 central 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 attitude 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 particular 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 letters 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 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 authorities 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 decrees 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 regulations 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
physicians at Montpellier led to a number of the race taking up the practice
of medicine without any further 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 wandering physicians.
As a consequence of this, the faculty at Paris, always jealous of its own
rights and those of its students, at the beginning of the fourteenth century
absolutely forbade Jews from practising on Christian patients within its
jurisdiction. Of course the faculty of the University of Paris was dominated
by ecclesiastical authorities. The medical school was, however, almost
entirely independent of ecclesiastical influence, and was besides largely
responsible 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
practised. 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 regard to medical practice will be
aware that a number of attempts were made by the ecclesiastical authorities
just at this time to regulate the practice of medicine. 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
neighboring University of Montpellier. After a time it was found that the
greatest number of violators of these decrees were Jews. Accordingly
special regulations were made against them. They happen to be
ecclesiastical regulations, because no other authority at that time claimed
the right to regulate medical education and the practice of medicine.
What is sure is that many Jewish physicians reached distinction under
Christian as well as Arabian 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 catalogue, 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 generally known in the Christian world at least, Maimonides, 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 or indirectly with his works, and the greater the
reputation of the scholar, as a rule, the more he knew of Maimonides,
Moses Ægyptæus, 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 connection 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 practice. While the narrow specialists
in each generation, the men who are quite sure that they are curing 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 discomfort 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 their profession. Hippocrates, Galen,
Sydenham, Auenbrugger, Morgagni, these are representatives of this great
class, and Maimonides must be considered one of them.
Moses Ben Maimum, whose Arabic name was Abu Amran Musa Ben
Maimum Obaid Alla el-Cordovi, who was called by his Jewish compatriots
Ramban 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 uplift in the intellectual life, or for any such
broad interest in what has been so well called the humanities—the
humanizing things that lift us above animal necessities—as would make for
genuinely liberal 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 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 opportunity 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 abiding profound interest in
real civilization in many a medieval city, much more general appreciation of
art, much more breadth of intelligence and sympathy 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 intelligence, of artistic taste, and everything that
makes for cultivation of intellect rather than of interest in merely material
things.
It is well said that it is hard to judge the Cordova of old by its tawdry
ruins of to-day. The educated visitor still stands in awe and admiration of
the great mosque which expressed the high cultivation 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 expression, 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 Roman Empire, and on this
foundation they made a marvellous development. "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 cultivated, and
the Arabs introduced their system of irrigation 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 porphyry, jasper, and marbles are
still in their places; the splendid glass mosaics, which artists from
Byzantium 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 Cordova,
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 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 growing youth. Even when persecution came,
Maimonides 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 Averroës, still she remained wonderfully
beautiful and attractive, 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 Talmud, mathematics, and astronomy, a good rounded education
in literature, the basis of law, and some exact physical science. After his
preliminary education at home Maimonides studied the natural sciences and
medicine with Moorish teachers. 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 needless 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. Recent 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 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 enables him to understand all things,
especially the Unity of God, and all knowledge and science serve only to
direct man to the knowledge of God. Passions 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 persecutions. Here it is
said that they had to submit to wearing the mask of Islam in order to lead a
peaceful 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 knowledge, 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 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
entrusted 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, became rather discouraged and despondent about
himself. 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, became the physician of Malie Alkamen, the brother of
Saladin, and, besides, was a physician to the hospital at Cairo. His son,
David, the grandson of Maimonides, practised medicine also at Cairo till
1300. He in turn left two sons, Abraham and Solomon, who achieved
reputation in the chosen profession 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 understand his time for
teaching. He was the physician to Saladin, whose relations with Richard
Cœur 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 officials 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 most precious lessons in caring for patients rather
than disease, in the art of medicine rather than medical 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 thoroughgoing 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, however, 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 conditions
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 person of the modern
time, he was quite sure that these symptoms portended some insidious
organic ailment that would surely bring an early death. When fathers,
having done all that there is to do, just expect 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 popular 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
abbreviate from a biographical sketch of Maimonides by Dr. Oppler, which
appeared in the "Deutsches Archiv für 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 necessary 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 moderation according to his needs. Before
a man sits down to table he should note whether he has any 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 occupation 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 substances. 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 ordinary nutritive materials. Large fish, cheese, milk more than
twenty-four hours after milking, the flesh of old oxen, beans, peas, unleavened bread,
sauerkraut, 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. Johannesbrod 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 impurities of the body. It is an axiom in medicine, that so long as
evacuations are absent, or difficult, or require strong efforts, the individual is liable to
serious disease. Every medical means should be taken to overcome constipation in
order to escape its dangers. 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 diseases 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 eating is a poison for men and the
cause of many diseases 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 overindulgence 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 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 beneficial. 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 frequently, 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 (the "r" months). After passing his fiftieth year an individual should
abstain from venesection. Venesection 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 bothersome occupation, and take no walk.
19. Whoever observes these rules of life faithfully 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 remain 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 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
Maimonides 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, Maimonides' 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 "The Influence of the Stars on Human
Constitutions" 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 Maimonides 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:—rational proof as in mathematical science,
the perception of the senses, or traditions from the prophets and learned
men." His biographer in the monograph "Maimonides," published by the
Jewish Publication Society of America[5], 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 defence and government.' He says,
that he had himself 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
dependent 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
modest 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 knowledge that obscures the real question at
issue. A great thinker, who lived in the century in which Maimonides 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 intellectual
progress the most, the fact that men feared to say, "I do not know."
One of the most interesting features of Maimonides' 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
education, this century made wonderful strides. Two of its greatest teachers,
Albertus Magnus and his pupil, Thomas Aquinas, quote from Moses
Ægyptæus, 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, Alexander of Hales and Duns Scotus, were also influenced by
Maimonides. In a word, the educational 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 themselves felt several thousand miles away.
Maimonides was, then, in his own time one of the world teachers, and, in a
certain sense, he must always remain that, as representing a special
development of what is best in human nature.

V

GREAT ARABIAN 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
cultivation 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 destruction 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 Nestorian 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 Christian 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 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 dissection 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 Mohammedan Empire
extended from India to Spain within a century after Mohammed's death.
Carthage was taken and destroyed, Constantinople was threatened. In 661,
scarcely forty years after the hegira or flight of Mohammed, from which
good Mohammedans 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 Mohammed 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 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
volumes. 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 Romans 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, Samarcand all became centres of culture and of
education. Large sums were paid for Greek manuscripts, and for
translations from them. Under the famous Harun al-Raschid, 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 wandering 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 philosophy 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 nourished.
Medicine was taken up with the other sciences and cultivated assiduously.
Freind, in his "Historia Medicinæ," 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 Alexandria in the eighth century, came under the influence
of the university still in existence there.
In the West, in Spain, the Arabs enjoyed the 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 Roman Empire in
the West that advanced most in culture before 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 flourishing province, and under the Spanish Cæsars, 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
Cæsars, the place of Spain in the history of the Roman Empire, and the
continuance 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 devotion 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-Razi, and who has hence been usually referred to in the
history of medicine as Rhazes. He was born about 850 at Raj, in the
Province of Chorasan in Persia. He seems to have had a liberal early
education in philosophy and in philology and literature. 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 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 native 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
enlarged 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 Aristotle. 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 aphorisms 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 indicate that Rhazes was absolutely wedded to
authority, there is another well-known maxim of his which shows how
much he thought of the value of experience 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, 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."
Rhazes 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 increase the patient's natural vitality. Hence his
advice: "In treating a patient, let your first thought be to strengthen his
natural vitality. If you strengthen that, you remove ever so many ills without
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." Another of his aphorisms seems worth while quoting:
"The patient who consults a great many physicians is likely to have a very
confused state of mind."
Some idea of Rhazes' strenuous activity as a writer on medical subjects
may be obtained from the fact that thirty-six of his works are still extant,
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 "Continens," 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 distinguished
medical writers, from Hippocrates to Honein Ben Ishac, also known as
Johannitius, a Christian Arabian physician, one of Rhazes' teachers. The
most frequently quoted of these authorities are Galen, Oribasius, Aëtius,
and Paul of Ægina. The work, however, is not made up entirely of
quotations, but contains many observations made by the author himself.
Gurlt says that the foundation of the theoretic medicine of Rhazes is the
system of Galen, while in practice he seems to cling more to the aphorisms
of Hippocrates. He has many practical points which show that he thought
for himself. For instance, in wounds of the abdomen, if the intestines 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
consequences.
It is impossible to give any adequate idea of the 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 suggests gargles, but when these fail he advises resection
and cauterization. Among the affections of the tongue he numbers abscess,
fissure, ulcer, cancer, ranula, shortening of the ligaments, hypertrophy,
erythema of the mucous membrane, and inflammatory swelling. In general
his treatment of the upper respiratory tract is much farther advanced than
we might think possible at this time. He advises tracheotomy whenever
there is great difficulty 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 Paré,
Malgaigne says that the first reference 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 superficial character, was rather well
understood, and so 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 certain 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 History of Medicine," declares
that Rhazes' most important work for pure medicine is his monograph on
smallpox. Its principal value is due to the fact that, though he has consulted
old authorities carefully, his discussion of the disease is founded almost
entirely on his own experience. His description 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 declares, are particularly serious in
which the eruption 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 water and acid
drinks should be administered 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 complications 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 Rhazes in the history 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
controversies that had come upon him because of his venturing to make his
observations for himself, accepted the post of physician to the Emperor
Charles V, he burnt a number of his manuscripts. Among these were his
translation of Rhazes and some annotations on Galen, which, as he says
himself, had grown into a huge volume. The Galenists were bitterly
decrying his refusal to accept Galen 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 Roelant: "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 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
complaints, and in spite of the fact that a number of friends who were
present urged me not to destroy them."
Vesalius' translation of Rhazes was probably undertaken 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 Rhazes, 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 observation, 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

Rhazes 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 century. 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 Regius," or "Royal Book of Medicine." This became
the leading text-book of medicine for the Arabs until replaced by the
"Canon of Avicenna" some two centuries later. The "Liber Regius" was an
extremely 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 developed 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 ailing animals before applying them to men. Of course, it
owes much to earlier writers on medicine, and especially to Paul of Ægina.
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 injured 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 instance, 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 come away, and then the tube
removed and the abdomen 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 "Regalis
Dispositio," the "Royal Disposition 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 Averroës, the philosophic theorist in medicine. Besides, it
may be recalled here that Maimonides, the great Jewish physician, was born
and educated at Cordova, in Spain. It might very well be a surprise that
these distinguished men among the Arabs should have flourished 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 development of science and philosophy. Anyone who
recalls, however, the history of Spanish intellectual influence in the Roman
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 intellectual 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 "The Miscellany." Most of
what he has to say about medical matters is taken from Rhazes. His work on
surgery, however, in three books, represents his special contribution to the
medical sciences. It contains a number of illustrations 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. Guy de Chauliac has quoted Albucasis about two hundred times in
his "Chirurgia Magna." Even as late as the beginning of the sixteenth
century Fabricius de Acquapendente, the teacher of Harvey, confessed that
he owed most to three great medical writers, Celsus (first century), Paul of
Ægina (seventh century), and Abulcasis (tenth century).
Abulcasis insisted that for successful surgery a detailed knowledge of
anatomy was, above all, necessary. 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 physicians 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 example of his method of teaching the practical
technique 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
appropriate 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 affection. There are only four
ways of arresting arterial 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 absence 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 advises 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 cutting of the meatus
when narrowed, dilatation of strictures with lead sounds, and even suggests
plans of operations to improve the condition in hypospadias. He gives the
signs for differentiation between epitheliomata and condylomata, and
distinguishes 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
impossible 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 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 removed 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 bladder becomes swollen and fills up the vaginal cavity. The
fracture will, as a rule, then be readily reduced. 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 rubber bags.

