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Medieval Medicine

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Title: Medieval Medicine

Author: James J. Walsh


        
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Medical History Manuals

_General Editor_--John D. Comrie,
M.A., B.SC., M.D., F.R.C.P.E.

MEDIEVAL MEDICINE


      *      *      *      *      *      *

IN THE SAME SERIES


PASTEUR AND AFTER PASTEUR

By STEPHEN PAGET, F.R.C.S.

With 8 full-page Illustrations.


THE EDINBURGH SCHOOL OF SURGERY BEFORE LISTER

By ALEX. MILES, M.D., F.R.C.S.

With 8 full-page Illustrations.


A. AND C. BLACK, LTD., 4 SOHO SQ., LONDON, W. 1

      *      *      *      *      *      *


[Illustration: AN AMPUTATION BELOW THE KNEE

This is the first picture of an amputation known

_From Gerssdorff's woodcut, reproduced in Gurlt's "Geschichte der
Chirurgie"_]


MEDIEVAL MEDICINE

by

JAMES J. WALSH
K.C.ST.G., M.D., PH.D., SC.D., LITT.D.

Medical Director, Sociological Department Fordham University, and
Professor Physiological Psychology Cathedral College, New York

Fellow A.M.A., A.A.A.S., Member of the French, German, and Italian
Societies for the History of Medicine, etc.

Author of "Makers of Modern Medicine," and Other Volumes on
Medical History

   "_Multum egerunt qui ante nos fuerunt, sed non peregerunt.
   Suspiciendi tamen sunt et ritu Deorum colendi._"
                                            SENECA: _Epist. LXIV._







A. & C. Black, Ltd.
4, 5 & 6, Soho Square, London, W.C. 1
1920

Made in Great Britain.




CONTENTS


  CHAPTER                                                             PAGE

  PREFACE                                                              vii

     I. INTRODUCTION                                                     1

    II. EARLY MEDIEVAL MEDICINE                                         21

   III. SALERNO AND THE BEGINNINGS OF MODERN MEDICAL EDUCATION          37

    IV. MONTPELLIER AND MEDICAL EDUCATION IN THE WEST                   61

     V. LATER MEDIEVAL MEDICINE                                         74

    VI. MEDIEVAL SURGEONS: ITALY                                        88

   VII. SURGEONS OUTSIDE OF ITALY: SURGEONS OF THE WEST OF EUROPE      109

  VIII. ORAL SURGERY AND THE MINOR SURGICAL SPECIALITIES               136

    IX. MEDICAL EDUCATION FOR WOMEN                                    154

     X. MEDIEVAL HOSPITALS                                             169

    XI. MEDIEVAL CARE OF THE INSANE                                    183

  APPENDIX I                                                           206

  APPENDIX II                                                          212

  INDEX                                                                217




LIST OF ILLUSTRATIONS


  AMPUTATION BELOW THE KNEE                                 _Frontispiece_

                                                               FACING PAGE

  HOLY GHOST HOSPITAL                                                   64

  SURGICAL INSTRUMENTS OF GUY DE CHAULIAC                              118

  BRUNSCHWIG'S SURGICAL ARMAMENTARIUM                                  134

  SURGICAL INSTRUMENTS OF THE ARABS                                    138

  THIRTEENTH-CENTURY HOSPITAL INTERIOR                                 172

  LEPER HOSPITAL OF ST. BARTHOLOMEW                                    176

  THE HARBLEDOWN HOSPITAL                                              180




"When we think of all the work, big with promise of the future, that went
on in those centuries which modern writers in their ignorance used once to
set apart and stigmatize as the 'Dark Ages'; when we consider how the
seeds of what is noblest in modern life were then painfully sown upon the
soil which Imperial Rome had prepared; when we think of the various work
of a Gregory, a Benedict, a Boniface, an Alfred, a Charlemagne, we feel
that there is a sense in which the most brilliant achievements of pagan
antiquity are dwarfed in comparison with these."--FISKE: _The Beginnings
of New England, or the Puritan Theocracy in its Relations to Civil and
Religious Liberty_.




  TO
  MOST REVEREND P. J. HAYES
  ARCHBISHOP OF NEW YORK

  AS A SLIGHT TOKEN OF GRATITUDE FOR THE PRIVILEGE
  OF CO-OPERATING IN THE EDUCATIONAL FOUNDATION
  THAT IS A MONUMENT TO HIS PRUDENT WISDOM




PREFACE


"Medieval Medicine" is the story of the medical sciences in the Middle
Ages. The Middle Ages are usually assumed to begin with the deposition of
Romulus Augustulus, 476, and end with the fall of Constantinople, 1453. In
this little volume, then, we have to outline the history of human efforts
to prevent and treat the ills of mankind for nearly one thousand years.
Until recently, it has been the custom to believe that there was so little
of genuine interest in anything like the scientific care of ailing human
beings during these centuries, that even a volume of this kind might seem
large for the tale of it. Now we know how much these men of the Middle
Ages, for so long called the "Dark Ages," were interested in every phase
of human progress. They created a great art and literature, and above all
a magnificent architecture. We have been cultivating the knowledge of
these for several generations, and it would indeed be a surprise to find
that the men who made such surpassing achievements in all the other lines
of human effort should have failed only in medicine.

As a matter of fact, we have found that the history of medicine and
surgery, and of the medical education of the Middle Ages, are quite as
interesting as all the other phases of their accomplishments. Hence the
compression that has been necessary to bring a purview of all that we know
with regard to medieval medicine within the compass of a brief book of
this kind. The treatment has been necessarily fragmentary, and yet it is
hoped that the details which are given here may prove suggestive for those
who have sufficient interest in the subject to wish to follow it, and may
provide an incentive for others to learn more of this magnificent chapter
of the work of the medieval physicians.




MEDIEVAL MEDICINE




CHAPTER I

INTRODUCTORY


To understand the story of Medieval Medicine, the reader must recall
briefly the course of Roman history. Rome, founded some eight centuries
before Christ, was at first the home of a group of adventurers who, in the
absence of women enough to supply wives for their warriors, went out and
captured the maidens of a neighbouring Sabine town. The feud which broke
out as a result was brought to an end by the women now become the wives of
the Romans, and an alliance was made. Gradually Rome conquered the
neighbouring cities, but was ever so much more interested in war and
conquest than in the higher life. The Etruscan cities, which came under
her domination, now reveal in their ruins art objects of exquisite beauty
and the remains of a people of high artistic culture. When Rome conquered
Carthage, Carthage was probably the most magnificent city in the world,
and Rome was a very commonplace collection of houses. Culture did not
come to Rome until after her conquest of Greece, when "captive Greece led
her captor captive."

Sir Henry Maine's expression that whatever lives and moves in the
intellectual life is Greek in origin may not be unexceptionably true, but
it represents a generalization of very wide application.

Rome was stimulated in art and architecture and literature by touch with
the Greeks, and her own achievements, important though they were, were
little better than copies of Greek originals. The Romans themselves
acknowledged this very frankly. When in the course of time the barbarian
nations from the North and West of Europe came down in large numbers into
Italy, and finally gained control of the Roman Empire, they had but very
little interest in the Greek sources, and decadence of the intellectual
life was inevitable. This was particularly true as regards scientific
subjects, and above all for medicine; for the Romans had always depended
on Greek physicians, and Galen in the second century, like Alexander of
Tralles in the seventh, represent terms in the series of physicians who
reached distinction at Rome.

The key to the history of medicine in the Middle Ages, then, is always the
presence of Greek influence. This persisted in the Near East, and
consequently serious scientific medicine continued to flourish there, at
first among the Christians and later among the Arabs. It was not for any
special incentive of their own that the Arabs became the intellectual
leaders of Europe during the tenth and eleventh centuries, but the fact
that their geographical position in Asia Minor close to Greek sources
provided them with the opportunity to know the old Greek authors,
especially in philosophy and medicine, and therefore to be almost forced
to become the channels through which Greek influences were carried into
the West once more.

Before the coming of the Arabs, however--that is, before the rise of
Mohammedanism--there was an important chapter of medieval medicine which
is often not appreciated at its true worth. The contributors to it deserve
to be well known, and fortunately for us in the modern time were properly
appreciated during the early days of the art of printing, in the
Renaissance time, and accordingly their books were printed, and came to be
distributed in many copies, which have rendered them readily available in
the modern time.

In Asia Minor, where Greek influence persisted as it did not in Italy, we
have a series of distinguished contributors to medicine, or rather,
medical literature--that is, men whose books represent a valuable
compilation and digestion of the important medical writings from before
their time, often enriched by their own experience. The first of these
was Aëtios Amidenus--that is, Aëtios of Amida--born in the town of that
name in Mesopotamia on the Upper Tigris (now Diarbekir), who flourished in
the sixth century. Aëtios, or in the Latin form Aëtius, wrote a textbook
that has often been republished in the modern time, and that shows very
clearly how well the physicians of this period faced their medical and
surgical problems, how thoroughly equipped they were by faithful study of
the old Greek writers, and how successfully they coped with the
difficulties of the cases presented to them. He is eminently conservative,
a careful observer, who uses all the means at his command and who well
deserves the interest that has been manifested in him at many periods
during the almost millennium and a half elapsed since his death.

After Aëtius came Alexander of Tralles, from another of these towns of
Asia Minor that we would consider insignificant, sometimes termed
Trallianus for this reason. He must be reputed one of the great
independent thinkers in medicine whose writings have deservedly attracted
attention not only in his own time, but long afterwards in the Renaissance
period, and with whose works everyone who cares to know anything about the
development of medical history must be familiar. One detail of his life
has always seemed to me to correct a whole series of misapprehensions with
regard to the earlier Middle Ages. Alexander was one of five brothers, all
of whose names have come down to us through nearly 1,500 years because of
what they accomplished at the great Capital of the East. The eldest of
them was Anthemios, the architect of the great Church of Santa Sophia. A
second brother was Methrodoros, a distinguished grammarian and teacher at
Constantinople. A third brother was a prominent jurist in the Imperial
Courts of the capital; while a fourth brother, Dioscoros, was, like
Alexander, a physician of repute, but remained in his birthplace Tralles,
and acquired a substantial practice there.

There is sometimes the feeling that at this time in the world's history,
the end of the sixth and the beginning of the seventh century, men had but
little initiative, and above all very little power of achievement in the
intellectual order. Anyone who knows Santa Sophia in Constantinople,
however, will recognize at once that the architect who conceived and
superintended the construction of that great edifice was a genius of a
high order, not lacking in initiative, but on the contrary possessed of a
wonderful power of original accomplishment. No greater constructive work,
considering all the circumstances, has perhaps ever been successfully
planned and executed. It would scarcely be expected that the brother of
the man who conceived and finished Santa Sophia would, if he set out to
write a textbook of medicine, make an egregious failure of it. Surely his
work would not be all unworthy of his brother's reputation, and the family
genius should lift him up to important accomplishment. This is literally
what we find true with regard to Alexander. After years of travel which
led him into Italy, Gaul, Spain, and Africa, he settled down at Rome, and
practised medicine successfully until a very old age, and probably
lectured there, for some of his books are in the form of lectures.

Fortunately for us, he committed his knowledge and his experience to
writing, which has come down to us.

A third of these greater writers on medicine in the early Middle Ages was
Paul of Ægina--Æginetus as he is sometimes known. There has been some
question as to his date in history, but as he quotes Alexander of Tralles
there seems to be no doubt now that his career must be placed in the first
half of the seventh century. We shall see more of him, as also of his
great contemporaries and predecessors of the early Middle Ages, Aëtios and
Alexander of Tralles, in a subsequent chapter. Besides these men who were
known for their writings, a series of less known Christian physicians
were praised by their contemporaries for their knowledge of medicine.
Among them are particularly to be noted certain members of an Arabian
family with the title Bachtischua, a name which is derived from the Arabic
words _Bocht Jesu_--that is, servant of Jesus--who, having studied among
the Greek Christians in the cities of Asia Minor, were called to the Court
of Haroun al-Raschid and introduced Greek medicine to the Mohammedans. I
have pointed out in my volume "Old-Time Makers of Medicine"[1] that "it
was their teaching which aroused Moslem scholars from the apathy that
characterized the attitude of the Arabian people towards science at the
beginning of Mohammedanism."

After this preliminary period of early medieval medical development, the
next important phase of medicine and surgery in the Middle Ages developed
in the southern part of Italy at Salerno. Here came the real awakening
from that inattention to intellectual interests which characterized Italy
after the invasion of the northern barbarians. The reason for the early
Renaissance in this neighbourhood is not far to seek. In the older times
Sicily had been a Greek colony, and the southern portion of Italy had been
settled by Greeks and came to be known as Magna Græcia. The Greek
language continued to be spoken in many parts even during the earlier
medieval centuries, and Greek never became the utterly unknown tongue it
was in Northern Italy. With the turning of attention to education in the
later Middle Ages, the Southern Italians were brought almost at once in
contact with Greek sources, and the earlier Renaissance began. With this
in mind, it is comparatively easy to understand the efflorescence of
culture in Southern Italy, and the development of the important University
of Salerno and its great accomplishment, particularly in scientific
matters, though all this came almost entirely as a consequence of the
opportunity for Greek influence to have its effect there.

It is sometimes said that Arabian influence meant much for the development
of Salerno, and that it was because the southern part of the Italian
peninsula was necessarily rather closely in touch with Arabian culture
that an early awakening took place down there. The Mohammedans occupied so
many of the islands of the Mediterranean, as well as Spain, that their
influence was felt deeply all along its shore, and hence the first
university of Europe in modern times came into existence in this part of
the world. Montpellier is sometimes, though not so often, said to have had
the same factor in its early development. Undoubtedly there was some
Arabian influence in the foundation of Salerno. The oldest traditions of
the University show this rather clearly. This Arabian influence, however,
has been greatly exaggerated by some modern historical writers. Led by the
thought that Christianity was opposed to culture, and above all to
science, they were quite willing to suggest any other influences than
Christian as the source of so important a movement in the history of human
progress as Salerno proved to be. The main influence at Salerno, however,
was Greek, and the proof of this is, as insisted by Gurlt in his "History
of Surgery," that the great surgeons of Salerno do not refer to Arabian
sources, but to Greek authors, and their books do not show traces of
Arabian influences, but on the contrary have many Græcisms in them.

Salerno represents an especially important chapter in the history of
Medieval Medicine. As we shall see, the teachers at the great medical
school there set themselves in strenuous opposition to the Arabian
tendency to polypharmacy, by which the Oriental mind had seriously hurt
medicine, and what is still more to the credit of these Salernitan
teachers, they developed surgery far beyond anything that the Arabs had
attempted. Indeed, surgery in the later centuries of Arabian influence
had been distinctly neglected, but enjoyed a great revival at Salerno.
Besides, the Salernitan physicians used all the natural methods of cure,
air, water, exercise, and diet, very successfully. If any other proof were
needed that Arabian influence was not prominent at Salerno, surely it
would be found in the fact that women physicians enjoyed so many
privileges there. This is so entirely opposed to Mohammedan ways as to be
quite convincing as a demonstration of the absence of Arabian influence.

From Salerno, the tradition of medicine and surgery spread to Bologna
early in the thirteenth century, and thence to the other universities of
Italy and to France. Montpellier represented an independent focus of
modern progress in medicine, partly due to close relationship with the
Moors in Spain and the Greek influences they carried with them from Asia
Minor, but not a little of it consequent upon the remnants of the older
Greek culture, still not entirely dead even in the thirteenth century,
because Marseilles, not far away, had been a Greek colony originally, and
still retained living Greek influence, and wherever Greek got a chance to
exercise its stimulant incentive modern scientific medicine began to
develop.

France owed most of her development in medicine and surgery at the end of
the Middle Ages to the stream of influence that flowed out of Italian
universities. Such men as Lanfranc, who was an Italian born but exiled;
Mondeville, who studied in Italy; and Guy de Chauliac, who has so freely
acknowledged his obligation to Italian teachers, were the capital sources
of medical and surgical teaching in France in the later Middle Ages.