AVICENNA

Undoubtedly the most important of Abulcasis' contemporaries is the
famous physician whose Arabic name, Ibn Sina, was transformed into
Avicenna. He was born toward the end of the tenth century in the Persian
province of Chorasan, at the height of Arabian influence, and is sometimes
spoken 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 compendium "Continens" of Rhazes,
and, in the East, continued until 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 carried great weight with it. There are very few subjects in medicine
that did not receive suggestive, if not always adequate, treatment at the
hands of this great Arabian medical thinker of the eleventh century. 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 regard 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 Avicenna, 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
Hebräische in der Anatomie," quotes some of them,—Bartholomæus de
Varignana, Gentilis de Fulgineis, Jacobus de Partibus, Didacus Lopez,
Jacobus de Forlivio, Ugo Senesis, Dinus de Garbo, Matthæus de Gradibus,
Nicolaus Leonicenus, Thaddæus 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 centuries 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 Averroës, who always speaks of him with great
respect. He is interesting as probably being the first to suggest 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, 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 require 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 begins with some discomfort, and then
some difficulty of swallowing, which is gradually and continuously
increased until finally there comes complete impossibility 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 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.

AVERROËS

Among the distinguished contributors to medicine at this time, though
more a philosopher than a physician, is the famous Averroës, 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
personal 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 philosophical 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 suspicion of free thinking and
was brought to trial with a number of personal friends, who occupied high
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 succeeded 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 Averroës 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, materia medica, hygiene, and therapy. Then there is
a commentary on the "Cantica of Avicenna," and a tractate on the "Theriac."
Averroës' idea in writing about medicine was to apply his particular system
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
medicine, 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 Averroës did in his time what Descartes did many centuries
later, and many another brilliant thinker has done before and since.

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 opportunities afforded. These were better than they could
secure at home in Christian countries, because the process of bringing
culture and devotion to literature and science into the minds of the Northern
nations, who had replaced the old Romans in Europe, was not yet
completed. Bagdad and Cordova 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 civilization 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 Gilles 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 probably 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 visitors 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 finding 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 established educational institutions which attracted wide attention. As
we have said, the two most famous of these were at Bagdad and at Cordova.
Mostanser, 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 beneficent
interest of this monarch and of other of the Abbasside rulers in education.
Its fate at the present time is typical of the attitude of the Mohammedans
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.
Scholarship 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 proclaiming
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 considerable degree and have been perpetuated in the
modern 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 recognition of a certain
amount of work done as recognized by the educational authorities. There
was always 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 acquired, and
developing it. There are a number of comparisons between this and later
periods of education that might be suggested if comparisons were not
odious.
The influence of Arabian medicine on modern medicine can, perhaps,
best be judged from the number 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 Renaissance period. Hyrtl,
without pretence of quoting them all, gives a list of these which is
surprising in its comprehensiveness. For instance, the mediastinum, the
sutura sagittalis, the scrobiculus cordis, the marsupium cordis, the chambers
of the heart, the velum palati, the trochanter, the rima glottidis, the
fontanelles, the alæ 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 Romans have quite other expressions, in which
the sense of our modern terms is not contained. This has given rise to many
misunderstandings, and to many attempts in the modern times to return to
the classic terminology rather than preserve what in many cases are the
barbarisms introduced through the Arabic, but it is doubtful 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 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 preserving 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 acceptance 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,"[6] declares that it is almost incredible how
earnestly some trivial questions 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 commentaries 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 the
scholastics were writing commentaries, but they are typically Oriental in
character, and it must be remembered that during the twelfth and early
thirteenth 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 Rarer Old Anatomists,"[7] says that "the Arabs
paid very little attention to anatomy, and, of course, because of the
prohibition in the Koran, added nothing to it. Whatever they knew they took
from the Greeks, and especially 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 soiling 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 principles 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, however, it seems better to confine attention to a few of the
most prominent Arabian writers on medicine, because they will serve to
illustrate how thoroughly 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
insisted on a preliminary education of three years of college work, on at
least four years of medical training, 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
department 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 practise 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 number of these licenses issued to women in the
neighborhood of Salerno. This subject of feminine medical education at
Salerno, because of its special interest in our time, will have a chapter by
itself.
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 mankind which are
culminating in our era. It is rather interesting, then, to study just how these
developments 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 centuries afterwards. With the invention of printing at the
time of the Renaissance most of them were printed and exerted profound
influence over the revival 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
department 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 ordinary natural process of
development in human interests. First man is interested in himself and in his
health, then in his property, and finally in his relations 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
emphasized by the fact that even the earliest chroniclers whose accounts we
have were not sure as to its origin, and even had some doubt about the age
of the school. Alphanus, usually designated Alphanus I because 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 Renzi and published in his "Collectio Salernitana," it is
definitely recorded that the medical school was founded by four doctors,—a
Jewish Rabbi 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 teachers 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 hospital 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
organization, 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 uncertain whether
clinical instruction was imparted in these institutions or not, but the whole
tenor of what we know about the practical character of the teaching at
Salerno and of the fine development of professional 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
practised there about the middle of the ninth century. Ragenifrid, 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 indicates that already foreigners
were being attracted, but more than this that they were obtaining
opportunities 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 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 became
Pope Victor III, regained his health at Salerno under the care of the great
Constantine Africanus, 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 chapter, there is some account
of the friendship between Abbot Desiderius of Monte Cassino and
Constantine Africanus, and the latter's withdrawal from his professorship to
become a Benedictine. One of the physicians 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 already 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 education at Salerno
and how much influence it exerted 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 before 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 attraction
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 doubtless were sufferers from incurable diseases and nothing 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 promised
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 regulations 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 Ruggiero (Roger) of the
Two Sicilies promulgated the law: "Whoever from this time forth desires to
practise medicine must present himself before our officials and judges, and
be subject to their decision. 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
personality rather than to his times,—as representing his very modern spirit
and his progressive way of looking at things. There is no doubt that certain
personal 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
Roger of the preceding century; and then it is easy to appreciate that
Frederick's regulation is only such a development of the governmental
attitude toward medical practice as might have been expected during the
century since Roger's time. It has sometimes been suggested that this law
made by the Emperor Frederick, who was so constantly in bitter opposition
to the Papacy, was issued in despite of the Church authorities and represents
a policy very different 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 ordering of the practice of medicine
was effectively 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 chastening 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 during 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 before
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 obtained, 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 education. 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 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,
regulating the practice of pharmacy, and the price as well as the purity of
drugs, and the relations of physicians, 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 documents 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 preliminary 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 utterly false one. The
preliminary training that is the undergraduate work at the universities
consisted of the Seven Liberal Arts—the trivium and quadrivium, 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, astronomy, and music. This was a
thoroughly rounded course in intellectual training. No wonder that
Professor Huxley said in his Inaugural Address as Rector of Aberdeen, "I
doubt if the curriculum of any modern university shows so clear and
generous a comprehension of what is meant by culture as this old trivium

and quadrivium does." There is no doubt at all about the value of the
undergraduate 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 subjects—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, Ægidius, 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 thoroughly scientific, and some of the results of
the medical investigations of that early day are interesting even now. The
descriptions of diseases that we have from the Salernitan school are true to
nature and are replete with many original observations. 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 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 consumption was suspected, the first prescription
was a good course of strengthening nourishment for the patient. On the
other hand, they declared that the cases in which diarrhea supervened
during consumption soon proved fatal. In general, with regard to people
who were liable to respiratory diseases, they insisted upon life in an
atmosphere of equable temperature. 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
recommended 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 number 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 affection, even down to our own day, that
this employment of one of its compounds is rather striking. 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 Medizin" (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 autochthonous centre of medical influence in the
whole West. One might almost say that it was like a versprengten Keim—a
displaced embryonic element—which, as it unfolded, rescued from
destruction the ruined remains of Greek and Roman medicine. 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
department of medicine was left without some advance, 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 science
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 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 polypragmasia. The work in internal medicine

was especially 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 uplift of professional dignity and advance in the
standards of medical education that are to be noticed in connection with
Salerno. Registration, licensure, preliminary education, adequate
professional studies, clinical experience under expert guidance, even special
training for surgical work, all came in connection 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 practice 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 important defect was not due to any Church opposition
to anatomy, as has often been said, but to the objection 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 generations ago, and the only way
that bodies could be obtained regularly was by "resurrecting" them, as it
was called, from graveyards. In the absence 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 corresponding organs in man. Copho's well-
known "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 comparative anatomy.

When their surgery came to be written down, however, it gave abundant
evidence of the thoroughness with which this department of medicine had
been cultivated by the Salernitan faculty. We have the text-book of Roger,
with the commentary of Rolando, and then the so-called commentary of the
Four Masters. These writings were probably made rather for the medical
school at Bologna than that of Salerno, though there is no doubt that at least
Roger and Rolando received their education at Salerno and embodied in
their writings the surgical traditions of that school. While I have preferred,
in order to have a connected story of surgical development, to treat of their
contributions to their specialty under the head of the "Great Surgeons of the
Medieval Universities," it seems well to point out here that they must be
considered as representing especially the surgical teaching of the older
medical school of Salerno. There are many interesting features 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.[8]
Much is often said about the place of Arabian surgery and medicine at
this time, and the influence that they had over the medical teaching and
thinking 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 Græcia. 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 Surgeons 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,"[9] far

from exerting a beneficial influence, it had a rather unfortunate effect. It led
especially 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 representative—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
significant therapeutic aids. With the coming of Arabian influence there
began, says Pagel, "as the literature of the times shows very well, that rule
of the apothecary in therapeutics which was an unfortunate exaggeration.
Now all the above-mentioned complicated prescriptions came to be the
order of the day. Apparently the more complicated a prescription the better.
Dietetics especially was relegated 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 authors 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 historians of
medicine because apparently they would 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 literary 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 together 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 professor. This represents a
development of co-operation 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 translated and