It is thus easy to see how the two periods of historical import in
medicine at the beginning and end of the Middle Ages may be placed in
their intimate relation to Greek influences. At the beginning, Greek
medicine was not yet dead in Asia Minor, and it influenced the Arabs. When
the revival came, it made itself first felt in the portions of Southern
Italy and Southern France where Greek influence had been strongest and
still persisted. Fortunately for us, the great Renaissance printers and
scholars, themselves touched by the Greek spirit of their time, put the
books of the writers of these two periods into enduring printed form, and
in more recent years many reprints of them have been issued. These volumes
make it possible for us to understand just how thoroughly these colleagues
of the Middle Ages faced their problems, and solved them with a practical
genius that deserves the immortality that their works have been given.

The history of medicine and surgery during the Middle Ages has been
greatly obscured by the assumption that at this time scientific medicine
and surgery could scarcely have developed because men were lacking in the
true spirit of science. The distinction between modern and medieval
education is often said to be that the old-time universities sought to
increase knowledge by deduction, while the modern universities depend on
induction. Inductive science is often said to be the invention of the
Renaissance period, and to have had practically no existence during the
Middle Ages. The medieval scholars are commonly declared to have preferred
to appeal to authority, while modern investigators turn to experience.
Respect for authority is often said to have gone so far in the Middle Ages
that no one ventured practically to assert anything unless he could find
some authority for it. On the other hand, if there was any acknowledged
authority, say Aristotle or Galen, men so hesitated to contradict him that
they usually followed one another like sheep, quoting their favourite
author and swearing by the authority of their chosen master. Indeed, many
modern writers have not hesitated to express the greatest possible wonder
that the men of the Middle Ages did not think more for themselves, and
above all did not trust to their own observation, rather than constantly
rest under the shadow of authority.

Above all, it is often asked why there was no nature study in the Middle
Ages--that is, why men did not look around them and see the beauties and
the wonders of the world and of nature, and becoming interested in them,
endeavour to learn as much as possible about them. Anyone who thinks that
there was no nature study in the Middle Ages, however, is quite ignorant
of the books of the Middle Ages. Dante, for instance, is full of the
knowledge of nature. What he knows about the ants, and the bees, and many
other insects; about the flowers, and the birds, and the habits of
animals; about the phosphorescence at sea and the cloud effects, and
nearly everything else in the world of nature around him, adds greatly to
the interest of his poems. He uses all these details of information as
figures in his "Divine Comedy," not in order to display his erudition, but
to bring home his meaning with striking concreteness by the metaphors
which he employs. There is probably no poet in the modern time who knows
more about the science of his time than Dante, or uses it to better
advantage.

It is sometimes thought that the medieval scholars did not consider that
experience and observation were of any value in the search for truth, and
that therefore there could have been no development of science. In an
article on "Science at the Medieval Universities"[2] I made a series of
quotations from the two great scientific scholars of the thirteenth
century, Albertus Magnus and Roger Bacon, with regard to the question of
the relative value of authority and observation in all that relates to
physical science. Stronger expressions in commendation of observation and
experiment as the only real sources of knowledge in such matters could
scarcely be found in any modern scientist. In Albert's tenth book of his
"Summa," in which he catalogues and describes all the trees, plants, and
herbs known in his time, he declares: "All that is here set down is the
result of our own experience, or has been borrowed from authors whom we
know to have written what their personal experience has confirmed; for in
these matters experience alone can be of certainty." In his impressive
Latin phrase, _experimentum solum certificat in talibus_. With regard to
the study of nature in general he was quite emphatic. He was a theologian
as well as a scientist, yet in his treatise on "The Heavens and the
Earth," he declared that: "In studying nature we have not to inquire how
God the Creator may, as He freely wills, use His creatures to work
miracles, and thereby show forth His power. We have rather to inquire
what nature with its immanent causes can naturally bring to pass."

Roger Bacon, the recent celebration of whose seven hundredth anniversary
has made him ever so much better known than before, furnishes a number of
quotations on this subject. One of them is so strong that it will serve
our purpose completely. In praising the work done by Petrus, one of his
disciples whom we have come to know as Peregrinus, Bacon could scarcely
say enough in praise of the thoroughly scientific temper, in our fullest
sense of the term, of Peregrinus's mind. Peregrinus wrote a letter on
magnetism, which is really a monograph on the subject, and it is mainly
with regard to this that Roger Bacon has words of praise. He says: "I know
of only one person who deserves praise for his work in experimental
philosophy, for he does not care for the discourses of men and their wordy
warfare, but quietly and diligently pursues the works of wisdom.
Therefore, what others grope after blindly, as bats in the evening
twilight, this man contemplates in their brilliancy, _because he is a
master of experiment_. Hence, he knows all of natural science, whether
pertaining to medicine and alchemy, or to matters celestial or
terrestrial. He has worked diligently in the smelting of ores, as also in
the working of minerals; he is thoroughly acquainted with all sorts of
arms and implements used in military service and in hunting, besides which
he is skilled in agriculture and in the measurement of lands. It is
impossible to write a useful or correct treatise in experimental
philosophy without mentioning this man's name. Moreover, he pursues
knowledge for its own sake; for if he wished to obtain royal favour, he
could easily find sovereigns who would honour and enrich him."

Roger Bacon actually wanted the Pope to forbid the study of Aristotle
because his works were leading men astray from the true study of
science--his authority being looked upon as so great that men did not
think for themselves, but accepted his assertions. Smaller men are always
prone to act thus at any period in the world's history, and we undoubtedly
in our time have a very large number who do not think for themselves, but
swear on the word of some master or other, and very seldom so adequate a
master as Aristotle.

Bacon insisted that the four great grounds of human ignorance are: "First,
trust in inadequate authority; second, that force of custom which leads
men to accept without properly questioning what has been accepted before
their time; third, the placing of confidence in the assertions of the
inexperienced; and fourth, the hiding of one's own ignorance behind the
parade of superficial knowledge, so that we are afraid to say, 'I do not
know.'" Prof. Henry Morley suggested that: "No part of that ground has yet
been cut away from beneath the feet of students, although six centuries
have passed. We still make sheepwalks of second, third, and fourth, and
fifth hand references to authority; still we are the slaves of habit,
still we are found following too frequently the untaught crowd, still we
flinch from the righteous and wholesome phrase, 'I do not know,' and
acquiesce actively in the opinion of others that we know what we appear to
know."

It used to be the custom to make little of the medieval scientists because
of their reverence for Aristotle. Generations who knew little about
Aristotle, especially those of the seventeenth and eighteenth centuries,
were inclined to despise preceding generations who had thought so much of
him. We have come to know more about Aristotle in our own time, however,
and as a consequence have learned to appreciate better medieval respect
for him. Very probably at the present moment there would be almost
unanimous agreement of scholars in the opinion that Aristotle's was the
greatest mind humanity has ever had. This is true not only because of his
profound intellectual penetration, but above all because of the
comprehensiveness of his intelligence. For depth and breadth of mental
view on a multiplicity of subjects, Aristotle has never been excelled and
has but very few rivals. The admiration of the Middle Ages for him,
instead of being derogatory in any way to the judgment of the men of the
time, or indicating any lack of critical appreciation, rather furnishes
good reasons for high estimation of both these intellectual modes of the
medieval mind. Proper appreciation of what is best is a much more
difficult task than condemnation of what is less worthy of regard. It is
the difference between constructive and destructive criticism. Medieval
appreciation of Aristotle, then, constitutes rather a good reason for
admiration of them than for depreciation of their critical faculty; and
yet they never carried respect and reverence to unthinking worship, much
less slavish adoration. Albertus Magnus, for instance, said: "Whoever
believes that Aristotle was a God must also believe that he never erred;
but if we believe that Aristotle was a man, then doubtless he was liable
to err just as we are." We have a number of direct contradictions of
Aristotle from Albert. A well-known one is that with regard to Aristotle's
assertion that lunar rainbows appeared only twice in fifty years. Albert
declared that he himself had seen two in a single year.

Galen, after Aristotle, was the author oftenest quoted in the Middle
Ages, and most revered. Anyone who wants to understand this medieval
reverence needs only to read Galen. There has probably never been a
greater clinical observer in all the world than this Greek from Pergamos,
whose works were destined to have so much influence for a millennium and a
half after his time. How well he deserved this prestige only a careful
study of his writings will reveal. It is simply marvellous what he had
seen and writes about. Anatomy, physiology, pathological anatomy,
diagnosis, therapeutics--all these were magnificently developed under his
hands, and he has left a record of accurate and detailed observation.
There are many absurdities easily to be seen in his writings now, but no
one has yet written on medicine in any large way who has avoided
absurdities, nor can anyone hope to, until we know much more of the
medical sciences than at present. The therapeutics of any generation is
always absurd to the second succeeding generation, it has been said. Those
in the modern time who know their Galen best have almost as much
admiration for him, in spite of all our advance in the knowledge of
medicine, as the medieval people had. No wonder, seeing the depth and
breadth of his knowledge, that he was thought so much of, and that men
hesitated to contravene anything that he said.

Even in the authorities to which they turned with so much confidence, the
medieval physicians are admirable. If man must depend on authority, then
he could not have better than they had. As with regard to this, so in all
other matters relating to the Middle Ages, the ordinarily accepted notions
prove to have been founded on ignorance of actual details, and
misconceptions as to the true significance of their point of view. To have
contempt give way to admiration, we need only to know the realities even
in such meagre details as can be given in a short manual of this kind. The
thousand years of the Middle Ages are now seen to have been full of
interesting and successful efforts in every mode of human activity, and
medicine and surgery shared in this to the full.




CHAPTER II

EARLY MEDIEVAL MEDICINE


There are two distinct periods in the history of Medieval Medicine. The
first concerns the early centuries, from the sixth to the ninth, and is
occupied mainly with the contributions to medicine made by those who were
still in touch with the old Greek writers; while the second represents the
early Renaissance, when the knowledge of the Greek writers was gradually
filtering back again, sometimes through the uncertain channel of the
Arabic. Both periods contain contributions to medicine that are well
worthy of consideration, and nearly always the writings that have been
preserved for us demonstrate the fact that men were thinking for
themselves as well as studying the Greek writers, and were making
observations and garnering significant personal experience. The later
Middle Ages particularly present material in this regard of far greater
interest than was presumed to exist until comparatively recent historical
studies were completed.

The real history of medicine in the Middle Ages--that is, of scientific
medicine--is eclipsed by the story of popular medicine. So much has been
said of the medical superstitions, many of which were rather striking,
that comparatively little space has been left for the serious medical
science and practice of the time, which contain many extremely interesting
details. It is true that after the Crusades mummy was a favourite
pharmacon, sometimes even in the hands of regular physicians; and _Usnea_,
the moss from the skulls of the bodies of criminals that had been hanged
and exposed in chains, was declared by many to be a sovereign remedy for
many different ills; but it must not be forgotten that both of these
substances continued to be used long after the medieval period, mummy even
down to the middle of the eighteenth century, and Usnea almost as late.
Indeed, it is probable that the seventeenth and eighteenth centuries
present many more absurdities in therapeutics than do the later centuries
of the Middle Ages. In this, as in so many other regards, the modern use
of the adjective medieval has been symbolic of ignorance of the time
rather than representative of realities in history.

Popular medicine is always ridiculous, though its dicta are often accepted
by supposedly educated people. This has always been true, however, and was
never more true than in our own time, when the vagaries of medical faddism
are so strikingly illustrated, and immense sums of money spent every year
in the advertising of proprietary remedies, whose virtues are often sadly
exaggerated, and whose tendency to work harm rather than good is
thoroughly appreciated by all who know anything about medicine. The
therapeutics of supposedly scientific medicine are often dubious enough. A
distinguished French professor of physiology quoted, not long since, with
approval, that characteristic French expression: "The therapeutics of any
generation are always absurd to the second succeeding generation." When we
look back on the abuse of calomel and venesection a century ago, and of
the coal-tar derivatives a generation ago, and the overweening confidence
in serums and vaccines almost in our own day, it is easy to understand
that this law is still true. We can only hope that our generation will not
be judged seven centuries from now by the remedies that were accepted for
a time, and then proved to be either utterly ineffectual or even perhaps
harmful to the patients to whom they were given.

When we turn our attention away from this popular pseudo-history of
Medieval Medicine, which has unfortunately led so many even well-informed
persons into entirely wrong notions with regard to medical progress during
an important period, we find much that is of enduring interest. The first
documents that we have in the genuine history of Medieval Medicine, after
the references to the organizations of Christian hospitals at Rome and
Asia Minor in the fourth and fifth centuries (see chapter Medieval
Hospitals), are to be found in the directions provided in the rules of the
religious orders for the care of the ailing. St. Benedict (480-543), the
founder of the monks of the West, was particularly insistent on the
thorough performance of this duty. The rule he wrote to guide his
religious is famous in history as a great constitution of democracy, and
none of its provisions are more significant than those which relate to the
care of the health of members of the community.

One of the rules of St. Benedict required the Abbot to provide in the
monastery an infirmary for the ailing, and to organize particular care of
them as a special Christian duty. The wording of the rule in this regard
is very emphatic. "The care of the sick is to be placed above and before
every other duty, as if, indeed, Christ were being directly served in
waiting on them. It must be the peculiar care of the Abbot that they
suffer from no negligence. The Infirmarian must be thoroughly reliable,
known for his piety and diligence and solicitude for his charge." The last
words of the rule are characteristic of Benedict's appreciation of
cleanliness as a religious duty, though doubtless also the curative effect
of water was in mind. "Let baths be provided for the sick as often as they
need them." As to what the religious infirmarians knew of medicine, at
least as regards the sources of their knowledge and the authors they were
supposed to have read, we have more definite information from the next
historical document, that concerning medical matters in the religious
foundation of Cassiodorus.

Cassiodorus (468-560), who had been the prime minister of the Ostrogoth
Emperors, when he resigned his dignities and established his monastery at
Scillace in Calabria, was influenced deeply by St. Benedict, and was
visited by the saint not long after the foundation.

His rule was founded on that of the Benedictines. Like that, it insisted
especially on the care of the sick, and the necessity for the deep study
of medicine on the part of those who cared for them. Cassiodorus laid down
the law in this regard as follows: "I insist, brothers, that those who
treat the health of the body of the brethren who have come into the sacred
places from the world should fulfil their duties with exemplary piety. Let
them be sad with others' suffering, sorrowful over others' dangers,
sympathetic to the grief of those whom they have to care for, and always
ready zealously to help others' misfortunes. Let them serve with sincere
study to help those who are ailing as becomes their knowledge of medicine,
and let them look for their reward from Him who can compensate temporal
work by eternal wages. Learn, therefore, the nature of herbs, and study
diligently the way to combine their various species for human health; but
do not place your entire hope on herbs, nor seek to restore health only by
human counsels. Since medicine has been created by God, and since it is He
who gives back health and restores life, turn to Him. Remember, do all
that you do in word or deed in the name of the Lord Jesus, giving thanks
to God the Father through Him. And if you are not capable of reading
Greek, read above all the translations of the Herbarium of Dioscorides,
which describes with surprising exactness the herbs of the field. After
this, read translations of Hippocrates and Galen, especially the
Therapeutics, and Aurelius Celsus' 'De Medicina,' and Hippocrates' 'De
Herbis et Curis,' and divers other books written on the art of medicine,
which by God's help I have been able to provide for you in my library."

The monasteries are thus seen to have been in touch with Greek medicine
from the earliest medieval time. The other important historical documents
relating to Medieval Medicine which we possess concern the work of the
men born and brought up in Asia Minor, for whom the Greeks were so close
as to be living influences. Aëtius, Alexander of Tralles, and Paul of
Ægina have each written a series of important chapters on medical
subjects, full of interest because the writers knew their Greek classic
medicine, and were themselves making important observations. Aëtius, for
instance, had a 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
neurotic 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--which 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 he remarks that
even "drinks when taken are returned through the nose."

Aëtius declares quite positively that all the tumours of the neck region,
with the exception of scirrhus, are easily cured, yielding either to
surgery or to remedies. The exception is noteworthy. He evidently saw a
good many of the functional disturbances and the enlargements of the
thyroid gland, which are often so variable in character as apparently to
be quite amenable to treatment, and which have actually been "cured" in
the history of medicine by all sorts of things from the touch of the
hangman's rope to the wrapping of the shed skin of the snake around the
neck. A few cervical tumours were beyond resource. Aëtius suggests the
connection between hypertrophy of the clitoris and certain exaggerated
manifestations of the sexual instinct, as well as the development of
vicious sexual habits.