committed to memory by many generations of physicians, is the celebrated
Salernitan medical poem on hygiene. The title of the original Latin was
"Regimen Sanitatis Salernitanum." It was probably written about the
beginning of the twelfth century. A century or so later it came to be the
custom to call medical books after flowers, and so we had the "Lilium
Medicinæ" and the "Flos Medicinæ" down at Montpellier, and this became
the "Flos Medicinæ" 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
Hippocrates or the sayings of Galen. Probably this enables us to understand
the great reputation that the Salernitan school enjoyed and the influence that
it wielded better than anything else. The poem is divided 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 something 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 medieval period
needed to have ready to memory. Some of its prescriptions, both in the
sense of formulæ and of directions to the patient, have quite a modern air.
One very interesting contribution to medical literature 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 professional life. It is an
extremely valuable document, as demonstrating how practical was the
teaching at Salerno. The work is usually ascribed to Archimattheas, 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 dwelling 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
patient 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 receive the
sacraments of the Church before the doctor 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
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 advice that might perhaps to a puritanic conscience
seem more politic than truthful. Since the old professor insists so much on
not disturbing the patient'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 suggestion than might be
thought at first glance. He says, "When the doctor quits the patient he
should promise 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
fragmentarily told, illustrates very well how old is the new in education,—
even in medical 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 much
attention over six hundred years ago. We owe most of our knowledge of the
details of its organization and teaching to De Renzi. Without the devotion of
so ardent a scholar it would have been almost impossible for us to have
attained so complete a picture of Salernitan activities. As it is, as a
consequence 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 thousand
years, but the ways and modes of facing problems 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 brought home to
us. It is for this that study of particular 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 AFRICANUS
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 interesting, 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
translations, 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
Benedictine 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 monastery 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
devote 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 Benedictine 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 Constantine established a school of
writers at Monte Cassino, for he could scarcely have accomplished so much
by himself as has been attributed to him. Besides, his works attracted so
much attention that writers of immediately succeeding generations who
wanted to secure attention for their works sometimes attributed them to him
in order to take advantage 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 authentic works meant much for his own
and after generations.
Constantine was born in the early part of the eleventh century, and died
near its close, having lived probably well beyond eighty years of age, his
years running nearly parallel with his century. His surname, 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 himself, however, at the same time to whatever of
physical 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 information 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 number 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 traditions in Asia Minor, were farther advanced in
their knowledge of the medical sciences than the scholars in the West. They
had better facilities for obtaining 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 translation of many well-known Arabian
medical authors proved eminently suggestive to seriously investigating
physicians all over the world in his time. Before 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 knowledge, 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
reputation of his extensive travels and wide knowledge soon attracted a
large clientele. This was followed quite naturally by the envy at least of his
professional brethren. Feeling became so bitter, that even the possibility of
serious personal consequences 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 examples 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 very serious weapon that
might be used against innovators. By craftily circulated rumors the
populace was brought to accuse him of magical practices, 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 seriously, 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.[10] 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 Robert 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 teaching 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 professorship—the highest
position in the medical world of the time—apparently with certain plans in
mind. 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
knowledge 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 Desiderius 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 undergraduate 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 departure 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
intellectual work. Desiderius seems, indeed, to have been a large factor in
influencing the great physician 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 having the learned
physician, the travelled scholar, at 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 themselves 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 Desiderius 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 Rome, 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
accomplish that writing for which Constantine and himself 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 were messages of brotherly interest and solicitude just as in
the old days. The great African physician's best known work, the so-called
"Liber Pantegni," which is really a translation of the "Khitaab el Maleki" of
Ali Ben el-Abbas, is dedicated to Desiderius. Constantine wrote a number
of other books, most of them original, but it is difficult now to decide 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 information 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 Constantine had
accomplished for those of lesser import. Under the patronage of the
Emperor Frederick Barbarossa, he published translations of Rhazes, Isaac
Judæus, Serapion, Abulcasis, and Avicenna. 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 the study of the old masters, issued
editions of certain, at least, of the works of Hippocrates ("Aphorisms") and
Galen ("Microtechnics"), and, in general, called attention to the precious
treasure of medical 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 "Handbook," does not hesitate to say that "a farther merit of
Constantine must be recognized, inasmuch as that not long after his career
the second 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 encouragement
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 Constantine'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 Saracen 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 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 commentaries 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 because 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 numbers 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
describes 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 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 published 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, Rhazes, 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
Judæus, 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 practical, far-
sighted scholar. Besides, it seems not unlikely that but for his interest in
them we would not at the present time possess the translations of these

minor Arabian writers, and that would be an unfortunate gap in medical
history.
The other misunderstanding with regard to Constantine refers to the fact
that it is now almost impossible 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, however,
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 manuscripts 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
translating himself, and that he probably must have organized a school of
medical translators at Monte Cassino. 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 probably
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 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 Renaissance, for a writer to attribute what he had written to
some distinguished literary man of the preceding 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 whenever the things written

have been really worth while. Literature that has deeply influenced mankind
has never paid. Publications that have paid are insignificant works that have
touched superficially a whole lot of people. To think of Constantine as a
plagiarist 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 regard to the history of
medicine in his time, Constantine's reputation has been constantly
enhanced. It is not so long since he was considered scarcely more than a
monkish chronicler, who happened to have taken medicine rather than
history for his field of work. Gradually we have come to appreciate all that
he did for the medicine of his time. Undoubtedly his extensive travels, his
wide knowledge, 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 Romans, set him among the great
intellectual forces of the Middle Ages. Salerno owed much to him, and it
must not be forgotten that Salerno was the first university of modern times,
and, above all, the first medical school that raised the dignity of the medical
profession, established standards of medical education, educated 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 anticipated 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 centuries 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 Græcia, there is no doubt at all that the
Benedictines 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, 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 beginning the
Benedictines recognized that a monastic career should be open to women as
well as to men, and Benedict's sister, Scholastica, established convents 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 advisability of affording women
the opportunity to study medicine, and of handing over to them the
department 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 expected 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 important 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 "Republic," as absolutely as any modern
feminist, that women should have the same opportunities for education as
men, and that at Rome, at the end of the Republic and the beginning of the
Empire, the women occupied very much the same position 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. Brigid's
school at Kildare was scarcely less famous than St. Patrick's at Armagh. It
had several 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 century we find women professors in
every branch at Italian universities. Some of them were at least assistants in
anatomy. The Renaissance 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 encouragement, for women in medicine, both among the
Greeks and the Romans, in the early centuries of the Christian era. Galen,
for instance, quotes certain prescriptions from women physicians. One
Cleopatra is said to have written a book on cosmetics. This name came
afterwards to be confounded with that of Queen Cleopatra, giving new

prestige to the book, but neither Galen nor Aëtius, 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 Aëtius in his "Tetrabiblion."
Daremberg, the medical historian, announced in 1851 that he had found a
Greek manuscript with the title, "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 manuscript on medical subjects, bearing this name,
mentioned 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 Romans 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 dedication leaves no doubt that she
was a woman in active 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 medical 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 physicians 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 compiled
"Nomenclatura Sanctorum Professione Medicorum" (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 Constantinople 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 professors, 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 in the life of Trotula, who seems to have
been the head of the department. Some of her books are well known, and
often quoted from, and she contributed 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 Rudolph Malcorona, who, in 1059, came
to Utica and remained there for a long time with Father Robert, his nephew.
"This Rudolph 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 possessed such an extensive knowledge of
the natural sciences that in the town of Salerno, where, since ancient times,
the best schools of medicine had existed, there was no one to equal him
with the exception of a very wise matron."
This wise matron has been identified with Trotula, many of the details of
whose life have been brought to light by De Renzi, in his "Story of the
School of Salerno."[11] According to very old tradition, Trotula belonged to
the family of Ruggiero. 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, as readers of Dante and Boccaccio are likely to
know. It was, indeed, as common as our own Rogers, of which it is the
Italian equivalent.
De Renzi 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, according to this, the mother of

the second Platearius, and the grandmother of the third, all of them
distinguished 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 treatment
for women's diseases that was being exploited. Rutebeuf, one of the
trouvères, 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 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
(experimentalis) 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 anticipate 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 régime which she should follow if the child is
to be properly nourished without disturbance.

Probably the most striking passage in her book is that with regard to a
torn perineum and its repair. 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 become
one foramen, having the same course. As a consequence, prolapse of the
uterus occurs, and it becomes indurated. In order to relieve this condition,
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
aforesaid 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 various cosmetics. How
many of these are original, however, is difficult to say. Trotula's name had
become 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 to determine which were
original. There are manuscripts 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 edition 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 attention it
has attracted even in comparatively recent times.
After Trotula we have a number of women physicians 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 herself 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 department of women's
diseases, their writings would seem to indicate that they studied all
branches of medicine. Besides, there are a number of licenses preserved 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 allowed 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 training women physicians
thoroughly, until well on in the fifteenth century, for we have the record of
Constance Calenda, the daughter of Salvator Calenda, who had been dean
of the faculty of 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 thirteenth

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 traced from this time. Gradually its reputation waned, and we have
practically no medical writer of distinction there at the end of the fourteenth
century, 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
profoundly in all branches of medicine and medical education, 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 universities, and, in connection with its medical school,
feminine education obtained a strong foothold. It is not surprising, then, that
with the further development of universities in Italy, feminine education
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. University life gradually spread westward, and Paris came into
existence as an organized institution of 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
Teutonic peoples have always had for their women folk and the privileges
accorded them. A single unfortunate incident, that of Abélard and Héloïse,
seems to have been sufficient to discourage efforts in the direction of
opportunities for feminine education 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
knowledge of diseases, as well as valuable practical training 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
information 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 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 Rhineland. 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 author. Hroswitha, like Hildegarde, was a German, and we
have the record, also, of another religious writer, abbess of the Odilian
Cloister, at Hohenberg, who wrote a book called "Hortus Deliciarum, 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 common 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 until
now the study of their books shows that they provided exactly the same
opportunities for women 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 themselves 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 Böckelheim, 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.
Accordingly, with eighteen of her nuns, Hildegarde withdrew to a new
convent at Rupertsberg, which English and American travellers will
remember because it is not far from Bingen on the Rhine. Here she came to
be a centre of attraction for most of the world of her time. She was in active

correspondence with nearly every important man of her generation. She was
an intimate friend of Bernard of Clairvaux, who was himself, perhaps, the
most influential man in Europe in this century. She was in correspondence
with four Popes, and with the Emperors Conrad and Frederick I, and with
many distinguished archbishops, abbots, and abbesses, and teachers and
teaching bodies of various kinds. These correspondences were usually
begun by her correspondents, who consulted her because her advice in
difficult problems was considered so valuable.
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 Simplicis Medicinæ," and the
second "Liber Compositæ Medicinæ." 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 religious, 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 infrequently 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, moreover, large estates; often
they had been cleared and made valuable by the work of preceding
generations 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
communities 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 Medicinæ," attracted attention rather early in the
Renaissance, 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 Wolfenbuttel, in 1858, by Dr. Jessen. This gave him an
interest in Hildegarde's contributions to medicine, and, in 1859, he noted in
the library at Copenhagen a manuscript with the title "Hildegardi Curæ et
Causæ." On examination, he was sure that it was the "Liber Compositæ
Medicinæ" 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 "Subtilitatum
Diversarum Naturarum Libri Novem." The second, in five books, treats of
the general diseases of created things, of the human body and its ailments,
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 interesting 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 precious stones, has 226 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 significance.
Modern scientists have not hesitated to declare that the descriptions abound
in observations worthy of a scientific inquiring spirit. We are, of course, not
absolutely sure that all the contents of the books come from Hildegarde.
Subsequent 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, showing how near we came to missing all knowledge of her
entirely.

Dr. Melanie Lipinska, in her "Histoire des Femmes Médecins," a thesis
presented for the doctorate 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 physical, 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 dysentery, 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 discusses the redness of the blood as a
sign of health, the characteristics of various excrementitious material 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 discussion of auto-intoxication in recent years is a distinct 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 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 before 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 upset 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 Mlle. Lipinska's thesis.
It is no wonder that Mlle. Lipinska thinks St. Hildegarde the most
important medical writer of her time. Reuss, the editor of the edition of
Hildegarde published in Migne's "Patrology," says: "Among all the saintly
religious who have practised 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
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
represent the spirit of their times and make it clear that definite knowledge
of things medical was considered 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
practices. 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 cultivation 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 collected and written down, and widely
disseminated.
Nicaise, in the introduction to his edition of Guy de Chauliac's "Grande
Chirurgie," reviews briefly the history of women in medicine, and

concludes:

"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, recognizes their right to
practise the art if they have undergone an examination before the regularly appointed
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 petition: 'Having heard the
petition of the Dean and the Masters of the Faculty of Medicine at the University 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 pretenders 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 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 becomes 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 almost 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 constantly 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
general. 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" (Fordham University Press, 1910), that
corresponding 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 reasons 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 science 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 department 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 scattered in thousands of copies in manuscript
all over the medical world of the fourteenth and early fifteenth centuries.
Even after the invention of printing, 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 dissection, which students of every
university had in hand when they made their dissection, or wished to
prepare 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 fourteenth and fifteen centuries than Mundinus,
or, as he was called in the Italian fashion, Mondino, who wrote this manual
of dissection.
Mundinus quem omnis studentium universitas colit ut deum (Mundinus,
whom all the world of students 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.[12]
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 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 preparations for demonstration
purposes. These demonstrations had to be hurried, owing to the rapid
decomposition of material consequent upon the lack of preservatives. The
various chapters were prepared with the idea of supplying explicit
directions and practical help during the anatomical demonstrations, 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 observations. 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 popularity.
Mondino followed Galen, of course, and so did every other teacher in
medicine and its allied sciences, until Vesalius' time. Even Vesalius
permitted 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. His works have never been translated into any modern
language except piecemeal, there is no complete 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 Raimondo. 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 particularly mentioned—Florence, Milan, Bologna,
Forli, and Friuli. There is, however, another Mondino, 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 question. Mondino was probably born in or near
Bologna. 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 graduation, and it is not
sure whether this is, beyond peradventure, so beneficial as is usually
thought.
That his early graduation did not hamper his intellectual 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 continued to occupy
with such distinction for the next twenty years, would seem to prove. His
public dissections 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 came from a family that had already distinguished 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 Raineri 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, however,
insisted always on the pharmacy feature as a specialty, and the fact was
made patent to the general 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.[13]
One of the fellow students of Mondino at the University of Bologna had
been Mondeville. He came from distant France to take a course in surgery
with 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 generation 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 indicate 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 education and study as the
cause.
At this time Italy was the home of the graduate teaching for all Europe.
The Italian Peninsula continued to be the foster-mother of the higher
education in letters and art, but also, though this is less generally known, in
science, for the next five centuries. Germany has come to be the place of
pilgrimage for those who want higher opportunities in science than can be
afforded in their own country only during the latter half of the nineteenth
century. France occupied it during the first half of the nineteenth century.
Except for short intervals, 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 educational prominence, Italy has always been the
European Mecca for advanced students. Practically all our great discoverers
in medicine, until the last century, were either Italians, or else had studied in
Italy. Mondino, Bertruccio, Salicet, Lanfranc, 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, Cæsalpinus, Columbus, Malpighi, Lancisi, Morgagni,
Spallanzani, Galvani, Volta, were all Italians. Mondeville, 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 the Church to science
during the Medieval and Renaissance periods. It is particularly surprising to
have them talk of Church opposition to the medical 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 directly under the
control of ecclesiastical authority than anywhere else, and nearly all of them
were dominated by papal influence. Bologna, while doing much of the best
graduate work in science, especially in medicine, was, in the Papal States,
absolutely under the rule of the Popes. The university was, practically, a
department of the Papal government. 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 assembled 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 became 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 utterly 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 men came for special higher studies in mathematics and
astronomy, in botany, in mineralogy, and in applied 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 possible 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 incentive in any department of science. This is coming 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 particularly true of the medieval period. We must go back to the
writers of those times.
If it seems surprising that the University of Bologna 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 departments at this time. Cimabue laid the foundation
of modern art towards the end of the thirteenth century, 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 not the same
generation produce a man who will accomplish 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 development and accomplishment than was the custom
sometime 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 environment at
Bologna itself was quite as stimulating, 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 reputation that came to them as world teachers
of medicine, we must know, first, this great teacher of Mondino 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 particular 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 magnetic teachers who attracted and inspired
pupils. 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, though 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 departments, and who then moved to Bologna, because of the
opportunity to teach afforded him by the university.
It is sometimes a little difficult for casual students of the time to
understand the marvellous reputation acquired by this medieval physician.
It should not be, however, when we recall the enthusiastic 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 Bologna came to appreciate Taddeo, as he is
familiarly known, looked upon him as a benefactor of the community, and
voted to relieve him of the burden of paying taxes. He came to be
considered as a public 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 surprised 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
scientific 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 organized 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 Taddeo 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
building up of a city, though their motives were probably much higher than
that, and their enlightened policy had its reward in the rapid growth of
Bologna until, very probably at the end of the thirteenth century, it had
more students than any university 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 especially 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 so that Dante, in his "Paradiso," when he wishes to find a
figure that would represent exactly the opposite to what St. Dominic, the
founder of the Dominicans, did for the love of wisdom and humanity, he
takes that of Taddeo, who had accomplished so much for personal
reputation and wealth.
This might easily lead to the impression that Taddeo's teaching was
unscientific, or merely empiric, 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 centuries 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. Indeed, most of those whose work has made them famous, down
to and including Galvani, did so. Taddeo wrote commentaries on the works
of Hippocrates and Galen, but he also translated the ethics of Aristotle, and
did much to make the learning of the Arabs easily available for his students.
His was a broad, liberal scholarship. Dr. Lewis Pilcher, in his article on
"The Mondino Myth,"[14] 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
thereafter 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
exaggeration. His methods of illustrating medical truths from many literary

and philosophical sources often caused the kernel of observation to be
hidden beneath 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 attention 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) 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 Bologna, 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 wonderful old man.
Knowing what we do of Taddeo it is not surprising that his pupil should
have accomplished work that was to influence succeeding generations more
than any other of that wonderful thirteenth century. Dr. Pilcher in the article
on "The Mondino Myth," so often placed under contribution 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[15] 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 pursuit of study on the human
cadaver as the common 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
history of departments of the intellectual life. Mondino'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 message. 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 of literature. We know now that
men had worked in art before Cimabue and Giotto, and had done
impressive 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 serious histories, that he was the first to
accomplish anything 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 dissections, and that he did at most but two or three. Only
those who are unacquainted with the magnificent 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 Gurlt'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 movement went, are likely to
accept any such declaration. There could not have been all that successful
surgery without much dissection not only of animals but also of human
bodies. The teaching of dissection 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 absurdity of the ordinarily accepted tradition in
this matter, that he has written a paper on the subject bearing the suggestive
title, "The Mondino Myth." He says:[16]

"We are accustomed to think of 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 testimonials from the masters teaching in the medical faculty, that he was
'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 embodiment 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
demonstration by Mondino, at Bologna in 1315, the decree 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 fashion 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 methods, 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 systematic
treatise written since the time of Galen, created for him in subsequent uncritical times
the reputation of being the Restorer 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 historians 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
context 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 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 happen 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 mystery and to figure it as an
unprecedented awe-inspiring 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 familiar 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.)
"... 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 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 details 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 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 experiences were not unusual. The lack of bodies for dissection 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
century. The case occurred in 1319 in Bologna, just four years after
Mondino's public dissections. Four students were involved in the charge of
body-snatching, all of them from outside the city of Bologna itself, three
from Milan and one from Piacenza. In modern experience, too, as a rule,
students from outside of the town where the medical college was situated,
were always a little readier than natives to violate graveyards. These four
students were accused 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 was teaching. The resurrection had been accomplished
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 medical 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 occurrences of it before the parties are brought to
trial, so that it seems not unlikely that a good many dissections 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 influence, political, monetary, diplomatic, and
ecclesiastical, in order to secure the bodies of criminals. Sometimes when

they failed in their purpose they waited until after burial and then took the
body without leave. When we recall the awfully deterrent condition in
which bodies must have been that were thus provided for dissecting
purposes, it is easy to understand that the enthusiasm of the students for
dissection must have been at a very high pitch. Certainly 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 unpleasantnesses, dissection is
only practised with assiduity if special care is exercised in requiring
attendance and superintending the work of the department.
In my book on "The Popes and Science" I have gathered the traditions
relating to Mondino's assistants in the chair of anatomy at Bologna. They
furnish abundant evidence of the fact that dissections, 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-education 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 Giliani, 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 demonstration
she would fill them with various colored liquids, which, after having been
driven into the vessels, would harden without destroying the vessels. 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 wonderful anticipation of our most modern methods—
injection, painting, hardening—of making anatomical preparations for class
and demonstration purposes.
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, and tells the story of the grief of her fiancé, who was
himself Mondino's other assistant.[17] 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 entertained 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 thirtieth year. The fact that both these assistants of
Mondino died young and suddenly, would seem to point to the fact that
probably dissection wounds in those early days proved even more fatal than
they occasionally did a century or more ago, when the proper precautions
against them were not so well understood. The death of Mondino's two
prosectors in early years would seem to hint at some such unfortunate
occurrence.
As regards the evidence of what the young man had accomplished before
his untimely death, probably the following quotation, which Medici has
taken from one of the old chroniclers, will give the best idea:
"What advantage indeed might not Bologna have had from Otto Agenius
Lustrulanus, whom Mondino had used as an assiduous prosector, if he had not been
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 continued at the university
will be best understood from what we know of Guy de Chauliac's visit to
the medical school here about the middle of the century. The great French
surgeon tells us that he came to Bologna to study anatomy under the
direction of Mondino'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 certain veins in it many times,
multitotiens.
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 situations, 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 illustrations. 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 would not be
difficult to think of further such illustrations 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 preparations 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 preserving bodies made it necessary to do dissections
hurriedly so as to get the rapidly decomposing material out of the way.
Beyond his book and certain circumstances connected 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 taking under him. Hence the body-snatching and other stories.
Mondino continued to be held in high estimation 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 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.
Undoubtedly 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 medicine 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 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' return to Rome 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.

X

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
general impression that this department of medicine did not develop until
quite recent years, and that particularly 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
evolution of surgery as a science.
There is probably no more amusing feature of quite a number of
supposedly respectable and presumably authoritative historical works
written in English than this assumption with regard to the absence of
surgery during the later Middle Ages. Only 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 jointing 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 centuries, 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
cultivated as during the rise and development of the universities 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.
Modern surgery may be said to owe its origin to a school of surgeons, the
leaders of whom were educated 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 medieval 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
realities of the situation, but on an assumption with regard 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, Rogero, 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 knowledge
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 simple, dietetic, hygienic, and general remedial measures 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 development 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 inspiration from Arab sources, insisted that "instead of any
Arabisms being found in his [Roger's] writings many Græcisms occur." The
Salernitan school of surgery drank at the fountain-head of Greek surgery.
Apart from Greek sources Roger's book rests entirely upon his own
experiences, those of his teachers 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."

ROGER, ROLAND, AND THE FOUR MASTERS

Ruggero, or Rogero, who is also known as Rogerio and Rogerus with the
adjective Parmensis, or Salernitanus, of Parma or of Salerno, and often in
German and English history simply as Roger, lived at the end of the twelfth
or the beginning of the thirteenth century and probably wrote his text-book
about 1180. This text-book was, according to tradition, originally drafted
for his lessons in surgery at Salerno. It attracted much attention and after
being commented on by his pupil Rolando, the work of both of them being
subsequently annotated by the Four Masters, this combined work became
the basis of modern surgery. Roger was probably born either in Palermo or
Parma. There are traditions of his having taught for a while at Paris and at
the University of Montpellier, though these are not substantiated. His book
was printed at Venice in 1546, and has been lately reprinted by De Renzi in
his "Collectio Salernitana."