It requires only a little study of this early medieval author to
understand why Cornelius, at the time of the Renaissance, was ready to
declare: "Believe me, that whoever is deeply desirous of studying things
medical, if he would have the whole of Galen abbreviated and the whole of
Orbiasius 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."

Alexander of Tralles was, as we have said, the brother of the architect of
Santa Sophia of Constantinople, and his writings on medical and surgical
subjects are worthy of such a relationship. His principal work is a
treatise on the "Pathology and Therapeutics of Internal Diseases" in
twelve books, the first eleven books of which were evidently material
gathered for lectures or teaching purposes. He treats of cough as a
symptom due to hot or cold, dry or wet, dyscrasias. Opium preparations
judiciously used he thought the best remedies, though he recommended also
the breathing in of steam impregnated with various ethereal resins.

He outlines a very interesting because thoroughly modern treatment of
consumption. He recommends an abundance of milk with a hearty nutritious
diet, as digestible as possible. A good auxiliary to this treatment in his
opinion was change of air, a sea voyage, and a stay at a watering-place.
Ass's and mare's milk are much better for these patients than cow's and
goat's milk. We realize now that there is not enough difference in the
composition of these various milks to make their special prescription of
physical importance, but it is probable that the suggestive influence of
the taking of an unusual milk had a very favourable effect upon patients,
and this effect was renewed with every drink taken, so that much good was
ultimately accomplished. For hæmoptysis, especially when it was acute and
due, as Alexander felt, to the rupture of a bloodvessel 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, however, that the patients must in addition
rest, as well as take acid and astringent drinks, while 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, he declared a milk cure [blood-maker]
very useful for the restoration of these patients to their former
strength.

He paid particular attention to diseases of the nervous system, and
discussed headache at some length. Chronic or recurrent headache he
attributed to diseases of the brain, plethora, biliousness, digestive
disturbances, insomnia, and prolonged worry. Hemicrania he thought due to
the presence of toxic materials, though it was also connected with
abdominal disorders, especially in women. Alexander has much to say of the
paralytic and epileptic conditions, and recommended massage, rubbings,
baths, and warm applications for the former, and emphasized the need for
careful directions as to the mode of life, and special attention to the
gastro-intestinal tract, in the latter. A plain, simple diet, with regular
bowels, he considers the most important basis for any successful treatment
of epilepsy. Besides, he recommended baths, sexual abstinence, and regular
exercise. He rejected treatment of the condition by surgery of the head,
either by trephining or by incisions or by cauterization. His teaching is
that of those who have had most experience with the disease in our own
time. For sore throat he prescribes gargles or light astringents at the
beginning, and stronger astringents, alum and soda dissolved in water,
later in the case.

He particularly emphasized that 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 placed 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 Alexander's therapeutics is
his 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
favourite remedies. He encouraged diaphoresis nearly always, and gave wine
and stimulating drugs when the patient was very weak.

Some of the general principles of medical practice which Alexander lays
down are very significant even from our modern standpoint. He deprecated
drastic remedies of all kinds. He did not believe in severe purgation nor
in profuse or sudden blood-letting. His diagnosis was thorough and
careful. He insisted particularly on inspection and palpation of the whole
body; on careful examination of the urine, of the fæces, and the sputum;
on study of the pulse and the breathing. He dwelt on the fact that much
might be learned from the patient's history taken carefully. The general
constitution was the most important element, in his estimation. 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
seconding nature's efforts to cure. Alexander had no sympathy at all with
the idea that nature was to be disturbed, much less that remedies must
work in opposition to natural tendencies to recovery.

Paul of Ægina, educated at the University at Alexandria, probably
flourished during the reign of the Emperor Heraclius, who died 641; his
works contain more of surgical than of medical interest.

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 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 hæmorrhage from the uterus, the
bleeding might be stopped by putting ligatures around the limbs. This
same method has been suggested for severe hæmorrhage 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 favourable physical effect in this
affection. Paul's description of the use of the speculum is as complete as
that in any modern textbook of gynæcology.

In the chapter on the medieval care of the insane, there are some clinical
observations and suggestions as to treatment from Paul which make it very
clear what a careful observer he was, and how rational in his application
of such knowledge as he had to the treatment of patients. Probably his
contributions to the difficult subject psychiatry, well above a thousand
years ago, will serve to make his genius as a physician clearer than
almost anything else that could be said of him.

Among the great Arabian physicians who represent the transition period,
from the earlier Middle Ages directly under Greek influence, still
surviving to the later Middle Ages, when the earlier Renaissance brought
back the Greek masters once more, were Rhazes, Ali Abbas, Avicenna--whose
name had been transformed from the Arabic Ibn Sina--Abulcasis, Avenzoar,
and Averroes, the last named a philosophic theorist but not a physician.
The first three named were born in the East, the last three in Spain.
Besides these Maimonides, the great Jewish physician, who was born and
educated at Cordova in Spain, deserves a place. In this earlier period
Rhazes must be mentioned, while the others who merit special attention
will be considered in the chapter on Later Medieval Medicine.

Rhazes (died 932) is one of the great epoch-makers in the history of
medicine. He was the first to give us a clear description of smallpox.
Some of his medical aphorisms are well worth noting, and make it very
clear that he was a careful observer.

"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." He considered 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."

During the ninth and tenth centuries the Arabs continued to be the most
important contributors to medicine, until the rise of the school at
Salerno gave a new impetus to clinical observation, and furnished a new
focus of medical attention in the West. Constantine brought whatever of
Arab influence there was in Salerno, as we have pointed out in the chapter
on the Beginnings of Medical Education; but after his time there is an
originality about Salernitan medicine which makes it of great value as the
foster-mother of the sciences related to medicine during the later Middle
Ages.




CHAPTER III

SALERNO AND THE BEGINNINGS OF MODERN MEDICAL EDUCATION


The first medical school of modern history, and the institution which more
than any other has helped us to understand the Middle Ages, is that of
Salerno. Indeed, the accumulation of information with regard to this
medical school, formally organized in the tenth century but founded a
century earlier, and reaching a magnificent climax of development at the
end of the twelfth century, has done more than anything else to
revolutionize our ideas with regard to medieval education and the
scientific interests of the Middle Ages. We owe this development of
knowledge to De Renzi, whose researches with regard to matters Salernitan,
and medical education generally in Italy in the Middle Ages, are well
deserving of the prestige that has been at length accorded them.

In his "Storia della Medicina in Italia," published so modestly at Naples,
the patient Italian student of medical history made an epoch-making
contribution to the history of medicine. Unless one has actually read his
book, it is difficult to understand how deep our obligations to him are.
Anyone who might be tempted to think that medicine was not taken
seriously, or that careful clinical observations and serious experiments
for the cure of disease were not made at Salerno, will be amply undeceived
by a reading of De Renzi. Above all, he makes it very clear that medical
education was taken up with rigorous attention to details and high
standards maintained. Three years of college work were demanded in
preparation for medical studies, and then four years at medicine, followed
by a year of practice with a physician, and even an additional year of
special study in anatomy, had to be taken, if surgery were to be
practised. All this before the licence to practise medicine was given;
though the degree of doctor, granting the privilege of teaching as the
word indicates, was conferred apparently after the completion of the four
years at the medical school. We have had to climb back to these medieval
standards of medical education in many countries in recent years, after a
period of deterioration in which often the requirements for the
physician's training for practice were ever so much lower.

It may seem surprising that the first medical school should have arisen in
the southern part of Italy, but for those who know the historical
conditions it will seem the most natural thing in the world that this
development should have come in this region. As we have said, touch with
Greek has always been the most important factor for modern educational and
intellectual development. Salerno was situated in the heart of that Greek
colony in the southern part of Italy which came to be known as Magna
Græcia. Apparently at no time during the Middle Ages was Greek entirely a
dead language in this part of Italy, and there were Greek travellers,
Greek sailors, and many other wanderers, who made their way along the
shores of the Mediterranean at this time, and carried with them everywhere
the stimulus that always came from association with the Greeks of Asia
Minor and of the Grecian Islands and peninsula.

There were two other factors that made for the development of the medical
school at Salerno. The first of these seems undoubtedly to have been the
presence of the Benedictines, who had a rather important school at
Salerno, and who were closely in touch with their great mother-house at
Monte Cassino not far away. It was they who imparted the academic
atmosphere to the town, and made it possible to gather together the
elements for the university which gradually came into existence around the
medical school, after that began to attract European attention.

The actual foundation of the medical school, however, seems to have been
due to the fortunate accident that Salerno became a health resort, a place
to which invalids were attracted from many parts of Europe because the
climate was salubrious, and opportunities for obtaining the medical advice
of men of many different schools of thought from all over the
Mediterranean, and securing the Oriental drugs which were so much
valued--as drugs from a distance always are--were there afforded. It is
easy to understand that, especially in the winter-time, better-class
patients from all over Europe would be glad to go down to the mild
temperate climate of Salerno and spend their time there.

It has been pointed out that the first modern university, that of Salerno,
had for a nucleus a medical school, representing man's interest in his
body as his primary intellectual purpose in modern history. The second
modern university, that of Bologna, gathered around a law school
representing man's interest in his property--his second formal purpose in
life. And the third, that of Paris, developed around a school of theology
and philosophy, demonstrating that man's intellectual interests rise
finally to the consideration of his relations to his fellow-man and to
God.

The first that we know definitely about the medical school of Salerno,
the origin of which is difficult to trace, is concerned with Alphanus,
usually designated "the First," because there are several of the name. He
was a Benedictine monk, distinguished as a literary man and known by his
contemporaries as both poet and physician, who was afterwards raised to
the Bishopric of Salerno. He had taught at Salerno in the Benedictine
school there before becoming Bishop, and when exercising the highest
ecclesiastical authority did much to encourage the development of Salerno.
He states that medicine flourished in the town even in the ninth century,
and there is an old chronicle published by De Renzi in his "Collectio
Salernitana" in which it is said that the medical school was founded by
four doctors--a Jewish Rabbi, Elinus; a Greek, Pontus; a Saracen, Adale;
and the fourth a native of Salerno--each of whom lectured in his native
language. This reads like a mythical legend that has formed around some
real tradition of the coming of physicians from many countries. Puschmann
in his "History of Medical Education" has suggested that the names are
probably as much varied as the absolute truth of the facts. Elinus, the
Jew, is probably Elias or Eliseus, Adale is probably a corruption of
Abdallah, and Pontus should be probably Gariopontus.

There was a hospital at Salerno that was somewhat famous as early as the
first quarter of the ninth century. This was placed under the control of
the Benedictines; and other infirmaries and charitable institutions,
similarly under the care of religious orders, sprang up in Salerno to
accommodate the patients that came. The practical character of the
teaching at Salerno, as preserved for us in the writings of the school,
would seem to argue that probably those who came to study medicine here
were brought directly in contact with the patients, though we have no
definite evidence of that fact.

The most interesting feature of the medical school at Salerno is
undoubtedly the development of legal standards of medical education in
connection with the school. Before the middle of the twelfth century
Roger, King of the Two Sicilies, issued a decree according to which
preliminary studies at the University were required as a preparation for
the medical school, and four years of medical studies were made the
minimum requirement for the degree of doctor in medicine, which was,
however, as we have said, not a licence to practise, but only a
certificate authorizing teaching. There seemed to have been, even thus
early, some further state regulations with regard to practice. About the
middle of the next century, however, there came, through a law of the
Emperor Frederick II., a still further evolution of legal standards for
medical education and medical practice in the Two Sicilies. This law
required that the student of medicine should have spent some years,
probably the equivalent of our undergraduate training, in the university
before studying medicine, and that he should then devote four years to
medicine, after which, on proper examination, he might be given the degree
of doctor--that is, teacher of medicine; but he must spend a further year
of practice with a physician before he would be allowed to practise for
himself.

This is such a high standard that, only that we have the actual wording of
the law, it would seem almost impossible that it could have been evolved
at this period in medical history. It actually represents the standard
that we have climbed back to generally only during the past generation or
two, and in the interval there have been many rather serious derogations
from it. This law of the Emperor Frederick is, moreover, a pure drug law,
regulating the sale of drugs and their purity, and inflicting condign
punishment for substitution; in this regard also anticipating our most
recent well-considered legislation. The penalty by which the druggist was
fined all his movable goods for substitution, while the government
inspector who permitted such substitution was put to death, would seem to
us in the modern time to make the punishment eminently fit the crime.
Almost needless to say, then, the law (see Appendix for full text)
represents one of the most important documents in the history of medicine,
particularly of medical education. The fee regulation included in it shows
that medicine was looked upon as a profession, and was paid accordingly.

From Salerno come many of the traditions of the conferring of degrees
which are still used in a large number of modern medical schools. Before
receiving his degree, the candidate had to take an oath, of which the
following were the principal tenets: "Not to contradict the teaching of
his college, not to teach what was false or lying, and not to receive fees
from the poor even though they were offered; to commend the sacrament of
penance to his patients, to make no dishonest agreement with the
druggists, to administer no abortifacient drug to the pregnant, and to
prescribe no medicament that was poisonous to human bodies."

It has sometimes been said that youths of tender age were admitted to the
study of medicine at Salerno, and that many of them were given their
degrees at the age of twenty-one. De Renzi's discussion would seem to show
that the usual age of receiving the degree was twenty-five to
twenty-seven. As medical students had to have three years of preparatory
studies in literature and philosophy, it would seem that they must have
been rather mature on their admission to the medical schools.

De Renzi tells us that the medical school of Salerno was of great
importance not only for medical education, but it acquired sufficient
means to extend its benefits over the entire city. Gifts were made of
statues to the churches, and especially to the shrine of St. Matthew the
Apostle, situated here; monuments were set up, inscriptions placed and
ample donations made to the various institutions of the city. The formal
name of the medical school was _Almum et Hippocraticum Medicorum
Collegium_. This is the first use that I know of the word _almum_ in
connection with a college, and may very well be the distant source of our
term _alma mater_. The medical school was situated in the midst of an
elevated valley which opened up on the mountain that dominates Salerno,
and while enjoying very pure air must have been scarcely disturbed at all
by the winds which can be blustery enough from the gulf. De Renzi says
that in his time some of the remains could still be seen, though visitors
to Salerno now come away very much disappointed because nothing of
interest is left.

The most famous of the teachers at Salerno was Constantine Africanus, so
called because he was born near Carthage. His life runs from the early
part of the eleventh century to near its close, and he lived probably well
beyond eighty years of age. Having studied medicine in his native town, he
wandered through the East, became familiar with a number of Oriental
languages, and studied the Arabian literature of science, and above all of
medicine, very diligently. The Arabs, owing to their intimate contact with
the Greeks in Asia Minor, had the Greek authors constantly before them,
and Hippocrates and Galen have always roused men to do good work in
medicine. Constantine seems not to have learned Greek, finding enough to
satisfy him in the Arabic commentaries on the Greek authors, and probably
confident, as all young men have ever been, that what his own time was
doing must represent an advance over the Greek. He brought back with him
Arabian books and a thorough knowledge of Arabian medicine. When he
settled down in Carthage he was accused of magical practices, his medical
colleagues being apparently jealous of his success--at least, there is a
tradition to that effect to account for his removal to Salerno, though the
immediate reason seems to have been that his reputation attracted the
attention of Duke Robert of Salerno, who invited him to become his
physician.

After Constantine's time the principal textbooks of the school became,
according to De Renzi, Hippocrates, Galen, and Avicenna. To these were
added the _Antidotarium_ of Mesue, and there were various compendiums of
medical knowledge, quite as in our own time--one well known under the name
of _Articella_. In surgery the principal textbook was the surgical works
of the Four Masters of Salerno, which interestingly enough was the sort of
combination work gathered from a series of masters that we are accustomed
to see so frequently at the present day. De Renzi insists that there was
much less Arabic influence at Salerno than is usually thought; and Gurlt
more recently has emphasized, as we have said, the fact that the great
textbooks of surgery which we have from Salerno contain not Arabisms, as
might be expected from the traditions of Arabic influence that we hear so
much of, but Græcisms, which show that here at Salerno there was a very
early Renaissance, and the influence of Greek writers was felt even in the
twelfth century.

Probably the best way to convey in brief form a good idea of the teaching
in medicine at Salerno is to quote the _Regimen Sanitatis Salernitanum_,
the Code of Health of the School of Salernum, which for many centuries was
popular in Europe, and was issued in many editions even after the
invention of printing. Professor Ordronaux, Professor of Medical
Jurisprudence in the law school of Columbia College (now Columbia
University, New York), issued a translation of it in verse,[3] which gives
a very good notion of the contents and the spirit and the mode of
expression of the little volume.

The _Regimen_ was written in the rhymed verses which were so familiar at
this time. Many writers on the history of medicine have marvelled at this
use of verse, but anyone who knows how many verse-makers there were in the
twelfth and thirteenth centuries all over Europe will not be surprised. It
used to be the custom to make little of these rhymed Latin verses of the
Middle Ages, but it may be well to recall that in recent years a great
change has come over the appreciation of the world of literature in their
regard. The rhymed Latin hymns of the Church, especially the _Dies Iræ_,
the _Stabat Mater_, and others, are now looked upon as representing some
of the greatest poetry that ever was written. Professor Saintsbury of the
University of Edinburgh has declared them the most wondrous wedding of
sense and sound that the world has ever known. The _Regimen Sanitatis_ of
Salerno is of course no such poetry, mainly because its subject was
commonplace and it could not rise to poetic heights. A good deal of the
deprecation of its Latinity might well be spared, for most of the mistakes
are undoubtedly due to copyists and interpolation. The verses not only
rhyme at the end, but often there are internal sub-rhymes. This too was a
very common custom among the hymn-writers, as the great sequence of
Bernard of Morlaix, so well known through its translations in our time, as
"Jerusalem the Golden" attests.

The _Regimen_ was not written for physicians, but for popular information.
It seems to have been a compilation of maxims of health from various
professors of the Salernitan School. Nothing that I know shows more
clearly the genuine knowledge of medicine, and the careful following of
the first rule of medical practice _non nocere_ to which Salerno had
reached at this time, than the fact that this popular volume contained
no recommendation of specific remedies, but only health rules for
diet, air, exercise, and the like, many of which are as valuable in our
time as they were in that, and very few of which have been entirely
superseded--together with some general information as to simples, and a
few details of medical knowledge that would give a convincing air to the
compilation.

The book was dedicated to the King of the English, _Anglorum regi scribit
schola tota Salerni_, and in the translation made by Professor Ordonaux
begins as follows:

  If thou to health and vigour wouldst attain,
  Shun weighty cares--all anger deem profane,
  From heavy suppers and much wine abstain.
  Nor trivial count it, after pompous fare,
  To rise from table and to take the air.
  Shun idle, noonday slumber, nor delay
  The urgent calls of Nature to obey.
  These rules if thou wilt follow to the end,
  Thy life to greater length thou mayst extend.[4]

Evidently it was rather easy to commit such rhymes to memory, and this
accounts for the fact that we have many different versions of the
_Regimen_ and disputed readings of all kinds. These medieval hygienists
believed very much in early rising, cold water, thorough cleansing,
exercise in the open air, yet without sudden cooling afterwards. The lines
on morning hygiene seem worth while giving in Ordonaux's translation.

  At early dawn, when first from bed you rise,
  Wash, in cold water, both your hands and eyes.
  With brush and comb then cleanse your teeth and hair,
  And thus refreshed, your limbs outstretch with care.
  Such things restore the weary, o'ertasked brain;
  And to all parts ensure a wholesome gain.
  Fresh from the bath, get warm. Rest after food,
  Or walk, as seems most suited to your mood.
  But in whate'er engaged, or sport, or feat,
  Cool not too soon the body when in heat.

The Salernitan writers were not believers in noonday sleep, though one
might have expected that the tradition of the _siesta_ in Italy had been
already established. They insist that it makes one feel worse rather than
better to break the day by a sleep at noonday.

  Let noontide sleep be brief, or none at all;
  Else stupor, headache, fever, rheums, will fall
  On him who yields to noontide's drowsy call.

They believed in light suppers--

  Great suppers will the stomach's peace impair;
  Wouldst lightly rest, curtail thine evening fare.

With regard to the interval between meals, the Salernitan rule was, wait
until your stomach is surely empty:

  Eat not again till thou dost certain feel
  Thy stomach freed of all its previous meal.
  This mayst thou know from hunger's teasing call,
  Or mouth that waters--surest sign of all.

Pure air and sunlight were favourite tonics at Salerno--

  Let air you breathe be sunny, clear, and light,
  Free from disease or cess-pool's fetted blight.

Taking "a hair of the dog that bit you" was, however, a maxim with
Salernitans for the cure of potation headaches.

  Art sick from vinous surfeiting at night?
  Repeat the dose at morn, 'twill set thee right.

The tradition with regard to the difficulty of the digestion of pork,
which we are trying to combat in the modern time, had already been
established at Salerno. The digestibility of pork could, however, be
improved by good wine.

  Inferior far to lamb is flesh of swine,
  Unqualified by gen'rous draughts of wine;
  But add the wine, and lo! you'll quickly find
  In them both food and medicine combined.

Milk for consumptives was a favourite recommendation. The tradition had
come down from very old times, and Galen insisted that fresh air and milk
and eggs was the best possible treatment for consumption. The Salernitan
physicians recommended various kinds of milk, goat's, camel's, ass's, and
sheep's milk as well as cow's. It is probable, as I pointed out in my
"Psychotherapy," that the mental influence of taking some one of the
unusual forms of milk did a good deal to produce a favourable reaction in
consumptives, who are so prone to be affected favourably by unusual
remedies. The _Regimen_ warned, however, that milk will not be good if it
produces headache or if there is fever. Apparently some patients had been
seen with the idiosyncrasy for milk, and the tendency to constipation and
disturbance after it which have been noted also in the modern time.

  Goat's milk and camel's, as by all is known,
  Relieve poor mortals in consumption thrown;
  While ass's milk is deemed far more nutritious,
  And e'en beyond all cow's or sheep's, officious.
  But should a fever in the system riot,
  Or headache, let the patient shun this diet.

Salerno's common sense with regard to diet is very well illustrated by a
number of maxims. Diet tinkering was not much in favour.

  We hold that men on no account should vary
  Their daily diet until necessary:
  For, as Hippocrates doth truly show,
  Diseases sad from all such changes flow.
  A stated diet, as it is well known,
  Of physic is the strongest cornerstone--
  By means of which, if you can nought impart,
  Relief or cure, vain is your Healing Art.

They believed firmly that many of the conditions of eating were quite as
important as the diet itself, and said:

  Doctors should thus their patients' food revise--
  _What_ is it? _When_ the meal? And what its _size_?
  How _often_? _Where?_ lest, by some sad mistake,
  Ill-sorted things should meet and trouble make.

They recommended the various simples, mallow, mint, sage, rue, the violet
for headache and catarrh, the nettle, mustard, hyssop, elecampane,
pennyroyal, cresses, celandine, saffron, leeks--a sovereign remedy for
sterility--pepper, fennel, vervaine, henbane, and others. There were
certain special affections, as hoarseness, catarrh, headaches, fistula,
for which specific directions for cure were given. Here for instance are
the directions to be given a patient suffering from rheum or catarrh. The
verses conveyed interesting information with nice long names for the
various affections, as well as the directions for its management.

  Fast well and watch. Eat hot your daily fare,
  Work some, and breathe a warm and humid air;
  Of drink be spare; your breath at time suspend;
  These things observe if you your cold would end.
  A cold whose ill-effects extend as far
  As in the chest, is known as a catarrh;
  Bronchitis, if into the throat it flows;
  Coryza, if it reach alone the nose.

The _Regimen_ conveyed a deal of information in compact form. It gives the
number of bones in the body as 219 with 32 teeth, and the number of veins
as 365, this number being chosen doubtless because of some supposed
relation to the number of days in the year. It contains also a good brief
account of the four humours in the human body--black bile, blood, phlegm,
and yellow bile; and of the four temperaments--the sanguine, the bilious,
the phlegmatic, and the melancholy. These four temperaments were
discussed at considerable length by all the psychologists and most of the
writers on religious life for centuries afterwards, largely on the basis
of the information conveyed by the Salernitan handbook. There are
descriptions of the symptoms of plethora or excess of blood, of excess of
bile, of excess of phlegm, and excess of black bile. The little volume
finally contains discussions as to bleeding, its indications,
contraindications, as in youth--"Ere seventeen years we scarce need
drawing blood"--and in old age; and then of the mode of practising it, and
the place whence the blood should be drawn to relieve different
symptoms.[5]

Salerno impressed itself much more deeply on surgery than on medicine, for
the magnificent development of medieval surgery, the knowledge of which
has proved so surprising in our day, began down at Salerno. Some of the
details of this phase of Salernitan accomplishment are given in the
chapter on Medieval Surgeons of Italy. Roger and Roland and the Four
Masters were great original founders in a phase of medical science that
proved extremely important for the next three or four centuries.
Undoubtedly the presence of a hospital at Salerno, where there were
gathered a number of the chronic cases from all over Europe, most of them
of the better-to-do classes looking for ease from their ills, gave the
incentive to this development. When the natural means of cure, tried for a
considerable time, failed, recourse was had to surgery for relief, and
often with excellent results. This chapter on Salerno's history shows how
thoroughgoing was the effort of the members of the faculty of the medical
school to develop every possible means of aid for their patients, even
when that required pioneer work.

Pagel's appreciation of Salerno's place in the history of medicine, in his
chapter on Medicine in the Middle Ages in Puschmann's "Handbuch Der
Geschichte der Medicin," Berlin, 1902, gives in very brief space a summary
of what was accomplished at Salerno that emphasizes what has been said
here, and his authority will confirm those who might possibly continue to
doubt of any institution of the Middle Ages having achieved so much. 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, easy-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 literary standpoint, as well as
from practical applications, came from ardent devotees."

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." It illustrates very well the
practical nature of the teaching of Salerno, and gives a rather vivid
picture of the medical customs of the time. The instruction as to the
conduct of the physician when he first comes into the house and is brought
to the 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
    demeanour 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 neighbourhood, 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 of 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 rest of the advice smacks rather more of sophistication than we care
to think of in a professional man, but its display of a profound knowledge
of human nature makes it interesting.

    "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."

Salerno taught as well as it could the science of medicine, and initiated
great advances in surgery; but it also emphasized the art of medicine,
and recognized very clearly that the personality of the physician counted
for a great deal, and that his influence upon his patients must be
fostered quite as sedulously as his knowledge of the resources of medicine
for their ills.




CHAPTER IV

MONTPELLIER AND MEDICAL EDUCATION IN THE WEST


After Salerno the next great medical school was that of Montpellier in the
South of France. The conditions which brought about its original
establishment are very like those which occasioned the foundation of
Salerno. Montpellier, situated not far from the Mediterranean, came to be
a health resort. Patients flocked to it from many countries of the West of
Europe; physicians settled there because patients were numerous, and
medical instruction came to be offered to students. Fame came to the
school. The fundamental reason for this striking development of the
intellectual life seems to have been that Montpellier was not far from
Marseilles, which had been a Greek colony originally and continued to be
under Greek influence for many centuries. As a consequence of this the
artistic and intellectual life of the southern part of France was higher
during the earlier Middle Ages than that of any other part of Europe,
except certain portions of South Italy. The remains of the magnificent
architecture of the Roman period are well known, and Provence has always
been famous for its intellectual and literary life. Among a people who
were in this environment, we might well look for an early renaissance of
education.

It is not surprising, then, that one of the earliest of the medical
schools of modern history around which there gradually developed a
university should have come into existence in this part of the world. What
is even more interesting perhaps for us, is that this medical school has
persisted down to our own day, and has always been, for nearly ten
centuries now, a centre of excellent medical education.

There gathered around the story of its origin such legends as were noted
with regard to the history of Salerno, and there is no doubt that Jewish
and Moorish physicians who became professors there contributed not a
little to the prestige of the school and the reputation that it acquired
throughout Europe. The attempt to attribute all of the stimulus for the
intellectual life at Montpellier to these foreign elements is, however,
simply due to that paradoxical state of mind which has so often tried to
minimize the value of Christian contributions to science and the
intellectual life, even by the exaggeration of the significance of what
came from foreign and un-Christian sources. Proper recognition must be
accorded to both Jewish and Moorish factors at Montpellier, but the one
important element is that these foreign professors brought with them, even
though always in rather far-fetched translations, the ideas of the great
Greek masters of medicine to which the region and the people around
Montpellier were particularly sensitive, because of the Greek elements in
the population, and hence the development of a significant centre of
education here.

The date of the rise of the medical school at Montpellier is, as suggested
by Puschmann, veiled in the obscurity of tradition. There seems to be no
doubt that it goes back to as early as the tenth century, it was already
famous in the eleventh, and it attracted students from all over Europe
during the twelfth century. When Bishop Adalbert of Mainz came thither in
1137, the school possessed buildings of its own, as we learn from the
words of a contemporary, Bishop Anselm of Havelberg. St. Bernard in a
letter written in 1153 tells that the Archbishop of Lyons, being ill,
repaired to Montpellier to be under the treatment of the physicians there.
Perhaps the most interesting feature of this letter is the fact that the
good Archbishop not only spent what money he had with him on physicians,
but ran into debt.

The two schools, Salerno and Montpellier, came to be mentioned by writers
of the period as representing the twins of medical learning of the time.
John of Salisbury, a writer of the early thirteenth century, declares that
those who wished to devote themselves to medicine at this time went either
to Salerno or Montpellier. Ægidius or Gilles de Corbeil, the well-known
physician, and Hartmann von der Aue, the Meistersinger, both mention
Salerno and Montpellier, usually in association, in their writings, and
make it very clear that in the West at least the two names had come to be
almost invariably connected as representing rival medical schools of about
equal prominence.

The reputation of Montpellier spread in Italy also, however, and we have
the best evidence for this from an incident that took place in Rome at the
beginning of the thirteenth century, which is more fully dwelt on in the
chapter on Medieval Hospitals. Pope Innocent III. wanted to create a model
hospital at Rome, and made inquiries as to who would be best fitted to
organize such an institution. He was told of the work of Guy or Guido of
Montpellier, who was a member of the Order of the Holy Ghost and had made
a great hospital at Montpellier. Accordingly Guy was summoned to Rome, and
the establishment of the Santo Spirito Hospital was entrusted to him. It
was on the model of this that a great many hospitals were founded
throughout the world, for Pope Innocent insisted that every diocese in
Christianity should have a hospital, and Bishops who came on formal visits
to the Holy See were asked to inspect the Santo Spirito for guidance in
their own diocesan hospital establishments. Many of the hospitals
throughout the world came as a result to be hospitals of the Holy Ghost
and this contribution alone of Montpellier to the medical world of the
time was of great significance and must have added much to her prestige.

[Illustration: HOLY GHOST HOSPITAL (LÜBECK)

_From "The Thirteenth: Greatest of Centuries," by J. J. Walsh_]

Montpellier, like Salerno, seems to have attracted students to its medical
school from all over the world. There were undoubtedly many English there,
and probably also Irish and Scotch, though the journey must have been much
longer and more difficult to make than is that from America to Europe at
the present time. Of course there came many from Spain and from North
France and the Netherlands. The fact that a number of Italians went there
before the close of the Middle Ages shows how deeply interested were the
men of this time in knowledge for its own sake, and indicates that
something of that internationality of culture which we are priding
ourselves on at the present time, because our students from all countries
go far afield for postgraduate work and there is an interchange of
professors, existed at this period. In spite of the fact that books were
only written by hand, the teaching of distinguished professors had a wide
diffusion, and students were quite ready to go through the drudgery of
making these handwritten copies of a favourite master's work. They had
plenty of common sense as well as powers of observation, and some of their
writing is still of great practical value.

A number of men who are famous in the history of medicine made their
medical studies at Montpellier in the twelfth and thirteenth centuries.
Among them are Mondeville, who afterwards taught surgery at Paris; and Guy
de Chauliac, who was a Papal Physician at Avignon and at the same time a
professor at Montpellier, probably spending a certain number of weeks, or
perhaps months, each year in the university town. Sketches of these men,
and of other students and teachers at Montpellier who reached distinction
in surgery, will be found in the chapter on Surgeons of the West of
Europe. Some other distinguished Montpellierians deserve brief mention.