Roland was a pupil of Roger's, and the two names that often occur in
medieval romance became associated in a great historic reality as a
consequence of Roland'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
teaching 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 departments 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 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 unwounded that
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 diagnosis in head
injuries—special care must be taken to look for symptoms in spite of the
lack of an external penetrating wound. Where there is good reason to

suspect a fracture because of the severity of the injury, 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
affecting it.
There are many warnings, however, of the danger of opening the skull
and of the necessity for definitely 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 percussion comes in the anterior part of the cranium, the
cranium is fractured on the opposite part."[18] They even seem to have
known of accidents such as we now discuss in connection with the
laceration of the middle 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 blood was found coagulated about his dura mater."
There are many interesting things said with regard to depressed fractures
and the necessity for elevating the bone. If the depressed portion is wedged
then an opening should be made with the trephine and an elevating
instrument called a spatumen used to relieve the pressure. Great care should
be taken, however, in carrying out this procedure lest the bone of the
cranium itself, in being lifted, should injure the soft structures within. The
dura mater should be carefully protected from injury as well as the pin.
Care should especially be exercised at the brow and the rear of the head and
at the commissures (proram et pupim et commissuras), since at these points
the dura mater is likely to be adherent. Perhaps the most striking
expression, the word infect being italicized by Gurlt, is: "In elevating the
cranium be solicitous lest you should infect or injure the dura mater."
For wounds of the scalp sutures of silk are recommended because this
resists putrefaction and holds the wound edges together. Interrupted sutures

about a finger-breadth apart are recommended. "The lower part of the
wound should be left open so that the cure may proceed properly." Red
powder was strewed over the wound and the leaf of a plant set above it. In
the lower angle of the wound a pledget of lint for drainage purposes was
inlaid. Hemorrhage was prevented by pressure, by the binding on of burnt
wool firmly, and by the ligature of veins and by the cautery.
There are rather interesting discussions of the 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 mortal. 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
operation was being performed. If this were not possible they were to be
done by candlelight, the candle being held as close as possible in a warm
room. These precautions are interesting as foreshadowing many ideas of
much more modern time and especially indicating 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 patients are sure that they
have taken cold. Such popular medical ideas are always derived from
supposedly 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 experiences with fractures at the
base of the skull. Hemorrhages 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 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

ingenious but eminently dangerous because of the infectious 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, however, adds to this "sed hoc aliquando fallit—but this
sign sometimes fails." Split or crack fractures were also diagnosticated by
the method suggested by Hippocrates of pouring some colored fluid over
the skull after the bone was exposed, when the linear fracture would show
by coloration. The Four Masters suggest 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 about the necessity for absolute cleanliness,—asepsis 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 trepanation. 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 menstruosæ, et manus ejus
debent esse mundæ, etc." My quotation is from Gurlt, Vol. I, p. 707. The
directions 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
prognosis. 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 arrived at the
recognition by observations on many patients that the satisfactory after-
course of these cases which were operated on by the surgeon after due
regard to such meticulous cleanliness as is suggested 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 surgeon'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 NORTH ITALIAN SURGEONS

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 following 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 "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 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 practical
use of various methods of anæsthesia. They used opium and mandragora for
this purpose and later employed an inhalant mixture, the composition of
which is not absolutely known. They seem, however, to have been very
successful in producing insensibility to pain for even rather serious and
complicated 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 anæsthesia was discovered about the
middle of the nineteenth century 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." Anæsthetics were experimented with almost as zealously, 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 anæsthesia. 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 anæsthetics has to be repeated for
what are deemed so surely modern developments,—asepsis and antisepsis. I
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 derived 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 Italian surgeons and especially in the group of those associated
with William of Salicet. Professor Clifford 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
intention and the modes by which it might be obtained. He, too, insisted on
cleanliness as the most important 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 perhaps be recalled so as to

remind readers how closely related they are to this great group of surgical
teachers. Salerno was founded very early, probably in the tenth century,
Bologna, Reggio, and Modena came into existence toward the end of the
twelfth century; Vicenza, Padua, Naples, Vercelli, and Piacenza, 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 Andrew of Piacenza, was completed at Padua in January, 1252. Gurlt
notes that he is the first of the Italian surgeons who quotes, besides the
Greeks, the Arabian writers on surgery. Eclecticism had definitely come
into vogue to replace exclusive devotion to the Greek authors, and men
were taking what was good wherever they found it. Gurlt tells us that Bruno
owed much of what he wrote to his own experience 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 medicine to be used only when the other two instruments, diet
and potions, have failed. He insists that surgeons must learn by seeing
surgical operations and watching them long and diligently. They must be
neither rash nor over bold and should be extremely cautious about
operating. While he says that he does not object to a surgeon taking a glass
of wine, the followers of this specialty must not drink to such an extent as
to disturb their command over themselves, and they must not be habitual
drinkers. While all that is necessary for their art cannot be learned out of
books, they must not despise books however, for many things can be
learned readily from books, even about the most difficult parts of surgery.
Three things the surgeon has to do:—"to bring together separated parts, to

separate those that have become abnormally united, and to extirpate what is
superfluous."
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 winter, because putrefactio 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 indispensable, and recommends for this a fine, square
needle. The preferable suture material in his experience 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 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, always 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 suggested, and if
necessary the wound must be enlarged. If the omentum finds its way out of
the wound, all of it that is black or green must be cut off. In cases where the
intestines are wounded they are to be sewed with a small needle and a silk
thread and care is to be exercised in bringing about complete closure of the
wound. This much will give a good idea of Bruno's thoroughness.
Altogether, Gurlt, in his "History of Surgery," gives about fifteen large
octavo pages of rather small type to a brief compendium of Bruno's
teachings.
One or two other remarks of Bruno are rather interesting in the light of
modern 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 treatment of them as
soon as noticed, bringing the edges of the hernial opening together by
bandages and then preventing the reopening of the hernia by prohibiting
wrestling and loud crying and violent motion. He has seen overgrowth of
the mamma in men, and declares that it is due to nothing else but fat, as a
rule. He suggests if it should hang down and be in the way on account of its
size it should be extirpated. He seems to have known considerable about the
lipomas and advises that they need only be removed in case they become
bothersomely large. The removal is easy, and any bleeding that takes place
may be stopped by means of the cautery. He divides rectal fistulæ into
penetrating and non-penetrating, and suggests salves for the non-penetrating
and the actual cautery for those that penetrate. He warns against the
possibility of producing incontinence by the incision of deep fistulæ, for
this would leave the patient in a worse state than before.

HUGH OF LUCCA

Bruno brought up with him the methods and principles 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 century. In 1214 he was called to Bologna
to become the city physician, and joined the Bolognese volunteers in the
crusade in 1218, being present at the 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 Gurlt, 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
bringing 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 anæsthetizing 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, entered the Dominican Order, then only recently established,
but continued his practice of medicine undisturbed. His ecclesiastical
preferment was rapid. He attracted the attention of the Bishop of Valencia,
and became his chaplain in Rome. At the age of about fifty he was made 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 Bologna
however, and he continued to practise medicine, 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 retained the custom of designating himself as a member 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
bandaging. Wine he insists on as the best possible dressing for wounds. It
was the most readily available antiseptic that they had at that time, and
undoubtedly 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 inhibitive 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 articles of diet which are particularly useful in
producing 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 necessity for not injuring nerves, though if nerves have been cut they
should be brought together as carefully as possible, the wound edges being
then approximated.
Probably the most interesting feature for our generation 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 insistence 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:[19]
"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, Paré, and Wurtz. In older wounds they did their best to obtain 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 matters wine after washing, purifying, and drying the raw surfaces
evaporates."

Theodoric comes nearest to us of all these old surgeons. The surgeon who
in 1266 wrote: "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 consolidation of the wound" was more than half a
millennium 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 aliquo inducebat, then further that he impugned 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 "incarcerate sanious material," it is easy to
understand that the claim that antiseptic surgery was anticipated six
centuries ago is no exaggeration and no far-fetched explanation with
modern ideas in mind of certain clever modes of dressing hit upon
accidentally 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 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 particularly on the legs, difficult to cure and ready of relapse, but
for which the outlook is not so bad. His description of noli me tangere and
of lupus is rather practical. Lupus is "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
corroding 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 surgery would suffer. He thought that the physician learned much by
seeing the interior of the body during 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 themselves somewhat similarly. Professor Clifford Allbutt is
quite emphatic in this matter and Professor Osler 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 preceding 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 William 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 allowed 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 account of the work of Pope
John XXI as an ophthalmologist 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 chapters 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 pedicle 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. Ranula 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 having 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 operation
I removed the teeth that were loose with certain parts of the jawbone."
In the next chapter there is an account of the treatment 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
methods again. He did not hesitate to treat goitre surgically, though he
considered there were certain internal 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 avoiding 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
Gurlt's abstract of the first twenty chapters of Salicet's first book. Altogether
Gurlt has more than ten pages of rather small print with regard to William;
most of it is as interesting and as practical and as representative of
anticipations 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 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 observation. He was evidently a thoroughly
observant physician, 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 succeeding 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 physician
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
medical faculty, Jean de Passavant, urged him to write a text-book of
surgery, not only for the benefit of 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. Lanfranc 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 department 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 introduction, 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 disposition. 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 properly, and to support what he has to say by good
reasons." 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 expressions 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, however, made no such mistake. He says that the
wounds of nerves, since the nerve is an instrument of sense and 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 restoration of the usefulness of the member is more complete
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 knowledge, for he
seems to have realized that the main diagnostic element is a change in the
disposition 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 treatment.
The treatment of snake bites and the bites of other poisonous animals was
supposed to follow the principles 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 surgeon 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 modern
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 general surgical literature. There is scarcely an
important 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 interested in Lanfranc to his own works or Gurlt.

MONDEVILLE

The next of the important surgeons who were to bring such distinction to
French surgery for five centuries was Henri de Mondeville. Writers usually
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
variants as Mundeville, Hermondaville, Amondaville, Amundaville,
Amandaville, Mandeville, Armandaville, Armendaville, Amandavilla occur.
We owe a large amount of our information with regard 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 publication, 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 Renaissance interest in it in its
incompleted state was never aroused sufficiently 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. 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.[20]
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
wandered far for opportunities in education. Though born in the north of
France and receiving his preliminary education there, he made his medical
studies 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 friendship 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 consultant practice and also
had to accompany the King on his campaigns. This made it extremely
difficult 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 before his
time whom Mondeville does not quote. Hippocrates, Aristotle, Dioscorides,
Pliny, Galen, Rhazes, Ali Abbas, Abulcasis, Avicenna, Constantine
Africanus, Averroës, Maimonides, Albertus Magnus, Hugo of Lucca,
Theodoric, William of Salicet, Lanfranc are all quoted, and not once or
twice but many times. Besides he 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 surgeon should be a scholar,
and that he needed to know much more than a physician. One of his
characteristic 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
everything 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 surgeons operate often, and he
ought to pay careful attention to their operations and commit their technique
to memory. Then he ought to associate himself with them in doing
operations. A man cannot 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 foresight
and wisdom, not beginning dangerous operations 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 disturbance of mind. He must
be highly moral, should care for the poor for God's sake, see that he makes
himself well paid by the rich, should comfort his patients by pleasant
discourse, and should always accede 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 medicine 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 children, 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 experience as he has seen it." The second tractate on the treatments
of wounds, contusions, and ulcers was founded on the second book of
Theodoric "with whatever by recent study has been newly acquired and
brought to light through the experience of modern 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 exhibit him as very
sympathetically human in his interests.
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 generations of younger men often made important additions 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, "always interesting, lively, and often full of meat." He had a
teacher's instinct, for in several of the earlier manuscripts 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 invented a
kind of small derrick for the extraction of arrows with barbs. Besides, he
suggested the surrounding 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 generations. 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 Mondeville'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 important 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
someone 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 surgeon 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, "For if the assistants
are not solicitous and faithful, and obedient to the surgeons in each and

every thing which may make for the cure of the disease, they put obstacles
and difficulties 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 assistants quarrel among themselves, or are heard
murmuring, 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 Mondeville's life to be sure
whether he was married or not. It is probable that he was not, for all of
these surgeons 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, however,
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 surgeon 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 medical 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 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 Rationalists, so Mondeville divides modern surgery into
three sects: first, that of the Salernitans, with Roger, Roland, and the Four
Masters; second, that of William of Salicet and Lanfranc; and third, that of
Hugo de Lucca and his brother Theodoric and their modern disciples. He
states briefly the characteristics 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 dilated wounds, never inserted
tents, and its members were extremely careful not to complicate wounds of
the head by unwise interference. His critical discussion of the three schools
is extremely interesting.
Another phase of Mondeville's work that is sympathetic to the moderns is
his discussion of the irregular practice of medicine and surgery as it existed
in his time. Most of our modern medicine and surgery 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 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 members of a great profession, he enumerates
the many different kinds of opponents that the medical profession 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 surgeons of themselves in order to make their living
under the cloak of healing."
What surprises Mondeville however, as it has always surprised every
physician who knows the situation, is that so many educated, or at least
supposedly well-informed people of the better classes, indeed even of the
so-called best classes, allow themselves 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 without 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 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 surgeon 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 anatomy 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: "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."[21] What Chauliac blames is
the attempt to replace dissections by pictorial demonstrations. Hyrtl,
however, suggests that this invention of Mondeville's was probably very
helpful, and was brought about by the impossibility of preserving bodies for
long periods as well as the difficulty of obtaining them.