One of the distinguished professors at Montpellier was the well-known
Arnold de Villanova, of whose name there are a number of variants,
including even Rainaldus and Reginaldus. In 1285 he was already a famous
physician, and was sent for to treat Peter III., King of Aragon, who was
severely ill. In 1299 he was summoned on a consultation to the bedside of
King Philip the Handsome (le Bel) at Paris. After this we hear of him in
many places, as at the Court of Pope Benedict XI. at Rome, and in 1308 as
the physician and friend of Pope Clement V. at Avignon. His writings were
printed in a number of editions in the Renaissance time, Venice 1505,
Lyons 1509, 1520, 1532, Basel 1585, and his medical and astronomical and
chemical works in separate volumes at Lyons in 1586.

His aphorisms are well known, and used to be frequently quoted during the
Middle Ages and afterwards, and some of them deserve to be remembered even
at the present time. For instance, he said: "Where the veins and arteries
are notably large, incision and deep cauterization should be avoided."
"When cauterization is to be done the direct cautery should be used;
caustic applications are only suitable for very timid patients." "The lips
of a wound will glue together of themselves if there is no foreign
substance between them, and in this way the natural appearance of the part
will be preserved." "In large wounds sutures should be used, and silk
thread tied at short distances makes the best sutures." "The infection of
the dura mater is followed in most cases by death." "A collection of pus
is best dissolved by incision and cleaning out of the purulent material."
"To put off the opening of an abscess brings many dangers with it." "In
most cases of scrofula external applications are better than the use of
the knife. Scrofulous patients always have other sources of infection
within them, and so it does them no good to operate externally." "Tranquil
and pure air is the best friend for convalescents."

Villanova advised that the bite of a mad dog should not be permitted to
heal at once, but the wound should be enlarged and allowed to bleed
freely, leeches and cups being used to encourage bleeding, and healing
should not be permitted for forty days. He believed very thoroughly in
drainage, and in the dilation of narrow fistulous openings. He describes
anthrax or carbuncle, and has chapters on various painful conditions for
which he employs the terms arthritis, sciatica, chiragra, podagra, and
gonagra.

Villanova's treatment of the subject of hernia shows how thoroughly
conservative he was, and how careful were his observations. In young
persons in recent hernias he advised immediate complete reposition of the
contents of the sac, the bringing together of the hernial opening by means
of adhesive plaster, above which a bandage was placed, and the patient
should be put to bed with the feet and legs elevated and the head
depressed for ten to fifteen days or more if necessary. He says that
"there are some--especially surgeons--who claim that they can cure hernia
by incision, and some others by means of a purse-string ligature, and
still others by the cautery or by some cauterizing material [they
manifestly had our complete catalogue of 'fakes' in the matter]; but I
prefer not to mention these procedures, since I have seen many patients
perish under them, and others brought into serious danger of death, and I
do not think that the surgeon will acquire glory or an increase of his
friends from such perilous procedures, and I do not approve their use."

One of the important writers of Montpellier was Gilbertus Anglicus
(Gilbert the Englishman), who is called in one of the old translations of
Mesue Doctor _Desideratissimus_, which I suppose might be Anglicized
"loveliest of doctors." After his studies in England he went for graduate
work to some of the famous foreign universities, and is named as a
chancellor of Montpellier. His best-known work is his "Compendium
Medicinæ," which bore as its full title "The Compendium of Medicine of
Gilbert the Englishman; useful not only to physicians, but to clergymen
for the treatment of all and every disease." Gurlt says that it contains
little that is original, being a copy of Roger of Parma and Theodoric of
Lucca, with a number of quotations from the Arabs, nearly all of whom
Gilbert seems to have read with considerable attention. It is interesting
to find that Gilbert was definitely of the opinion that cancer is
incurable except by incision or cauterization. He declares that it yields
to no medicine except surgery.

Another of the men whose names are connected with Montpellier was John of
Gaddesden, often called _Joannes Anglicus_. He was a student of Merton
College, and received his degree of doctor of medicine at Oxford. He
studied afterwards at Montpellier and also at Paris, and settled down to
practise in London. He treated the son of King Edward II. for smallpox,
and having wrapped him in red cloth and made all the hangings of his bed
red, so that the patient was completely surrounded by this colour, he
declared that he made "a good cure, and I cured him without any vestiges
of the pocks." The treatment is interesting, as an anticipation in a
certain way of Finsen's red light treatment for smallpox in our own time.
Hanging the room, and especially the doors and the windows, with red when
smallpox was to be treated was a favourite treatment down at Montpellier.
Gaddesden's book is called by the somewhat fanciful name "Rosa Anglica."
Bernard Gordon of Montpellier had written a "Lilium Medicinæ," and we
have a "Flos Medicinæ" from Salerno, so that flower names for medical
textbooks were evidently the fashion of the time.

Gaddesden's book is almost entirely a compilation, and except in the
relation of his surgical experience, contains little that is new. Guy de
Chauliac was quite impatient with it, and declared that "lately there had
arisen a foolish Anglican rose which was sent to me and I looked it over.
I expected to find the odour of sweetness in it, but I found only some old
fables." The criticism is, however, as Gurlt remarks, too severe and not
quite justified, representing rather Guy's high ideal of the originality
that a new textbook should possess, than a legitimate critical opinion. If
our own textbooks were to be judged by any such lofty standard, most of
them would suffer rather severely.

Another of the well-known teachers at Montpellier was Valesco de Taranta.
There are the usual variants of his name, his first name being written
also Balesco, and his last name sometimes Tharanta. He was a Portuguese
who studied in Lisbon, and later in Montpellier, where he taught
afterwards and was considered one of the distinguished professors of his
day, being for a time chancellor. He became so well known that he was
summoned in consultation to the French King Charles VI., and there is some
doubt as to whether he did not become his regular physician. One of his
works, the "Philonium Pharmaceuticum et Chirurgicum de medendis omnibus,
cum internis tum externis, humani corporis affectionibus," had the honour
of being printed at Lyons in two editions in 1490, and one at Venice the
same year, at Lyons 1500, Venice 1502, Lyons 1516, 1521, 1532, 1535,
Venice 1589, and Lyons 1599. It has also been reprinted subsequently in a
number of editions, so that it must have been a much-read book. Valesco
had two favourite authors, Galen and Guy de Chauliac. The fact that he
should have appreciated two such great men so thoroughly is of itself the
best evidence of his own ability and critical judgment. His book, from the
number of printed editions, must have been in the hands of practically all
the progressive physicians of the southern part of France, at least during
the fifteenth, sixteenth, and part of the seventeenth centuries.

A very well-known teacher of Montpellier, who has had a reputation in
English-speaking countries because his name was supposed to indicate that
he was a Scotchman, was Bernard Gordon or de Gordon, whose name is,
however, also written Gourdon. He was a teacher at Montpellier at the end
of the thirteenth and the beginning of the fourteenth century. His
textbook of medicine, in accordance with the custom of the time, is
called by the flowery title "Lilium Medicinæ," the Lily of Medicine.
While much of his information was derived from the Arabs, some of his
teaching was an advance on theirs, and he described the acute fevers,
leprosy, scabies, anthrax, as well as erysipelas, and still more strangely
phthisis, as contagious. Dr. Garrison has called attention in his "History
of Medicine" to the fact that the book is notable as containing the first
description of a modern truss, and a very early mention of spectacles
under the Latin name _oculus berellinus_. In recent years it has come to
be the custom to think of Gordon or Gourdon as probably not of Scotch but
of French origin--that is, born somewhere in the confines of what we now
call France. There are a number of French places of the name of Gourdon
from any of which he might have come.

Montpellier represented for the West of Europe then very nearly what
Salerno did for Italy and Eastern Europe. It very probably attracted many
of the English and Scotch students of medicine, though not all the names
supposed to be of British origin have proved to be so with the development
of our knowledge. Montpellier has survived, however, while Salerno
disappeared as a force in medical education. Its story would well deserve
telling in detail, and doubtless the new national spirit of the French
after the war will prove an incentive to the writing of it.




CHAPTER V

LATER MEDIEVAL MEDICINE


Medicine in the later Middle Ages, that is, from the tenth to the middle
of the fifteenth centuries, was greatly influenced by the medical schools
which arose in Italy and the West of Europe during this period. These were
organized mainly in connection with universities, Salerno, Montpellier,
Bologna, Paris, Padua, in the order of their foundations, so far as they
can be ascertained. These university medical schools represented serious
scientific teaching in medicine, and certainly were not more prone to
accept absurdities of therapeutics and other phases of supposed medical
knowledge than have been the universities of any other corresponding
period of time. Five centuries represent a very long interval in the
history of humanity, and provide opportunities for a great many curious
developments and ups and downs of interest, all of which must not be
considered as representing any particular generation or even century in
the history of that time. The absurdities came and went quite as in more
modern times; but all the while there was an undercurrent of solid medical
knowledge, founded on observation and definite clinical research,
superadded to the information obtained from the classics of medicine.

Even as early as the tenth century the thoroughly conservative teaching of
Salerno in medicine made itself felt, and above all counteracted the
Oriental tendencies to over-refinement of drugging, which had led to the
so-called calendar prescription. This was the most noteworthy element in
the medical practice of the later Middle Ages, but its significance has
been dwelt on in the chapter on Salerno and the Beginnings of Medical
History. While Arabic polypharmacy is the most striking feature of
Mohammedan influence on medicine at this time, there were a number of
Arabian and Jewish physicians who made a deep impression on the medicine
of the later Middle Ages--that is, subsequent to the tenth century. Their
work was felt not only in their own time, but for many subsequent
centuries even down to and beyond the Renaissance, and they therefore must
find a place in medieval medical history. This influence was exerted ever
so much more outside of Italy than in the Italian peninsula, where the
tradition of their contact with the original Greek authors still remained,
and where they were making medicine and surgery for themselves quite
apart from Arabian influence.

The more one knows about the conditions in Italian medicine the less
question is there of Arabian contributions to it. De Renzi in his History
of Italian Medicine makes it very clear that the Arabs exercised no
significant influence either at Salerno or elsewhere. The Benedictines and
Cassiodorus afford evidence of the study of the Greek medical classics in
Latin translations. Muratori cites a manuscript which he had consulted in
the Medicean Library at Florence, and which, though written between the
eighth and ninth centuries, says not a word of the Arabs and bears the
title of "Abstracts from Hippocrates, Galen, Oribasius, Heliodorus,
Asclepiades, Archigenes, Dioclis, Amyntas, Apollonius, Nymphiodorus,
Ruffius, Ephesinus, Soranus, Ægineta, and Palladius." These and not the
Arabs were the masters of the Italians, and it was fortunate, for the
world was thus saved many Arabian mistakes and their tendency to neglect
surgery. Before Salerno began to exert its real influence, some of the
Arabian physicians came to occupy places of prominence in the medicine of
the time.

The most important of these was Avicenna, born toward the end of the tenth
century in the Persian province of Chorasan, at the height of Arabian
influence. He is sometimes spoken of as the Arabian Galen. His famous
book, "The Canon," was the most consulted medical book throughout Europe
for centuries. There are very few subjects in medicine that did not
receive suggestive treatment at his hands. He has definite information
with regard to Bubonic plague and the _filaria medinensis_. He has special
chapters with regard to obesity, emaciation, and general constitutional
conditions. He has chapters on cosmetics and on affections of the hair and
nails that are interesting reading. The Renaissance scholars wrote many
commentaries on his work, and for long after the introduction of printing
his influence was felt widely.

His Arabic colleague in the West was Avenzoar, to call him by the
transformation of his Arabic family name, Ibn-Zohr. He was born near
Seville, and probably died there, in 1162, well past ninety years of age.
He was the teacher of Averröes, who always speaks of him with great
respect. He is interesting as probably the first to suggest nutrition per
rectum. His apparatus for the purpose consisted of the bladder of a goat
with a silver cannula fastened into its neck. Having first carefully
washed out the rectum with cleansing and purifying clysters, he injected
the nutriment--eggs, milk, and gruel--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.

The bladders of animals were very commonly used by these Moorish
physicians and by their disciples, and the profession generally, for
generations, for a great many purposes for which we now use rubber bags.
Abulcasis, for instance, used a sheep's bladder introduced into the vagina
and filled with air as a colpeurynter for supporting the organs in the
neighbourhood, and also in fractures of the pubic arch.

Avenzoar suggested feeding _per rectum_ in cases of stricture of the
oesophagus, but he also treated the oesophageal stricture directly. He
inserted a cannula of silver through the mouth until its head met an
obstruction. This was pushed firmly, but withdrawn whenever there was a
vomiting movement, until it became engaged in the stricture. Through it
then _freshly milked_ milk, or gruel made from farina or barley, was to be
poured. He had evidently seen cases improve this way, and therefore must
have had experience with functional stricture of the oesophagus. He adds
that some physicians believe that nutrition may be absorbed through the
pores of the whole body, and that therefore in these cases the patient
might be put in a warm milk or gruel bath; but he has not very much faith
in the procedure, and says that the reasons urged for it are weak and
rather frivolous. It is easy to understand that a man who could recommend
manipulative modes of treatment of such kinds, and discuss questions of
nutrition so sensibly, knew his medicine very practically and wrote of it
judiciously.

Maimonides (1135-1204) was one of these wise old Jews who quotes with
approval from a Rabbi of old who had counselled his students: "Teach thy
tongue to say, I do not know." Knowing thus the limitations of his own
knowledge, it is not surprising that Maimonides should have left a series
of practical observations for the maintenance of health which represent
the common sense of all time in the matter. Maimonides anticipated the
modern rule for taking fruits before meals, as we all do now at breakfast,
and so often as fruit cocktails at the beginning of other meals. He
thought that grapes, figs, melons, should be taken before meals, and not
mixed with other food. He set down as a rule that what was easily
digestible should be eaten at the beginning of the meal, to be followed by
what was more difficult of digestion. He declared it to be an axiom of
medicine "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."

Salerno's influence was felt much more deeply on surgery than on medicine,
as can be seen very clearly from the chapter on Medieval Surgeons--Italy.
These great surgeons of the period were also the leaders in medicine--for
almost needless to say, there was no separation between the two modes of
practice--men were as a rule both physicians and surgeons, even though for
us their most important work by far was done in surgery. Certain passages
from the works of these great surgeons that have come down to us deserve a
place in the treatment of the more distinctly medical questions of the
time.

Lanfranc the great French surgeon's description of the treatment of the
bite of a rabid dog is interesting. He suggests that 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 manifestly 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 animals supposed to be
poisonous, or at least suspicious, followed the principles laid down for
handling the bite of a mad dog. This was the case particularly as to the
encouragement of free bleeding and the use of the cautery.

A characteristic example of the power of clinical observation of the
medieval physicians, and one which illustrates much better than many of
the absurd tales told as typical of their superstitious tendencies, but
really representing that tendency always present in mankind to believe
wonders, is to be found in how much they learned of rabies. Even in our
own time there are many absurd beliefs with regard to this disease, with
some denials of its existence and many grossly exaggerated tales, widely
believed; yet the medieval people seem to have reached some quite rational
notions with regard to it. Bartholomæus Anglicus is the author of a
popular encyclopedia which was very widely read in the medieval period. He
was an English Franciscan of the thirteenth century, who gathered together
a lot of information and wrote a volume that for centuries after his
time, even down to Shakespeare's boyhood, was popular in England.

Here is his description of rabies as he knew it. The most important
element is his recognition of the uncertainty of the length of the
incubation period, but it contains two other ideas that are very
interesting, because medicine in subsequent centuries has come back to
them over and over again. One is that free bleeding may remove the virus,
and the other that the cautery may help in preventing the infection.

    "The biting of a wood-hound is deadly and venomous, and such venom is
    perilous. For it is long hidden and unknown, and increaseth and
    multiplieth itself, and is sometimes unknown to the year's end, and
    then the same day and hour of the biting it cometh to the head, and
    breedeth frenzy. They that are bitten of a wood-hound have in their
    sleep dreadful sights, and are fearful, astonished, and wroth without
    cause. And they dread to be seen of other men, and bark as hounds, and
    they dread water most of all things, and are afeared thereof, full
    sore and squeamous also. Against the biting of a wood-hound wise men
    and ready use to make the wounds bleed with fire or with iron, that
    the venom may come out with the blood that cometh out of the wound."