YPERMAN

One of the maxims of the old Greek philosophers was that good is
diffusive of itself. As the scholastics 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 surgery. We have the accounts of men from
many nations who went to the universities and returned to benefit their own
people. Early in the thirteenth century Richard the Englishman was in Italy,
having previously been in Paris and probably at Montpellier. Bernard
Gordon, probably also an Englishman, was one of the great lights in
medicine down at Montpellier, 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 matter. One was Yperman, of the town
of Ypres in Belgium; the other Ardern of England. Yperman 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 inhabitants. The
great hall of the cloth gild, which has been such an attraction for visitors
ever since, was 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 manuscript copies of his book on surgery and gathered
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 compendium of internal
medicine, which is very interesting, 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, hemorrhage, blood-spitting, liver abscess, hardening
of the spleen, affections of the kidney, bloody urine, diabetes, incontinence
of urine, dysuria, strangury, gonorrhea, and involuntary seminal emissions
—all these terms are quoted directly from Pagel's account of his work; the
original is not available in this country.

JOHN ARDERN

In English-speaking countries of course we are interested in what was
done by Englishmen at this 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
modification of the more familiar Arden, whose career well deserves
attention. I have given a sketch of his work in "The Popes and Science."[22]
He was educated at Montpellier, and practised surgery for a time in France.
About the middle of the century however, 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
devoted 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
histories which Ardern had gathered, partly from his own and partly from
others' experience. The therapeutic 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 number
of suggestions from which to choose. He must have been an expert
operator, and had excellent success 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 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 valuable 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 development 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 complete 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
subheading, "Method of Administering Clysters." The iliac passion, passio
iliaca of the old Latin, is usually taken to signify some obstruction of the
intestines causing severe pain, vomiting, and eventually fecal vomiting. A
good many different forms of severe painful conditions, especially all those
complicated by peritonitis, were included under the term, and the modern
student of surgery is likely to wonder whether these old observers had not
noted that the right iliac region was particularly prone to be the source of
fatal conditions. There is a chapter entitled "Against Pain in the Loins and
the Kidneys," followed by the chapter subheading, "Against Stone in the
Kidneys." There is a chapter with the title, "Against Ulceration of the
Bladder 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 demonstrates what fine work they did. It is surely not
too much to say that the chapter on university education 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 expressions 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 suffering humanity. Their work utterly contradicts
the idea so frequently emphasized that the great students of the Middle
Ages were lacking in practicalness. 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, developing 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 comparatively recent years, the other side of medieval
accomplishment. Our ignorance led us into misunderstanding of what these
generations really did. It was our own fault, because during the Renaissance
practically all of these books were edited and printed under the direction of
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
Renaissance 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 history 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 history 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 history 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 notions so
commonly accepted with regard to the Middle 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 procedure. 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 experiences.
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 applying science and scientific principles, then it
is comparatively 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.
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 developed. 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 traditions as to the backwardness of our
medieval forbears in medicine, that are readily accepted by many
presumably educated people, but it is the best possible antidote for that
insistent misunderstanding of the Middle Ages which attributes profound
ignorance of science, almost complete failure of observation, and an
absolute lack of initiative in applications 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
Montpellier, 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 with the great masters in medicine
naturally went down into the Peninsula. Traditions as to the attitude 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 involved more expense and
time than would even the voyage from America to Europe in our time.
Chauliac realized, however, that both time and expense would be well
rewarded, and his ardor for the rounding 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 surgery
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 information 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 Lozère.
The records of births and deaths were not considered 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 thirteenth 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 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 "Handbook of the History of
Medicine," says, on the authority of Nicaise and others, that Chauliac
received his early education from the village clergyman. His parents were
poor, and but for ecclesiastical interest in him it would have been difficult
for him to obtain his education. The Church supplied at that time to a great
extent for the foundations 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 judgment 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 Chauliac 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 Royal Physician by official
appointment of whom we have any account. John is mentioned by Chaucer
in his "Doctor of Physic," and is usually looked upon as one of the fathers
of English medicine. Chauliac did not think much of him, though his reason
for his dislike of him will probably be somewhat startling to those who
assume that 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 explanation of his well-known expression,
"Last of all arose the scentless rose of England ['Rosa Angliæ' 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 encountered only the
fictions of Hispanus, of Gilbert, and of Theodoric."
The presence of a Scotch professor and an English fellow-student,
afterwards a royal physician, at Montpellier, at the beginning of the
fourteenth century, shows how much more cosmopolitan was university 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
received the special instruction of Bertruccio, who was attracting students
from all over Europe at this time and was making some excellent
demonstrations in anatomy, employing human dissections very freely.
Chauliac tells of the methods that Bertruccio 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 dissections in different ways.

In Roth's life of Vesalius, which is usually considered one of our most
authoritative medical historical 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
because 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
dissection and, therefore, preventing the development of anatomy. In the
notes to his history of dissection during this period in Bologna Roth says:
"Without doubt the passage in Guy de Chauliac which tells of having
frequently seen dissections, must be considered 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 so likely to become
putrefied. In the second, he demonstrated the spiritual members; in the
third, the animate members; in the fourth, the extremities.'" (Roth, "Andreas
Vesalius." Basel, 1896.)
Bertruccio's master, Mondino, is hailed in the history 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
Renaissance time. Mondino had devoted himself to the subject with
unfailing ardor and enthusiasm, and from everywhere in Europe the
students came to receive inspiration in his dissecting-room. Within a few
years such was the enthusiasm for dissection aroused by him in Bologna
that there were many legal prosecutions for body-snatching, the
consequence 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
tradition, 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 anatomy
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 of my "Popes and Science," where those who are
interested in the matter may follow it to their satisfaction.[23]
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
establish 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 establishment of a good school of surgery in connection with
the university. The teaching so well begun by Lanfranc was magnificently
continued by Mondeville 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.
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 circumspectus vir, dominus
Guido de Cauliaco, canonicus et præpositus ecclesiæ Sancti Justi Lugduni,
medicusque domini Nostri Papæ." All the rest of his life was passed in the
Papal capital, which Avignon was for some seventy years of the fourteenth
century. 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 anticipations 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 interpretation 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 Middle 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 follow the
doctrine of Galen, which is entirely made up of experience and reason, and
in which one investigates things and despises words."
After all, this is what great authorities in medicine have always insisted
on. Once every hundred years or so one finds a really great observer who
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 contemporaries often refuse to
listen to him at first. His observations, however, eventually make their way.
We blame the Middle Ages for following authority, 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 master in medicine comes along his discovery is neglected
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 number 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 Ruskin once said, "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 (quæ juxta modicitatem mei ingenii utilia reputavi). Indeed it is the
critical judgment displayed by Chauliac in selecting from his predecessors
that best illustrates at once the practical 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 encyclopedic in intellect and gathered all kinds
of information without discrimination, is a very common criticism of
medieval writers. No one can say this of Chauliac, however, and, above all,
he was no respecter of authority, merely for the sake of authority. His
criticism of John of Gaddesden's book shows that the blind following of
those who had gone before was his special bête 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 account of his recommendations as to the value
of surgical 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, interference
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 with only a slight defect of
memory, and even this disappeared after a time. He lays down exact
indications for the opening of the thorax, that noli me tangere of surgeons at
all times, even our own, and points out the relations of the ribs and the
diaphragm, 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 anticipation of modern
views is most surprising. He recognized that wounds of the intestines were
surely fatal unless leakage could be prevented. Accordingly 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 surgeon, even to have invented a
special needleholder.
To most people it would seem absolutely out of the question that such
surgical procedures could be practised 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 centuries. 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 already seen, methods of anæsthesia 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 anæsthesia.
In discussing amputations he has described in general certain methods of
anæsthesia in use in his time, and especially the method by means of
inhalation. 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 patient 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, however,
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 subserve. 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 Foundation 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, toward the end of the thirteenth century (1292), says:
"It was an admirable hospital in every way, and it is doubtful if we to-day surpass
it. It was isolated; the ward was separated from the other buildings; 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 ventilators 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 depression that comes from sight of others in pain.
"It was, moreover, in great contrast to the cheerless 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 Architecture."[24]

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 Rome, and all of them did good work. The
surgeons of Guy de Chauliac's time would indeed find hospitals wherever
they might be called in consultation, even in small towns. They were more

numerous in proportion to population than our own 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
surgical 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
patient, 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 invention of a
well-developed method of taxis, or manipulation 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 according 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 principles 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 deformities due to these pathological conditions. In a
word, we have a picture of the skilled surgeon of the modern time in this
treatise of a fourteenth-century teacher of surgery.
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 respect 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, following 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 insistence on the most absolute
cleanliness of the surgeon before the operation, and careful details of
cleanliness during the operation, made possible the performance of many
methods of surgical intervention 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 produces healthy
natural union, should have come to the thought of the necessity for the
formation of laudable pus before union might be expected. The mystery 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
development 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 predecessors, and there was a beginning of surgical meddlesomeness
reasserting itself.
It must not be thought, however, that it was only with the coarse
applications of surgery that Chauliac concerned himself. He was very much
interested 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 became Pope,
and under the name of Peter of Spain was looked up to as one of the
distinguished scientists of his time, had written a book on eye diseases 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 selection of patients may be appreciated from his
treatment 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
practical 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
recognized the dentists as specialists, calls them dentatores, 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
though of long standing, that he brushes them aside with some impatience if
they have not proved themselves 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 ils donnent beaucoup de promesses, et peu, d'opérations."

It is no wonder that Chauliac has been enthusiastically 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 Hippocrates. 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 Chauliac'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 having 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 he was for
three centuries the classic par excellence. He rendered the study 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. Bégin, in his work on Ambroise Paré, 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, "I do not
fear to say that, Hippocrates 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 Chauliac.'"
Daremberg said, "Guy seems to us a surgeon 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 "Conférence sur Les Chirurgiens
Érudits," says, "The services rendered by the 'Great Surgery' were immense;
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 collected by Nicaise. Modern
writers on the history of medicine have all been enthusiastic in their
admiration of him, just in proportion to the thoroughness 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 unfortunately too little read, too little pondered." Malgaigne declares
Chauliac's "Chirurgia Magna" to be "a masterpiece of learned and luminous
writing." Professor Clifford Allbutt, the Regius Professor 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."[25]
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 sufficient 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 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 himself the self-sacrificing labor
of caring for the sick, doubly harassing because so many of his brother
physicians were absent. He denounces their conduct 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 physicians 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 carried added weight. In the Introductory chapter of his
"Chirurgia Magna" he said:
"The surgeon should be learned, skilled, ingenious, 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, according to the work, the means of the sick, the character of the issue or
event, and its dignity."

No wonder that Malgaigne says of him, "Never since Hippocrates has
medicine heard such 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
Chauliac'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 existence 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, Roger
Bacon, Thomas Aquinas, and the other famous scholars of the early days of
the mendicant orders, and had made the intellectual mould of university
training in which men's minds for seven centuries were to be formed, so
that Chauliac, instead of being an unusual phenomenon is only a fitting
expression of the interest of this time in everything, including the physical
sciences and, above all, medicine and surgery.
For some people it may be a source of surprise that Chauliac should have
had the intellectual training 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
disadvantages. Those who would be satisfied with any such explanation,
however, know nothing of the educational opportunities provided in the
period of which Chauliac was the fruit. He is a typical university man of the
beginning of the fourteenth century, and the universities must be given due
credit for him. It is ordinarily assumed that the universities 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 Rectorial 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 representative 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 have been more interested in him than in anyone
who comes during the intervening six centuries. Chauliac, however, instead
of meeting with any opposition, encountered encouragement, liberal
patronage, generous interest, and even enjoyed the intimate 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
generalizations 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
profound 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
everyone cannot have all the books, and even if he did have them it would
be too tiresome to read them all and completely, and it would require a
godlike memory to retain them all." He realized, however, that each
generation, provided it took the opportunities 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
admirably 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 complete manuscripts of the "Great Surgery": 22 of
these are in Latin, 4 are in French, 3 are in English, 2 only in Provençal,
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 Bibliothèque Nationale, Paris; a second is number 3666 English of the
Sloane collection in the British Museum, and a third is in the Library of the
University of Cambridge.[26]
Paulin Paris, probably one of the best of recent authorities on the age and
significance of old manuscripts, says in the third volume of his "Manuscrits
Français," 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
composition 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 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 cirurgicale parte of medicine compiled and
complete in the yere of our Lord 1363, with some additions of other doctours,
necessary to the foresaid arte or crapte (crafte?)."[27]

What we find in the period of manuscripts, however, 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 editions of
the "Great Surgery." Nine others that are mentioned by authors have
disappeared and apparently 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. Altogether 129 editions are extant. Of these there are
sixteen Latin editions, forty-three French, five Italian, four Low Dutch, five
Catalan, and one English. 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 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
translation 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 successors 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 further advances in
surgery. As matter of fact, decadence in surgery is noted immediately after
his death. Three men taught at the University of Montpellier at the end of
the fourteenth and the beginning of the fifteenth century, John de
Tornamira, Valesco de Taranta, and John Faucon. They cannot 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 impression that surgery had now
reached a point of development beyond which it could not advance.
Unfortunate political conditions, wars, the withdrawal of the Popes from
Avignon to Rome, and other disturbances, distracted men's minds, and
surgery deteriorated to a considerable extent, until the new spirit at the time
of the Renaissance came to inject fresh life into it.

XII

MEDIEVAL DENTISTRY—GIOVANNI OF
ARCOLI
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 conviction 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 developed 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 number
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 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 dentistry.
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 Egyptians,
there is convincing evidence of a high development of dentistry. M. Ernest
Renan, during an exploring 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 surprising, 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 teeth
and dental appliances from the mouth of corpses before embalming them, in
preparation for the next world, because there was some religious objection
to such 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 examples of bridgework. 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
observations on them. In one specimen, which is especially 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 unexpected source for this. While examining the
specimen 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 permanent tooth was
erupted in order to get this structure absolutely unworn for his purpose. A
number of examples of bridgework have been found in the old Etruscan
tombs. The dates of their construction are probably not later than 500 b.c.,
and some of them are perhaps earlier than 700 b.c.

The Etruscans affected the old Romans in the matter 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 Rome, 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 exception.
In Pope Julius' Museum in Rome there is a specimen 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 Republican times at Rome. At the end of the
Republic 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, dentrifices of nearly
every kind were invented, and dentistry evidently reached a high stage of
development, 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 conditions, 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. Aëtius, the first important Christian writer on medicine and
surgery, discusses, 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 interesting 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 Ægina
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 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 expanded 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
renewal 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
surgery, "Le Grande Chirurgie." An extremely interesting 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
valuable 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 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
opportunity for the development of decay. The eating of sweets, and

especially the sticky sweets—preserves 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 general
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 Guerini in his "History of Dentistry," the translation of
which was published under the auspices of the National Dental Association
of the United States of America,[28] Chauliac recognized the dentists as
specialists. Besides, it should be added, as is evident from his enumeration
of the surgical 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 detailed
than we have reason to know that they were at certain subsequent periods.
In fact, though Guy de Chauliac frankly confesses that he touches on the
subject of dentistry only in order to complete his presentation of the subject
of surgery and not because he has anything of his own to say with regard to
the subject, there is much that is of present-day interest in his brief
paragraphs. He observes that operations on the teeth are special and belong
to the dentatores, or dentists, to whom doctors had given them over. He
considers, however, that the operations in the mouth should be performed
under the direction of a physician. It is in order to give physicians the
general principles with which they may be able to judge of the advisability
or necessity for dental operations that his short chapters are written. If their
advice is to be of value, physicians should know the various methods of
treatment suitable for dental diseases, including mouth washes, gargles,
masticatories, anointments, rubbings, fumigations, cauterizations, fillings,
filings, and the various manual operations. He says that the dentator must
be provided with the appropriate instruments, among which he names
scrapers, rasps, straight and curved spatumina, elevators, simple and with
two branches, toothed tenacula, and many different forms of probes and
canulas. He should also have small scalpels, tooth trephines, and files.

Chauliac is particularly emphatic in his insistence on not permitting
alimentary materials to remain in cavities, and suggests that if cavities
between the teeth tend to retain food material they should even be filed in
such a way as to prevent these accumulations. His directions for cleansing
the teeth were rather detailed. His favorite treatment for wounds was wine,
and he knew that he succeeded by means of it in securing union by first
intention. It is not surprising, then, to find that he recommends rinsing of
the mouth with wine as a precaution against dental decay. A vinous
decoction of wild mint and of pepper he considered particularly beneficial,
though he thought that dentifrices, either powder or liquid, should also be
used. He seems to recommend the powder dentifrices as more efficacious.
His favorite prescription for a tooth powder, while more elaborate,
resembles to such an extent, at least some, if not indeed most of those, that
are used at the present time, that it seems worth while giving his directions
for it. He took equal parts of cuttle bone, small white sea-shells, pumice
stone, burnt stag's horn, nitre, alum, rock salt, burnt roots of iris,
aristolochia, and reeds. All of these substances should be carefully reduced
to powder and then mixed. His favorite liquid dentifrice contained the
following ingredients,—half a pound each of sal ammoniac and rock salt,
and a quarter of a pound of sacharin alum. All these were to be reduced to
powder and placed in a glass alembic and dissolved. The teeth should be
rubbed with it, using a little scarlet cloth for the purpose. Just why this
particular color of cleansing cloth was recommended is not quite clear.
He recognized, however, that cleansing of the teeth properly often
became impossible by any scrubbing method, no matter what the dentifrice
used, because of the presence of what we call tartar and what he called
hardened limosity or limyness (limosité endurcie). When that condition is
present he suggests the use of rasps and spatumina and other instrumental
means of removing the tartar.
Evidently he did not believe in the removal of the teeth unless this was
absolutely necessary and no other method of treatment would avail to save
the patient from continuous distress. He summarizes the authorities with
regard to the extraction of teeth and the removal of dental fragments and
roots. He evidently knew of the many methods suggested before his time of
removing teeth without recourse to instrumental extraction. There were a
number of applications to the gums that were claimed by older authors to

remove the teeth without the need of metal instruments. We might expect
that Chauliac would detect the fallacy with regard to these and expose it. He
says that while much is claimed for these methods he has never seen them
work in practice and he distrusts them entirely.
The most interesting phase of what Guy de Chauliac has to say with
regard to dentistry is of course to be found in his paragraphs on the artificial
replacement of lost teeth and the subject of dental prosthesis generally.
When teeth become loose he advises that they be fastened to the healthy
ones with a gold chain. Guerini suggests that he evidently means a gold
wire. If the teeth fall out they may be replaced by the teeth of another
person or with artificial teeth made from oxbone, which may be fixed in
place by a fine metal ligature. He says that such teeth may be serviceable
for a long while. This is a rather curt way of treating so large a subject as
dental prosthesis, but it contains a lot of suggestive material. He was
quoting mainly the Arabian authors, and especially Abulcasis and Ali Abbas
and Rhazes, and these of course, as we have said, mentioned many methods
of artificially replacing teeth as also of transplantation and of treatment of
the deformities of the dental arches.
On the whole, however, it must be confessed that we have here in the
middle of the fourteenth century a rather surprising anticipation of the
knowledge of a special department of medicine which is usually considered
to be distinctly modern, and indeed as having only attracted attention
seriously in comparatively recent times.
After Guy de Chauliac the next important contributor to dentistry is
Giovanni of Arcoli, often better known by his Latin name, Johannes
Arculanus, who was a professor of medicine and surgery at Bologna and
afterwards at Padua, just before and after the middle of the fifteenth century,
and who died in 1484. He is famous principally for being the first we know
who mentions the filling of teeth with gold.
It might possibly be suggested that coming at this time Arculanus should
rather be reckoned as a Maker of Medicine in the Renaissance than as
belonging to the Middle Ages and its influences. His education, however,
was entirely completed before the earliest date at which the Renaissance
movement is usually said to begin, that is with the fall of Constantinople in

1452, and he was dead before the other date, that of the discovery of
America in 1492, which the Germans have in recent years come to set down
as the end of the Middle Ages. Besides, what he has to say about dentistry
occurs in typical medieval form. It is found in a commentary on Rhazes,
written just about the middle of the fifteenth century. In the later true
Renaissance such a commentary would have been on a Greek author. In his
commentary Arculanus touches on most of the features of medicine and
surgery from the standpoint of his own experience as well as from what he
knows of the writings of his predecessors and contemporaries. With the rest
he has a series of chapters on diseases of the teeth. Guerini in his "History
of Dentistry" says that "this subject [dentistry] is treated rather fully, and
with great accuracy." Even some short references to it will, I think,
demonstrate this rather readily.[29]
Arculanus is particularly full in his directions for the preservation of the
teeth. We are rather prone to think that prophylaxis is comparatively a
modern idea, and that most of the principles of conservation of human
tissues and the prevention of deterioration and disease are distinctly
modern. It needs only a little consideration of Arculanus' instruction in the
matter of the teeth, however, to undo any such false impression. For
obvious reasons I prefer to quote Guerini's summation of this medieval
student of dentistry's rules for dental hygiene:
"For the preservation of teeth—considered by him, quite rightly, a matter of great
importance—Giovanni of Arcoli repeats the various counsels given on the subject by
preceding writers, but he gives them as ten distinct canons or rules, creating in this
way a kind of decalogue of dental hygiene. These rules are: (1) It is necessary to
guard against the corruption of food and drink within the stomach; therefore, easily
corruptible food—milk, salt fish, etc.—must not be partaken of, and after meals all
excessive movement, running exercises, bathing, coitus, and other causes that impair
the digestion, must also be avoided. (2) Everything must be avoided that may provoke
vomiting. (3) Sweet and viscous food—such as dried figs, preserves made with honey,
etc.—must not be partaken of. (4) Hard things must not be broken with the teeth. (5)
All food, drink, and other substances that set the teeth on edge must be avoided. (6)
Food that is too hot or too cold must be avoided, and especially the rapid succession
of hot and cold, and vice versa. (7) Leeks must not be eaten, as such a food, by its
own nature, is injurious to the teeth. (8) The teeth must be cleaned at once, after every
meal, from the particles of food left in them; and for this purpose thin pieces of wood
should be used, somewhat broad at the ends, but not sharp-pointed or edged; and
preference should be given to small cypress twigs, to the wood of aloes, or pine,
rosemary, or juniper and similar sorts of wood which are rather bitter and styptic; care
must, however, be taken not to search too long in the dental interstices and not to
injure the gums or shake the teeth. (9) After this it is necessary to rinse the mouth by

using by preference a vinous decoction of sage, or one of cinnamon, mastich, gallia,
moschata, cubeb, juniper seeds, root of cyperus, and rosemary leaves. (10) The teeth
must be rubbed with suitable dentrifices before going to bed, or else in the morning
before breakfast. Although Avicenna recommended various oils for this purpose,
Giovanni of Arcoli appears very hostile to oleaginous frictions, because he considers
them very injurious to the stomach. He observes, besides, that whilst moderate
frictions of brief duration are helpful to the teeth, strengthen the gums, prevent the
formation of tartar, and sweeten the breath, too rough or too prolonged rubbing is, on
the contrary, harmful to the teeth, and makes them liable to many diseases."