A very interesting development of therapeutics in the Middle Ages was the
employment of the red light treatment to shorten the course and the
severity of the fever in smallpox, and above all to prevent pitting; it
was employed successfully by John of Gaddesden in the case of the son of
King Edward II. Recent investigation by Cholmeley has shown that both
Gilbertus Anglicus (1290) and Bernard de Gordon (1305) antedated John of
Gaddesden in references to the red light treatment. All of these men were
professors at Montpellier, showing that the medical school of the South of
France was a rival in the use of natural methods of cure to its
better-known predecessor of Southern Italy. Curiously enough, the "Rosa
Anglica" of Gaddesden, in which the reference to the red light is made, is
deservedly characterized by Garrison as "a farrago of Arabist quackeries
and countrified superstitions"; it well deserves Guy de Chauliac's bitter
criticism of it as "a scentless rose."

The idea included under the word autointoxication in our time--that is,
that the human body has a tendency to produce poisons within itself, which
act deleteriously on it and must be eliminated--was a favourite one during
the Middle Ages. It became the custom in our time to have recourse to
antiseptics or to surgical measures of various kinds for the relief and
prevention of autointoxication. In the Middle Ages they thought to reduce
its harmfulness at least by direct elimination, hence the use of drastic
purgatives. It seems worth while remarking, however, that the employment
of these did not come into general use until the close of the Middle Ages.
Basil Valentine, if he really lived in the Middle Ages, and is not merely
a name for a writer of the early sixteenth century, as modern historians
seem inclined to think, suggested the use of antimony for the removal of
the materies morbi from the body that has so much obsessed physicians for
many generations. Antimony continued to be used down to the nineteenth
century. It was gradually replaced by venesection, which was employed very
strenuously during the eighteenth and early nineteenth centuries, in spite
of the objection of such men as Morgagni, who refused to allow this mode
of treatment to be used on him.

Venesection was succeeded by large doses of calomel, and the calomel era
continued on almost to our own generation.

As a rule, however, the medieval physicians trusted nature much more than
did their colleagues of modern history--that is, after the Renaissance
until the present epoch of medical science began. It has always been
difficult, however, for physicians to continue long in the persuasion that
nature is a helpful auxiliary, and not a hampering factor to be combated.
It is all the more to the credit of the medieval physicians to find,
then, that in spite of many absurdities they continued for all the later
centuries of the Middle Ages to extol the value of the natural means of
cure.

I shall have much to say of John of Ardern in the chapter on Medieval
Surgeons of the West of Europe, but he deserves a place also in the
chapter on Medicine. Ardern's advice to patients suffering from renal
disease, which is contained in a separate tract of his lesser writings
with the title in an old English version of "The Governaunce of
Nefretykes," is extremely interesting, because it shows very clearly how
long ago thoughtful physicians anticipated most of the directions that we
now give such patients. Though we are inclined to think that any real
knowledge of renal disease is quite modern, and above all has come since
Bright's time, this paragraph of Ardern's shows how long before definite
pathological knowledge had developed, careful clinical observation worked
out empirically the indications of the affection. The paragraph is of
special interest, because it contains the first reference to the possible
danger that there may be for sufferers from kidney disease using the dark
or red meats rather than the white meats. The tradition as to the
distinction between the red and white meats has continued ever since his
time, and though our modern chemistry does not enable us to find any such
distinction between these substances as would justify the differentiation
thus dwelt on, it has been maintained for no other reason that I have ever
been able to find than because of the long years of tradition and clinical
observation behind it.[6]

    "Nefretykes must putte awey ire, hyghly and moche besynesse and
    almanere [business and all manner of] thynge that longeth to the soule
    saff [save] only joye.... They schulle forbere almanere metys that ben
    to grete of substaunse and viscous, as olde beeff that is myghtyly
    pooudryd and enharded with salt and also fressch porke but yf it lye
    in salt iiii dayes afore.... They mowe use grete wyne and the fflessch
    of calvys that ben soowkynge and also of all ffowlys saff thoo that
    ben of the lakys and dichys [dykes?] ... and squamous ffyssches, i.e.,
    fyssch of the rivere, of the stony waterys and rennynge ryveres and
    not of the standyne waterys and they schulle eschywe [eschew] almaner
    mete made of paast [pastries] and all bred that is dowgh bakene and
    all fatnesse. And they schulle use the reynes of te beeste other roste
    or sode. And in especiall he schall use a ffowl that is callyd Cauda
    tremula or Wagstertte [the wagtail, an English bird] other fressch or
    salte or bakene withoute drynesse ffor and it be drye it is nought
    woorth. And note that the use of the powdir or of the flessch of the
    Wagstertte avayleth gretly to breke the stone in the bladdere."[7]




CHAPTER VI

MEDIEVAL SURGEONS: ITALY


Strange as it may seem, and quite contrary to the usual impressions in the
matter, the most interesting department of the history of the medical
science during the Middle Ages is that of surgery. Because of this fact we
have to divide the subject into two chapters, one for the surgery of
Italy, the other for the surgery of the rest of Europe.

We have two series of medieval textbooks which treat largely of surgical
subjects in a thoroughly scientific and professional way. The first of
these comes to us from the earlier centuries of the Middle Ages, when
Greek classic influence on medicine and the medical sciences was on the
wane; and the other set comes to us from the later Middle Ages, when the
earlier Renaissance of Greek influence was just making itself felt in
Europe. Both sets of books serve to show very well that the men of these
times were not only deeply interested in the affections for which surgery
can provide the only relief possible, but that they had reached very
definite, indeed sometimes ultimate, solutions of a large number of the
constantly recurring problems of surgery.

The greatest surprise of the whole range of medical history is that these
medieval surgeons of both periods anticipated not a few of the surgical
advances that we have been accustomed to think of as having been reserved
for our time to make. Our knowledge of these details of the work of the
medieval surgeons not only of the sixth and seventh centuries, but also of
the thirteenth and fourteenth, is not founded on tradition, nor on a few
scattered expressions which a modern medievalist might exaggerate, but on
actual textbooks, which fortunately for us were reprinted as a rule during
the Renaissance period, and have been preserved for us usually in a number
of rather readily available copies. Most of them have been reprinted
during the past generation, and have revolutionized our knowledge of the
history of surgery; for these textbooks exhibit in detail a deep knowledge
of surgical affections, a well-developed differential diagnosis, a
thoroughly conservative treatment, and yet a distinct effort to give the
patient every possible surgical opportunity for his life, compatible with
reasonable assurance of successful surgical intervention. As I have
pointed out, the surgical history of the old Crusades was as interesting
and almost as valuable for civil surgery as that of our own Great War.[8]

Three writers whom we have already mentioned (Early Medieval
Medicine)--Aëtius, Alexander of Tralles, and Paul of Ægina--were, as we
have seen, all of them interested in surgery, and wrote very interestingly
on that subject. It is, however, from the end of the Middle Ages--that is,
from the writers of the twelfth century down to the end of the
fifteenth--that surprising contributions were made to surgical knowledge.
This surgery of the end of the Middle Ages began its development at
Salerno. The first great textbook was that of Roger--known also as Rogero
and Ruggiero, with the adjective Parmensis or Salernitanus, of Parma or
Salerno--who wrote his work about 1180. It is of this that Gurlt, in his
"History of Surgery," vol. i., p. 701, says: "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." He insisted,
further, that Arabisms are not found in Roger's writings, while many
Græcisms occur. The Salernitan School of Surgery drank, then, at the
fountain-head of Greek surgery.

After Roger comes Rolando, his pupil, who wrote a commentary on his
master's work, and then the combined work of both of them was subsequently
annotated by the Four Masters. It is this textbook, the work of many hands
and the combined experience of many great teachers, that is the foundation
stone of modern surgery. Some of the expressions in this volume will serve
to give the best idea of how thoroughly these surgeons of the later
medieval period studied their cases, how careful they were in observation,
and how well they solved many problems that we are inclined to think of as
having come up for serious consideration only much later than this time.
After studying their chapter on Injuries of the Head, it is easy to
understand why Gurlt should declare that, though there is some doubt about
the names of the authors, this volume makes it very clear that these
writers drew their opinions from a rich experience.

They warn about the possibility of fracture of the skull even when there
is no penetrating wound of the scalp, and they even suggest the
advisability of exploratory incision when there is some good reason for
suspicion of, though no evident sign of, fracture. In "Old-Time Makers of
Medicine," I quoted some of the details of this teaching as to head
surgery that may serve to illustrate what these surgeons taught on this
important subject.

There are many warnings 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 observation 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." 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 pia. Care should especially be exercised at the brow, and the rear
of the head, and at the commissures (_proram et pupim et commissuras_),
since at these points the dura mater is likely to be adherent. Perhaps the
most striking expression, the word "infect" being italicized by Gurlt, is:
"In elevating the cranium, be solicitous lest you should _infect_ or
injure the dura mater."

While these old-time surgeons insisted on the necessity for treating all
depressed fractures, and even suggested that many fissure fractures
required trephining, they deprecated meddlesome surgery of the cranium,
unless there was evident necessity, quite as much as we do now. Surgeons
who in every serious wound of the head have recourse to the trephine must,
they said, be looked upon as fools and idiots (_idioti et stolidi_). When
operations were done on the head, cold particularly was to be avoided. The
operations were not to be done in cold weather, and above all not in cold
places. The air of the operating-room must be warmed artificially. Hot
plates should surround the patient's head while the operation was being
performed. If this were not possible they were to be done by candlelight,
the candle being held as close as possible in a warm room. They had many
experiences with fractures at the base of the skull. Hæmorrhages from the
mouth and nose and from the ears were considered a bad sign. They even
suggested, for diagnostic purposes, what seems to us the rather dangerous
procedure that the patient should hold his mouth and nostrils tight shut
and blow strongly. One of their methods of negative diagnosis for
fractures of the skull was that, if the patient were able to bring his
teeth together strongly, or to crack a nut without pain, then there was no
fracture present. One of the commentators, however, adds to this, as well
he might, _sed hoc aliquando fallit_--"but this sign sometimes fails."
Split or crack fractures were also diagnosticated by the methods suggested
by Hippocrates of pouring some coloured fluid over the skull after the
bone was exposed, when a linear fracture would show by coloration. The
Four Masters suggest a sort of red ink for this purpose.

One might well expect that, with trephining as frequent as this textbook
of the Four Masters more than hints, the death-rate of these medieval
surgeons must have been very high in head cases. We can scarcely
understand such intervention in the conditions of operation assumed to
exist in the Middle Ages without almost inevitable infection and
consequent death. They seem to have come to an empiric recognition of the
advantage of absolute cleanliness in such operations. Indeed, in the light
of our modern asepsis and its development during our own generation, it is
rather startling to note the anticipation of what is most recent in the
directions that are given to a surgeon to be observed on the day when he
is to do a trephining. I give it in the original Latin as it may be found
in Gurlt (vol. i., p. 707): "_Et nota quod die illa cavendum est medico a
coitu et malis cibis æra corrumpentibus, ut sunt allia, cepe, et
hujusmodi, et colloquio mulieris menstruosæ, et manus ejus debent esse
mundæ_, etc." The directions are most interesting. The surgeon's hands
must be clean; he must avoid coitus and the taking of food that may
corrupt the air, such as onions, leeks, and the like; must avoid
menstruating women; and in general must keep himself in a state of
absolute cleanliness.

After the South Italian surgeons, some of whom taught at Bologna, a group
of North Italian surgeons, most of whom probably were either direct or
indirect pupils of the Salernitan School, must be considered. This
includes such distinguished names in the history of surgery as Bruno da
Longoburgo, usually called simply Bruno; Theodoric and his father Hugh of
Lucca; William of Salicet; Lanfranc, the disciple of William who taught at
Paris, and gave that primacy to French surgery which was maintained all
the centuries down to the nineteenth (p. 1); and Mondino, the author of
the first manual on dissection, which continued for two centuries to be
used by practically everyone who anywhere did dissection throughout
Europe. Practically all of these men did their best work between 1250 and
1300. Bruno of Longoburgo taught at Padua and Vicenza, and his textbook,
the "Chirurgia Magna," was completed in Padua in January, 1252. Gurlt
notes that "He is the first of the Italian surgeons who besides the Greeks
quotes also the Arabian writers on surgery." Eclecticism had definitely
come into vogue to replace exclusive devotion to the Greek authors, and
men were taking what was good wherever they found it.

Bruno begins his work by a definition of surgery, _chirurgia_, tracing it
to the Greek and emphasizing that it means handwork. He then declares that
it is the last instrument of medicine to be used, only when the other two
instruments, diet and potions, have failed. He insists that surgeons must
learn by seeing surgical operations, and watching them long and
diligently. They must be neither rash nor over-bold, and should be
extremely cautious about operating. While he says that he does not object
to a surgeon taking a glass of wine, the followers of this specialty must
not drink to such an extent as to disturb their command over themselves,
and they must not be habitual drinkers. While all that is necessary for
their art cannot be learned out of books, they must not despise books,
however, for many things can be learned readily from books, even about the
most difficult parts of surgery. Three things the surgeon has to do--"to
bring together separated parts, to separate those that have become
abnormally united, and to extirpate what is superfluous."

While the old textbooks had emphasized the necessity for not allowing the
circulation in the head to be disturbed by the cold, and insisted on the
taking of special precautions in this matter, Bruno insists that wounds
must be more carefully looked to in summer than in winter, because
"putrefaction is greater in warm than in cold weather"--_putrefactio est
major in æstate quam in hyeme_. He is particularly insistent on the
necessity of drainage. In wounds of the extremities the limb must always
be so placed as to encourage drainage. To secure it the wound may be
enlarged; if necessary, even a counter-opening must be made to provide
drainage. In order to secure 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 the preferable suture material in his experience is
silk or linen. He discusses healing by first and second intention, and
declares that with proper care the healing of a great many wounds by first
intention can be secured. All his treatment of wounds is dry. Water he
considered always did harm, and it is quite easy to understand that his
experience taught him this, for the water generally available for surgeons
in camps and battlefields and in emergency surgery was likely to do much
more harm than good.

Some of the details of his technique of abdominal wounds will be
particularly interesting to modern surgeons.

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 development 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.

The most interesting feature of the work of the North Italian surgeons of
the later Middle Ages is their discovery and development of the two
special advances of our modern surgery in which we are inclined to take
most pride. These are, union by first intention, and anæsthesia. It is of
course very startling to think that surgeons of seven centuries ago should
have made advances in these important phases of surgery--which were
afterwards to be forgotten; but human history is not a story of constant
progress, but of ups and downs, and the mystery of human history is the
decadence that almost inevitably follows any period of supremely great
accomplishment by mankind. The later Middle Age enjoyed a particularly
great period of efflorescence and achievement in surgery, and this, quite
as with literature and other phases of human accomplishment, was followed
by distinct descent of interest in surgical theory, and decadence in
surgical practice, until the Renaissance came to provide another climax
of surgical development. It would be perilous to say, however, that the
acme of the curve of Renaissance surgical progress was higher than its
predecessor, though once more there is the surprise to find that this high
point was followed by another descent, until the curve ascended again in
our time.

What we have said already with regard to the requirement of cleanliness in
operating upon the skull, insisted upon by the Salernitan School, will
suggest that some of the practical value of asepsis had come home to these
old-time surgeons. The North Italian surgeons went, however, much farther
in their anticipations of asepsis. They insisted that if a surgeon made a
wound through an unbroken surface and did not secure union by first
intention, it was usually his own fault.

It is to them we owe the expression "union by first intention"--_unio per
primam intentionem_--which means nothing to us except through its Latin
equivalent. They boasted of getting linear cicatrices which could scarcely
be seen, and evidently their practice fostered the best of surgical
technique and was founded on excellent principles. The North Italian
surgeons replaced the use of ointments by wine, and evidently realized its
cleansing--that is, antiseptic--quality. What is often not realized is,
that the very old traditional treatment of wounds by the pouring of wine
and oil into them represented a mild antiseptic and a soothing protective
dressing. The wine inhibited the growth of ordinary germs, the oil
protected the wound from dust and dirt. They were not ideal materials for
the purpose, but they were much better when discreetly used than many
surgical dressings of much more modern times founded on elaborate
theories.

Professor Clifford Allbutt, reviewing the practice of these North Italian
surgeons of the thirteenth century, says:[9]

    "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. Powder they regarded as
    too desiccating, for powder shuts in decomposing matters; wine, after
    washing, purifying, and drying the raw surfaces, evaporates."

Theodoric wrote in 1266 on that question that so much disturbed the
surgeons of the generations before ours, as to whether pus was a natural
development in the healing of wounds or not. While laudable pus was for
centuries after his time supposedly a scientific doctrine, Theodoric did
not think so, and emphatically insisted that such teaching represented a
great error. He said: "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." The italics in the word modern are mine, but the whole expression
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 his father had obtained without the use of any
ointment--_pulcherrimas cicatrices sine unguento inducebat_--then,
further, that he impugned the use of poultices and of oils in wounds,
while powders were too drying, and besides had a tendency to prevent
drainage (the literal meaning of the Latin words he employs, _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.

After Bruno, who brought with him the methods and principles of surgery
from the South of Italy, his contemporary of the North, Hugh of Lucca--Ugo
da Lucca, or Luccanus, as he is also called--deserves to be mentioned. He
was called to Bologna in 1214 as City Physician, and was with the regiment
of crusaders from Bologna at Damietta in 1220. He returned to Bologna in
1221 and occupied the post of legal physician. The Civic Statutes of
Bologna are, according to Gurlt, the oldest monument of legal medicine in
the Middle Ages. Hugh seems to have been deeply intent on chemical
experiments, and especially anodyne and anæsthetic drugs. He is said to
have been the first to have taught the sublimation of arsenic. Like many
another distinguished practitioner of medicine and surgery, he left no
writings. All that we know of him and his work, and above all his
technique, we owe to the filial devotion of his son Theodoric.

Anæsthesia is perhaps an even greater surprise in the Middle Ages than
practical antisepsis. A great many of these surgeons of the time seem to
have experimented with substances that might produce anæsthesia.
Mandragora was the base of most of these anæsthetics, though a combination
with opium seems to have been a favourite. They succeeded apparently, even
with such crude means, in producing insensibility to pain without very
serious dangers. One of these methods of Da Lucca was by inhalation, and
seems to have been in use for a full century. Guy de Chauliac describes
the method as it was used in his day, and a paragraph with regard to it
will be found in the chapter on Surgeons of the West of Europe. It is
quite clear that the extensive operations which are described in their
textbooks of surgery at this time could not possibly have been performed,
only that the surgeons were able to secure rather a deep and prolonged
insensibility to pain. With anæsthesia combined with antisepsis, it is
easy to understand how well equipped the surgeons of this time were for
the development of their speciality.

The fourth of these great surgeons at the North of Italy was William of
Salicet. He was a pupil of Bruno of Longoburgo. Some idea of his practice
as a surgeon may be obtained from even the first chapter of his first
book. 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 incision because of the danger of it. He had successfully
treated some of these difficult cases, however, by puncturing the scalp
and membrane by a cautery, a very small opening being made and fluid being
allowed to escape only drop by drop. William did not quote his
predecessors much, but depended to a great extent on his own experience.
He has many interesting details of technique with regard to the special
subject of surgery of the nose, the ear, the mouth; and he did not even
hesitate to treat goitre when it grows large, and says that if the sac is
allowed to remain it should be thoroughly rubbed over on the inside with
"green ointment." He warned "that in this affection many large
bloodvessels make their appearance, and they find their way everywhere
through the fleshy mass."

A very interesting development of surgery along a line where it would
probably be least expected was in plastic surgery. In the first half of
the fifteenth century the two Brancas, father and son, performed a series
of successful operations for the restoration of the nose particularly, and
the son invented a series of similar procedures for the restoration of
mutilated lips and ears. The father seems to have built up the nose from
other portions of the face, possibly using, as Gurlt suggests, the skin of
the forehead, as the Indian surgeons had done, though without any known
hint of their work. Fazio, the historian of King Alphonso I. of Naples,
who died in 1457, describes the favourite operation of Antonio Branca, the
son, who in order not to disfigure any further the face in these cases,
made the new nose from the skin of the upper arm; and in anticipation of
Tagliacozzi, who attracted much attention by a similar operation in the
latter half of the sixteenth century, separated the new nose from the arm
sometime during the third week. There is abundance of other evidence as to
the Brancas' work from contemporary writers--for instance, Bishop Peter
Ranzano the annalist, the poet Calenzio, and Alexander Benedetti, the
physician and anatomist--so that there can be no doubt of the fact that
this wonderful invention in surgical technique was actually made before
the close of the Middle Ages.

It is interesting to realize that, while we hear much about the work of
the Brancas, and from ecclesiastical authorities, there is no word of
condemnation of the practice of restoring the nose or other facial
features until much later in history. Tagliacozzi, who revived the
operation of rhinoplasty just about the beginning of the seventeenth
century, did not share so kind a fate. The latter Italian surgeon was
roundly abused by some of his colleagues, even, it is said, by Fallopius
and Paré, and bitterly satirized in Butler's "Hudibras." As late as 1788
(!) the Paris faculty interdicted face-repairing altogether. It is this
sort of intolerance, on some superstitious ground or other, that is
usually attributed to the Middle Ages. For such events the adjective
medieval seems particularly adapted. As a matter of fact, we find
comparatively little trace of such intolerance in medieval times; but it
is comparatively easy to find the bitterest treatment of fellow-mortals
for all sorts of foolish reasons in the seventeenth and eighteenth
centuries.




CHAPTER VII

SURGEONS OUTSIDE OF ITALY: SURGEONS OF THE WEST OF EUROPE

    "Sciences are made by addition, and it is not possible that the same
    man should begin and finish them...." "We are like infants at the neck
    of a giant, for we can see all that the giant sees and something
    more."--(GUY DE CHAULIAC, Papal Physician to the Popes at Avignon.)


The very interesting and in many ways astonishing development of surgery
which occurred in Italy in the twelfth and thirteenth centuries, was
followed up by similar developments in the western countries of Europe.
France was the first to fall into the line of progress with important
advances in surgery, and owes her teaching directly to the Italians; but
in Flanders, in England, in Spain, and in Germany, we have records of some
significant advances in surgery, and distinguished surgeons wrote books
that fortunately for the history of surgery were preserved. The most
important of the surgical writings of the time, put in type during the
great nascent period of printing at the Renaissance, have come down to us.
Many of these have been republished in recent years, and as the texts are
now readily available they enable anyone to see for himself just what were
the interests of the surgeons of the later medieval period, their
technique, and their successful applications of great practical principles
to the solution of important surgical problems.

The beginning of French scientific surgery came with the exile from Italy
of Lanfranc, as he is known, though his Italian name was Lanfranchi or
Lanfranco, and he is sometimes spoken of as Alanfrancus. He had practised
as physician and surgeon in Milan until banished from there by Matteo
Visconti, about 1290. He made his way then to Lyons, where he attracted so
much attention by his success as a surgeon that he was offered the chair
of professor of surgery at the University of Paris. "He attracted an
almost incredible number of scholars to his lessons in Paris, and by
hundreds literally they accompanied him to the bedside of his patient and
attended his operations" (Gurlt). Paris was at this time at the very
height of its glory as a University. It had had a series of distinguished
professors whose writings are still known and honoured, Albert the Great,
Thomas Aquinas, Roger Bacon, and Duns Scotus; and during the latter half
of the thirteenth century Louis IX. had encouraged the University in
every way, and had helped in the foundation of the Sorbonne. There were
probably more students in attendance at the University of Paris about the
time that Lanfranc was there than there has ever been in attendance at any
University before or since. The prestige of Lanfranc's position, then, and
his opportunity to impress the world of his time, can be readily
appreciated.

The Dean of the medical faculty of Paris, Jean de Passavant, urged
Lanfranc to write a textbook of surgery, partly for the familiar academic
reason that the students were clamouring for some definite record of his
teaching, but also because the Dean felt that the many copies of these
lessons which the students would take away with them, and which would be
consulted by others, would add greatly to the prestige of the medical
school. Medical school officials are not so different after more than six
and a half centuries. Lanfranc completed his textbook of surgery, called
"Chirurgia Magna," in 1296, and dedicated it to Philippe le Bel, the then
reigning King of France. It is from this work that we are able to judge
exactly what the value of Lanfranc's surgical teaching was.

In the second chapter of his textbook--the first containing the definition
of surgery and a general introduction--Lanfranc devotes some paragraphs to
the surgeon himself, and the qualities that a surgeon should possess if
he is to be successful in his speciality. It is about the sort of advice
that older surgeons are still likely to give young men who are entering on
the practice of the speciality, and more or less what is said at many a
commencement in the modern time when the maker of the address to the
graduates is a surgeon.

"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 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. (What a desideratum for the modern time is thus
outlined!) 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."

Lanfranc was himself a scholar well read in the literature of his
profession, but who had well digested his reading. He quotes altogether
more than a score of writers on surgery who had preceded him, and
evidently was thoroughly familiar with general surgical literature. He is
a particular favourite of Gurlt, the German historian of surgery, who has
devoted more than twenty-five closely printed large octavo pages to the
discussion of this old Paris professor and his work. Lanfranc's discussion
of wounds of nerves is of itself sufficient to show the character of his
work. Many generations after his time have used the word nerves for
tendons, and mistaken the function of these two structures, but Lanfranc
distinguished very clearly between them. He declared that since the nerves
are instruments of sense and motion, wounds of them should be carefully
treated, especially as the sensitiveness of these structures is likely to
cause the patient much subsequent pain if they are neglected. Longitudinal
wounds of nerves are much less dangerous than those across them. When a
nerve is completely divided in cross section Lanfranc was of the opinion,
though Theodoric and some others were opposed to it, that the nerve ends
should be stitched together. He says that the suture insures the
reintegration of the nerve much better. Besides, after this operation the
restoration of the usefulness of the member is more assured and is
commonly more complete.

After Lanfranc at Paris came Henri de Mondeville, whom Latin writers
usually quote as _Henricus_. At least a dozen variants of the second
portion of his name are found in literature, from Armondeville to
Hermondaville. 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 in the latter half 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, and then 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
practice 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.

There is an historical tradition which has led many to believe that the
surgery of the fourteenth century was mainly in the hands of the barber
surgeons--ignorant men who plied a rude handicraft in connection with some
conventional use of the lancet--and that the physicians quite despised
their surgical colleagues. Mondeville is a striking contradiction of this.
He was a scholarly man, who quotes not only all the distinguished
contributors to medicine and surgery before his time, the Greeks and
Latins, the Arabs, and his Italian masters, but who also has quotations
from poets and philosophers, Aristotle, Plato, Diogenes, Cato, Horace,
Ovid, Seneca, and others.

The Regius Professors of Medicine at both Oxford and Cambridge in our
generation are on record with the declaration that medicine and surgery
have been allowed to drift too far apart, and that above all the physician
should see more of surgical operations for the confirmation of diagnoses,
for they are real bioscopys. It is rather interesting to find, then, that
Mondeville felt the necessity in his time for close relations between
physicians and surgeons, and said:

"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 deference 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 speciality.

Mondeville is particularly interesting for the history of surgery because
he himself ventured to trace some of the recent history of the development
of his speciality. Following Galen's example, who had divided the
physicians of the world into three sects, the Methodists, the Empirics,
and the Rationalists, 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 Ugo
da Lucca and his son Theodoric and their modern [_sic_] disciples.

The characteristics of these three sects are in brief. The first limited
patients' diet, used no stimulants, dilated all wounds and looked for
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. Almost needless to
say, his critical discussion of the three schools is extremely
interesting.

Mondeville was himself a broadly educated scholar, who considered that the
surgeon should know everything worth while knowing about medicine, for his
work was greater than that of the physician. While he had high ideas,
however, of the value of theoretic knowledge, he insisted above all on the
value of practical training. He said, in his textbook on surgery, as to
what the training of the surgeon should be:

    "A surgeon who wishes to operate regularly ought first for a long time
    to frequent places in which skilled surgeons often operate, 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 proper
    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."

The other great French surgeon of the fourteenth century was Guy de
Chauliac, who well deserves the name of father of modern surgery. He was
educated in a little town in the South of France, made his medical studies
at Montpellier, and then went on a journey of hundreds of miles to Italy
in order to make his postgraduate studies. While it is not generally
realized, for some seven centuries before the nineteenth Italy was the
home of graduate teaching in all departments. Whenever a man in any
country in Europe, from the beginning of the twelfth until the end of the
eighteenth century, wanted to secure opportunities for the higher
education that were not available in his home country, he went down into
Italy. At the beginning of the nineteenth century France usurped
Italy's place for half a century, and Germany pre-empted the position to a
great degree during the latter half of the nineteenth. The journey to
Italy in the Middle Ages was more difficult, and involved more expense and
time, than would even the voyage from America to Europe in our time; yet
many a student from France, Germany, and England made it for the sake of
the postgraduate opportunities, and it is matter for professional pride
that this was particularly true of our medieval colleagues in medicine and
surgery.

[Illustration: SURGICAL INSTRUMENTS OF GUY DE CHAULIAC, NOS. 1, 2, 3, AND
4 (FOURTEENTH CENTURY); AND SURGICAL APPARATUS OF HANS VON GERSSDORFF,
NOS. 5, 6 AND 7 (FIFTEENTH CENTURY)

_After plates in Gurlt's "Geschichte der Chirurgie"_

    1. Trepan

    2. Balista used for extraction of arrows

    3. Cauterizing shears with cannula for cauterization of the uvula

    4. Bistoury

    5. Extension arrangement for reducing upper arm dislocations, called
    "The Fool"

    6. Screwpiece for extending a knee contracture

    7. Extension apparatus in the form of armour-arm and armour-leg plates
    ("harness instruments") for contractures of the elbow and knee joints]

To know Guy de Chauliac's works well is to have ready contradictions at
hand to practically all of the objections so frequently repeated as to the
lack of scholarly work during the Middle Ages. For instance, Guy de
Chauliac insisted on the value of experience rather than authority, and of
original work rather than mere copying. He criticized in bitter satire
John of Gaddesden's book on medicine, called after the fashion of the time
by the poetical title "Rosa Anglica," of which he said: "Last of all
bloomed the scentless Rose of England, which on its being sent to me I
hoped to find bearing the odour of sweet originality. But instead of that
I encountered only the fictions of Hispanus, of Gilbert, and of
Theodoric." His mode of satirical expression is all the more interesting
and significant, because it shows that the men of the time were
critically minded enough as regards many of the passages in the writings
of their predecessors with which fault has been found in the modern time,
though we have usually been inclined to think that medieval readers
accepted them quite uncritically. Chauliac's 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 description of the methods of anæsthesia practised by the
surgeons of his time, especially in cases of amputation, is particularly
interesting to us because the anæsthetic was administered by inhalation.
Chauliac says:

    "Some surgeons prescribe medicaments, such as opium, the juice of the
    morel, hyoscyamus, mandrake, ivy, hemlock, lettuce, which send the
    patient to sleep, so that the incision may not be felt. A new sponge
    is soaked by them in the juice of these and left to dry in the sun;
    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."[10]

Chauliac was particularly interested in the radical cure of hernia, and he
discusses six different operations for this purpose. Gurlt points out that
Chauliac's criticism of these operations is quite modern in its viewpoint.
He declared that practically 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 as a support; it
was to be left in the tissues, and was 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 criticizes the operation in this respect, but says
that he has "seen many cases in which men possessed of but one testicle
have procreated, and this is a problem where the lesser of two evils is
to be chosen."

While he discussed hernia operations so freely, the great French surgeon
did not believe that everyone who suffered from a hernia ought to be
submitted to an operation. He quite agreed with Mondeville who, in the
preceding generation, declared that many operations for hernia were done
not for the benefit of the patient but for the benefit of the surgeon--a
mode of expression that is likely to strike a sympathetic chord in some
physicians' minds even at the present time. Chauliac's rule was that no
operation should be attempted unless the patient's life was put in danger
by the hernia, but that a truss should be worn to retain it. He emphasized
that trusses should not be made according to rule, but must be adapted to
each individual, and he invented several forms of trusses himself. He
developed the method of taxis by which hernias might be reduced, suggested
an exaggerated Trendelenburg position for operations for hernia and for
the manipulations necessary for the reduction of hernia.