All this is so modern in many ways that we might expect a detailed exact
knowledge of the anatomy of the teeth and even something of their
embryology from Arculanus. It must not be forgotten, however, that coming
as he does before the Renaissance, the medical sciences in the true sense of
the word are as yet unborn. Men are accumulating information for practical
purposes but not for the classification and co-ordination that was to make
possible the scientific development of their knowledge.
Giovanni of Arcoli's acquaintance with the anatomy of the teeth was
rather sadly lacking. He does not know even with certainty the number of
roots that the teeth have. This has been attributed to the fact that he obtained
most of his information from books, and had not the time to verify
descriptions that he had found. It has been argued from this that he was
himself probably not a practical dentist, and turned to that specialty only as
a portion of his work as a general surgeon, and that consequently he was not
sufficiently interested to verify his statements. His chapters on dentistry
would seem to bear out this conclusion to some extent, though the very fact
that one who was himself not specially interested in dental surgery should
have succeeded in gathering together so much that anticipates modern ideas
in dentistry, is of itself a proof of how much knowledge of the subject there
was available for a serious student of that time. The anatomy of the teeth
continued to be rather vague until about the middle of the next century
when Eustachius, whose investigations of the anatomy of the head have
deservedly brought him fame and the attachment of his name to the
Eustachian canal, wrote his "Libellus de Dentibus—Manual of the Teeth,"
which is quite full, accurate, and detailed. Very little has been added to the
microscopic anatomy of the teeth since Eustachius' time. He had the
advantage, of course, of being intimately in contact with the great group of
Renaissance anatomists,—Vesalius, Columbus, Varolius, Fallopius, and the
others, the great fathers of anatomy. Besides, his position as Papal

Physician and Professor of Anatomy at the Papal Medical School at Rome
gave him opportunities for original investigation, such as were not easily
obtained elsewhere.
Arculanus can scarcely be blamed, therefore, for not having anticipated
the Renaissance, and we must take him as merely the culmination of
medieval knowledge with regard to anatomy and surgery. Medieval medical
men did not have the time nor apparently the incentive to make formal
medical science, though it must not be forgotten, as has been said, that they
did use the knowledge they obtained by their own and others' observation to
excellent advantage for the practical benefit of ailing humanity. The
sciences related to medicine are conscious developments that follow the
evolution of practical medicine, nor must it be forgotten that far from
always serving as an auxiliary to applied medical science, often indeed in
the history of medicine scientific pursuits have led men away into side
issues from which they had to be brought back by some genius medical
observer. As might be expected, then, it is with regard to the practical
treatment and general consideration of ailments of the teeth that Giovanni
of Arcoli is most interesting. In this some of his chapters contain a
marvellous series of surprises.
Arculanus was probably born towards the end of the fourteenth century.
The date of his death is variously placed as either 1460 or 1484, with the
probability in favor of the former. From 1412 to 1427 he was professor at
Bologna, where in accordance with the non-specializing tendencies of the
time he did not occupy a single chair but several in succession. He seems
first to have taught Logic, then Moral Philosophy, and finally Medicine. His
reputation in medicine drew many students to the university, and his fame
spread all over Italy. The rival University of Padua then secured him, and he
seems to have been for some twenty years there. Later apparently he
accepted a professor's chair at Ferrara, where the D'Estes were trying to
bring their university into prominence. It was at Ferrara that he died. He
was a man of wide reading, of extensive experience, both of men and
medicine, and one of the scholars of his time. His works are, as we have
said, mainly excerpts from earlier writers and particularly the Arabians, but
they contain enough of hints drawn from his own observation and
experience to make his work of great value.

While, as Gurlt remarks in his "History of Surgery," Arculanus' name is
one of those scarcely known—he is usually considered just one of many
obscure writers of the end of the Middle Ages—his writings deserve a
better fate. They contain much that is interesting and a great deal that must
have been of the highest practical value to his contemporaries. They
attracted wide attention in his own and immediately succeeding
generations. The proof of this is that they exist in a large number of
manuscript copies. Just as soon as printing was introduced his books
appeared in edition after edition. His "Practica" was printed in no less than
seven editions in Venice. Three of them appeared before the end of the
fifteenth century, which places them among the incunabula of printing.
Probably nothing in the history of human intellectual interest is more
striking than the excellent judgment displayed by the editors who selected
the works to be printed at this time. Very few of them were trivial or
insignificant. Fewer still were idle speculations, and most of them were
almost of classical import for literature and science. Four editions of this
work were printed in Venice in the sixteenth century, one of them as late as
1560, when the work done by such men as Vesalius, Columbus, Eustachius,
and Fallopius would seem to have made Arculanus out of date. The dates of
the various editions are Venice, 1483, 1493, 1497, 1504, 1542, 1557, and
1560. Besides there was an edition printed at Basel in 1540.
Arculanus is said to have re-introduced the use of the seton, that is the
method of producing intense counter-irritation by the introduction of some
foreign body into an incision in the skin. We owe to him, too, according to
Pagel in the chapters on medieval medicine in Puschmann's "Handbook of
the History of Medicine," an excellent description of alcoholic insanity.
His directions for the treatment of conditions in the mouth and nose apart
from the teeth are quite as explicit and practical, and in many ways quite as
great an anticipation of some of our modern notions as what he has to say
with regard to the teeth. For instance, in the treatment of polyps he says that
they should be incised and cauterized. Soft polyps should be drawn out with
a toothed tenaculum as far as can be without risk of breaking them off. The
incision should be made at the root so that nothing or just as little as
possible of the pathological structure be allowed to remain. It should be cut
off with a fine scissors, or with a narrow file just small enough to permit its

ingress into the nostrils, or with a scalpel without cutting edges on the sides,
but only at its extremity, and this cutting edge should be broad and well
sharpened. If there is danger of hemorrhage, or if there is fear of it, the
instruments with which dissection is made should be fired (igniantur), that
is, heated at least to a dull redness. Afterwards the stump, if any remains,
should be touched with a hot iron or else with cauterizing agents so that as
far as possible it should be obliterated.
After the operation a pledget of cotton dipped in the green ointment
described by Rhazes should be placed in the nose. This pledget should have
a string fastened to it, hanging from the nose in order that it may be easily
removed. At times it may be necessary to touch the root of the polyp with a
stylet on which cotton has been placed that has been dipped in aqua fortis
(nitric acid). It is important that this cauterizing fluid should be rather
strong so that after a certain number of touches a rather firm eschar is
produced. In all these manipulations in the nose Arculanus recommends that
the nose should be held well open by means of a nasal speculum. Pictures
of all these instruments occur in his extant works, and indeed this
constitutes one of their most interesting and valuable features. They are to
be seen in Gurlt's "History of Surgery."
In some cases he had seen the polyp was so difficult to get at or was
situated so far back in the nose that it could not be reached by means of a
tenaculum or scissors, or even the special knife devised for that purpose.
For these patients Arculanus describes an operation that is to be found in the
older writers on surgery, Paul of Ægina (Æginetus), Avicenna, and some of
the other Arabian surgeons. For this three horse-tail hairs are twisted
together and knotted in three or four places, and one end is passed through
the nostrils and out through the mouth. The ends of this are then pulled on
backward and forward after the fashion of a saw. Arculanus remarks
evidently with the air of a man who has tried it and not been satisfied that
this operation is quite uncertain, and seems to depend a great deal on
chance, and much reliance must not be placed on it. Arculanus suggests a
substitute method by which latent polyps or occult polyps as he calls them
may be removed.
There is scarcely an important disease for which Arculanus has not some
interesting suggestions, and the more one reads of him the more is one

surprised to find how many things that we might think of as coming into the
purview of medicine long after his time or at least as having been neglected
from the time of the Greeks almost down to our own time are here treated
explicitly, definitely, and with excellent practical suggestions. He has a
good deal to say with regard to the treatment of angina, which he calls
synanche, or synanchia, or cynanche, or angina. Parasynanche is a
synonymous term, but refers to a milder synanche. He distinguished four
forms of it. In one called canine angina, because the patient's tongue hangs
out of his mouth, somewhat the same as from an overheated dog in the
summer time, while at the same time the mouth is held open and he draws
his breath pantingly, Arculanus suggests an unfavorable prognosis, and
would seem to refer to those cases of Ludwig's angina in which there is
involvement of the tongue and in which our prognosis continues to be of the
very worst even to our own day. At times the angina causes such swelling in
the throat that the breathing is interfered with completely. For this
Arculanus' master, Rhazes, advised tracheotomy. Arculanus himself,
however, apparently hesitated about that.
It is not surprising, then, to find that Arculanus is very explicit in his
treatment of affections of the uvula. He divides its affections into apostema,
ulcus, putredo sive corrosio, et casus. Apostema was abscess, ulcus any
rather deep erosion, putredo a gangrenous condition, and casus the fall of
the uvula. This is the notorious falling of the soft palate which has always
been in popular medical literature at least. Arculanus describes it as a
preternatural elongation of the uvula which sometimes goes to such an
extent as to make it resemble the tail of a mouse. For shorter elongations he
suggests the cautery; for longer, excision followed by the cautery so that the
greater portion of the extending part may be cut off. If people fear the knife
he suggests following Rhazes, the application of an astringent powder
directly to the part by blowing through a tube. His directions for the
removal of the uvula are very definite. Seat the patient upon a stool in a
bright light while an assistant holds the head; after the tongue has been
firmly depressed by means of a speculum let the assistant hold this
speculum in place. With the left hand then insert an instrument, a stilus, by
which the uvula is pulled forward, and then remove the end of it by means
of a heated knife or some other process of cauterization. The mouth should
afterwards be washed out with fresh milk.

The application of a cauterizing solution by means of a cotton swab
wrapped round the end of a sound may be of service in patients who refuse
the actual cautery. To be successful the application must be firmly made and
must be frequently repeated.
After this it is not surprising to find that Arculanus has very practical
chapters on all the other ordinary surgical affections. Empyema is treated
very thoroughly, liver abscess, ascites, which he warns must be emptied
slowly, ileus especially when it reaches stercoraceous vomiting, and the
various difficulties of urination, he divides them into dysuria, ischuria, and
stranguria, are all discussed in quite modern fashion. He gives seven causes
for difficulty of urination. One, some injury of the bladder; two, some
lesion of the urethra; three, some pathological condition in the power to
make the bladder contract; four, some injury of the muscle of the neck of
the bladder; five, some pathological condition of the urine; six, some kidney
trouble, and seven, some pathological condition of the general system. He
takes up each one of these and discusses the various phases, causes,
disposition, and predispositions that bring them about. One thing these men
of the Middle Ages could do, they reasoned logically, they ordered what
they had to say well, and they wrote it out straightforwardly.
That Arculanus' work with regard to dentistry was no mere chance and
not solely theoretic can be understood very well from his predecessors, and
that it formed a link in a continuous tradition which was well preserved we
may judge from what is to be found in the writings of his great successor,
Giovanni or John de Vigo, who is considered one of the great surgeons of
the early Renaissance, and to whom we owe what is probably the earliest
treatise on "Gun-shot Wounds." John of Vigo was a Papal physician and
surgeon, generally considered one of the most distinguished members of the
medical profession of his time. Two features of his writing on dental
diseases deserve mention. He insists that abscesses of the gums shall be
treated as other abscesses by being encouraged to come to maturity and
then being opened. If they do not close promptly, an irritant Egyptian
ointment containing verdigris and alum among other things should be
applied to them. In the cure of old fistulous tracts near the teeth he employs
not only this Egyptian ointment but also arsenic and corrosive sublimate.
What he has to say with regard to the filling of the teeth is, however, most
important. He says it with extreme brevity, but with the manner of a man

thoroughly accustomed to doing it. "By means of a drill or file the putrefied
or corroded part of the tooth should be completely removed. The cavity left
should then be filled with gold leaf." It is evident that the members of the
Papal court, the Cardinals and the Pope himself, had the advantage of rather
good dentistry at John de Vigo's hands even as early as the beginning of the
sixteenth century.
John de Vigo, however, is not medieval. He lived on into the sixteenth
century and was influenced deeply by the Renaissance. He counts among
the makers of modern medicine and surgery, as his authorship of the treatise
on gun-shot wounds makes clear. He comes in a period that will be treated
of in a later volume of this series on "Our Forefathers in Medicine."