The technique of some of these old surgeons is a never-ending source for
surprise. The exaggerated Trendelenburg position in the operation for the
radical cure of hernia--the patient being fastened on an inclined board,
head down, so that the intestines would fall away from the site of
operation--was used by Guy de Chauliac, who probably obtained a hint of it
from Italy. He also employed extension in the treatment of fracture of the
thigh, inventing an apparatus by which this might be continued for a long
time until the muscles were relaxed from overtiredness. He made use for
this purpose of a weight suspended on a cord which ran over rollers. He
also adapted stiffened bandages of various kinds, especially employing
white of egg for this, and sometimes moulding bandages to the limbs in
cases of fracture. Yperman, the Flemish surgeon of this time, knew and
used the oesophagus tube for artificial feeding, and a number of various
kinds of instruments were invented for the urethra, including bougies of
wax, tin, and silver. In diseases of the bladder and in gonorrhoea John
Ardern employed astringent injections.

Probably what ought to be considered the most important work of the French
surgeons of the Middle Ages has been quite misunderstood until recent
years. In his paper on "The Origin of Syphilis," at the Seventeenth
International Congress of Medicine (London, 1913), Professor Karl Südhoff
of Leipzig (see Transactions) reviewed the use of mercury in the form of
mercurial ointment during the later Middle Ages, and the reputation that
it had acquired for the cure of ulcers, skin eruptions of various kinds,
and other distinctly objective lesions. It is perfectly clear now that the
success of this form of therapy was due to the fact that syphilis was
being treated. The French surgeons of the South of France developed the
empiric discovery of the value of this remedy, the first hint of which had
probably come to them from the Italians. It is one of the few specifics in
the history of medicine. Needless to say, it is still with us, and still
the accepted medication in spite, as Professor Südhoff notes, of the
often-attempted replacement of it down the centuries by some form or other
of arsenic treatment, though this has always been afterwards abandoned,
and it would seem as though our generation might furnish another instance
of the triumph of the medieval mercurial treatment over arsenic.

The real reason then, it would seem, why syphilis came to be called the
_morbus Gallicus_, or French Disease, was because when knowledge of its
differential diagnosis was generalized, physicians at the same time
learned of the remedy which could be so successfully employed for its
treatment, the value of which had been determined as the result of the
careful observations of the surgeons of South France. It is probable, as I
have said, that the original idea for this form of treatment came from
the Italian surgical traditions brought over from Italy by Lanfranc and
his contemporaries at the end of the thirteenth century. There can be no
doubt at all, however, of the power of clinical observation of the
medieval surgeons who gave us this wonderful advance in therapeutics.

The most distinguished pupil of Guy de Chauliac was Pietro d'Argelata, who
died about 1423 as a professor at Bologna, but whose textbook, "The
Cirurgia," was among the first of medical books to be printed at Venice in
1480. His teaching was still a living force at that time, and it is
evident that he had attracted wide attention in his own generation. He
taught the dry treatment of wounds, suggesting various powders to be
employed on them, and gave his experience with sutures and drainage tubes
in wounds.

Ligatures are often supposed to have been invented much later. They have
been attributed to Ambroise Paré and other surgeons of the Renaissance
period, but were probably used at many times during the Middle Ages, and
had been invented and frequently employed by the Greeks. They invariably
went out of use after a time, however, and had to be reinvented. As I said
in "Old-Time Makers of Medicine":

    "It is hard to understand how so useful an auxiliary to the surgeon as
    the ligature--it seems indispensable to us--could possibly be allowed
    to go out of use and even be forgotten. It will not be difficult,
    however, for anyone who recalls the conditions that obtained in
    old-time surgery to understand the succession of events. The ligature
    is a most satisfying immediate resource in stopping bleeding from an
    artery, but a septic ligature inevitably causes suppuration, and
    almost inevitably leads to secondary hæmorrhage. In the old days of
    septic surgery, secondary hæmorrhage was the surgeon's greatest and
    most dreaded bane. Some time from the fifth to the ninth day a septic
    ligature came away under conditions such that inflammatory disturbance
    had prevented sealing of the vessel. If the vessel was large, the
    hæmorrhage was fast and furious, and the patient died in a few
    minutes. After a surgeon had had a few deaths of this kind he dreaded
    the ligature.

    "Eventually he abandoned its use, and took kindly even to such methods
    as the actual cautery, red-hot knives for amputations and the like,
    that would sear the surfaces of tissues, and the bloodvessels, and not
    give rise to secondary hæmorrhage. A little later, however, someone
    not familiar with the secondary risks would reinvent the ligature. If
    he were cleanly in his methods, and, above all, if he were doing his
    work in a new hospital, the ligature worked very well for a while. If
    not, it soon fell into innocuous desuetude again. In any case, it was
    only a question of time until it would be abandoned."

There was at least one, and probably a number of English surgeons who were
doing excellent work in the latter part of the Middle Ages, but John of
Ardern wrote a book which has come down to us, and from him we may judge
the character of his contemporaries. He was educated at Montpellier, and
practised surgery for a time in France. About the middle of the fourteenth
century, according to Pagel, he went back to his native land and settled
for some twenty years at Newark in Nottinghamshire; and for nearly thirty
years longer, until near the end of the century, practised in London.
Ardern's speciality was diseases of the rectum, but he made special
studies in the treatment of fistulas everywhere in the body. He was an
expert operator, and seems to have had excellent success in this field. He
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 some new instruments and of a clyster
apparatus. We know something also about his fees, and there is no doubt
that he obtained quite as good fees in proportion to the value of money as
even any specialist of the modern time.

Ardern gives many evidences of his power of clinical observation, and
incidentally makes it very clear that the eyes of the men of his time were
not so held from seeing the things that lay before them as is often
assumed. Mr. D'Arcy Power, in the paper on "The Lesser Writings of John
Ardern" which he read before the section on the History of Medicine at the
Seventeenth International Congress (see Transactions), has quoted a series
of paragraphs from Ardern which make it very clear how accurate an
observer this fourteenth-century Englishman was. Here, for instance, is
his description of epidemic sore throat in his time, probably diphtheria,
for the death within five days through strangling would seem to point to
this:

    "And note diligently that in the sqwynancy [quinsy] and in all the
    swellynges of the throte and the nekke and in all the lettynges and
    swolowynge as whanne the pacient thereof is oftetymys dysposyd to the
    deeth withinne schort time and I have seye manye deyed thereof within
    v dayes thorough stranglynge. To the weche it is to know that ther is
    nothynge more profytablere therefore thane to use glysteryes of
    malowys, mercurye [cheno-podium?] branne and oyle or buttre, hony and
    Sal gemme or comone salt. This operacione draweth the wykkyd humours
    to the inner partyes that causeth the syknesse and so it helpeth the
    sqwynnancye."

Ardern's description of rabies, its fatality, and of how a mad dog acts,
exemplifies still further his accuracy of clinical observation. Only one
who had seen many cases and understood them, and had had many mad dogs
under observation, could have given the details he does. A single
paragraph confirms the idea that the medieval surgeons had very clearly
recognized the disease, and knew as much about it as was known until our
own generation added something of more definite knowledge of the affection
than could be gained by mere clinical observation. Ardern says:

    "The bytynge of a wood [mad] dogge is more venemous and perilous thane
    it is of a serpente, ffor the venyme of a wood dogge ys hydd often
    tymes by the hole yere togydere and other whyle by the ii [two] yere
    and after some auctours it wole endure vii yere or it sle [slay] a
    man. And note wheyther it be longe tyme hydd or schorte or that it
    slee ther comene tofore to the pacient thes tokenys medlynge and
    chaungynge of wytte and resone and abhominacione and lothsomnesse of
    cold water that is clene and pure. And whane suche sygnys fallen to
    him that is byten of a wood hound schall unnethe or ellys [seldom or
    never] escape it.

    "The tokenys of a wood dogge ben these; the furste is he knoweth not
    his lord ne his mayster and he falleth into a voyd goyinge allone with
    boowynge of his heed and hangynge of the erys [ears] as other wyse
    than ne he hadde hemin his helthe and the yene [eyes] of him ben rede
    and the fome cometh out at the mowth and he wole berke at his oune
    schadowe and he hath ane hos [hoarse] berkynge, and other houndes
    fleene from hyme and berken towardys hyme. And yf a schyvere [slice]
    of breed be folden or wette in the bytynge of the sore and yoven a
    dogge to ete, yf that he ete it, it is a token that the dogge is not
    wood, for and the dogge be wood tha other dogge that the breed is
    yoven to wole not ete it, but that he be over moche hungry, and yf he
    denye to ete the seyde breed, out-take [unless on] the condicione
    aforeseyd, thane is the dogge wood."

Ardern's description of a case of traumatic tetanus is very interesting,
because it contains so many elements that are familiar in the history of
this affection. The fact that it occurred in a gardener from a hook, so
likely to be infected with tetanus bacilli from hay or grass, and that the
wound was made where the thumb joins the hand and where, as we know now,
the construction of the tissues is so favourable to that burying of the
tetanus bacilli away from the free oxygen of the air, giving it a chance
to grow anaerobically, all show the disease exactly as in our own time.
The other details of the case probably indicate a wound of an important
bloodvessel, secondary hæmorrhage after suppuration had been established,
and then the development of fatal subacute tetanus.

    "A gardinere whyle that he wrowghte in the vynes kytte his owne hande
    with ane hooke uppone a ffryday after the ffeste of Seynt Thomas of
    Caunterbury in somere so that the thoombe was altogydere departyd from
    the hande saff only in the juncture that was joyned to the hande, and
    he myghte boowe bakward the thoombe to his arme and ther stremyd out
    therof moche blood.

    "And so touchynge to the cure. The thoombe was furst reduced in to his
    furste ordre and sowyd and the blood was restreyned with the reed
    pouder of launfrankes [Lanfranc's red powder] and with the heerys
    [hairs] of ane hare and it was not remevyd une-to the iiide day when
    it was remevyd tther apperyd no blood. Thanne was ther putte therto
    tho medicines that engendren blood, every day ones repeyrynge the
    wounde, and tho it begane to purge itselffe and to gadere mater. And
    in the iiiithe nyght after the blood brak out abowte mydnyght in the
    wheyghte of ii poundes. And whane the blod was restreyned the wounde
    was repeyred frome day to day as it was furste.

    "Also in the xithe nyght abowte the forseyd oure the blood brake owt
    ayene [again] in more quantyte thane it dyde afore tyme, nevertheless
    the blood was staunched, and by the morne the pacient was so taken
    with the crampe in the chekes [cheeks] and in the arme that he myght
    resseyve no mete in-to his mowth ne neyther opene the mowyth (lockjaw)
    and so vexynge the pacient in the xv day the blood brake out ayene owt
    of mesure and alwey the crampe endured forth and in the xx day he
    dyde."

Another important surgeon of the West of Europe whose book has come down
to us was John Yperman, who owes his name to the fact that he was a native
of the town of Ypres (in Flemish Ypern) in Flanders. Yperman was sent by
his fellow-townsmen to Paris in order to study surgery, apparently at the
expense of the municipality, because they wanted to have a good surgeon
in their town, and Paris seemed the best school at that time. Ypres, so
familiar now as the scene of bloody battles, had become even before the
war one of the less important cities even of Belgium, with less than
20,000 people. It was in the thirteenth century one of the greatest
commercial cities of Europe, and probably had several hundred thousand
inhabitants. The great hall of the Cloth Guild, one of the architectural
triumphs of the time, and such an attraction for visitors to the town ever
since (destroyed in the war) was built at this time, and is another
tribute to the community feeling of the citizens, who determined upon the
very sensible procedure of assuring the best possible surgery for
themselves and fellow-citizens by having one of their townsmen specially
educated for that purpose. Yperman's book on surgery was well known in his
own time, but remained unprinted until about half a century ago (1854),
when Carolus of Ghent issued an edition. Subsequent editions were issued
by Broeckx, the Belgian historian (Antwerp, 1863), and by van Leersum
(1913), who gathered some details of the great Flemish surgeon's life.
After his return from Paris, Yperman obtained great renown, which
maintains 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 tuberculous, tysiken), apoplexy, epilepsy,
frenzy, lethargy, fallen palate, cough, shortness of breath, lung abscess,
hæmorrhage, blood-spitting, liver abscess, hardening of the spleen,
affections of the kidney, bloody urine, diabetes, incontinence of urine,
dysuria, strangury, gonorrhoea, and involuntary seminal emissions--all
these terms are quoted directly from Pagel's account of his work.

There is not much to be said of the surgery of Germany during the Middle
Ages, though toward the end of this period a series of important documents
for the history of surgery were written which serve to show how much was
being accomplished, though the subsequent religious and political
disturbances in Germany doubtless led to the destruction of many other
documents that would have supplied valuable information. Heinrich von
Pfolspeundt's book, which is a work on bandaging--"Bundth-Ertzney"--was
published in 1460, and the experience for it was therefore all obtained
in the Middle Ages. While its main purpose is bandaging, it contains many
hints of the surgical knowledge of the time. There are chapters devoted to
injuries and wounds, though it is distinctly stated that the book is for
"wound physicians" (_Wund Aertzte_) and not for cutting physicians
(_Schneide Aertzte_)--that is, for those who do operations apart from
wounds. There are two operations described, however, that have particular
interest. One of them involves the plastic surgery of the nose, and the
other the repair of a hare-lip.

Pfolspeundt suggested that stitches should be placed on the mucous surface
as well as on the skin surface, after the edges of the cleft in hare-lip
had been freshened in order to be brought closely together for healing
with as little deformity as possible. Perhaps his most interesting
surgical hint for us is a description of a silver tube with flanges to be
inserted in the intestines whenever there were large wounds, or when the
intestines had been divided. The ends of the gut were brought together
carefully over the tube and stitched together, the tube being allowed to
remain _in situ_. Pfolspeundt says that he had often seen these tubes used
and the patient live for many years afterwards. While this resembles some
of the mechanical aids to surgery of the intestines that have been
suggested in our time, this was not the first mechanical device of this
kind that had been thought of. One of the later medieval surgeons in
Italy, one of the Brancas, had employed the trachea of an animal as the
tube over which the wounded intestines were brought together. This had the
advantage of not having to be passed, for after a time it became
disintegrated in the secretions, but it remained intact until after
thorough agglutination of the intestines had occurred.

[Illustration: BRUNSCHWIG'S SURGICAL ARMAMENTARIUM

_From Gurlt's "Geschichte der Chirurgie"_]

Hans von Gerssdorff and Hieronymus Brunschwig, who flourished in the
latter half of the fifteenth century in Germany, have both left early
printed treatises on Surgery which give excellent woodcuts showing
pictures of instruments, operations, and costumes, at the end of the
medieval period.




CHAPTER VIII

ORAL SURGERY AND THE MINOR SURGICAL SPECIALITIES


The surgical specialities, as they are called--that is, the surgery of the
mouth, throat, and nose, and of the eye and ear, as well of course as of
certain other portions of the body--have developed to a striking extent in
our time. As a consequence of this recent development, there is an
impression prevalent that this is the first time that serious attention
has been paid by surgeons to these phases of their work. The feeling is
probably that the minor operations usually required in the surgical
specialities were either thought so trivial, or involved such delicate
technique, that they never received due attention, rather than that they
were deliberately neglected.

Because of this very general persuasion, even among physicians, it is all
the more interesting to trace the phases of attention during the Middle
Ages to these special subjects in surgery, which was far from lacking at
any time, and which led at various periods to some rather important
developments. While specialism is considered new by most people, it must
not be forgotten that at every time in the world's history, when men have
had much chance to think about themselves rather than the actual
necessities of the situation in which they were placed, and the things
they were compelled to do for actual self-preservation, specialism has
enjoyed a period of more or less intense evolution. It is rather easy to
trace this in the Ebers Papyrus near the beginning of the second
millennium B.C.; and Herodotus called attention to the fact that the old
Egyptians had divided the practice of medicine into many specialities. His
passage on the subject is well known.[11]

If the surgical specialities had been neglected in the Middle Ages, then
that fact would have constituted the surest evidence of that backwardness
of medical and surgical progress which is usually supposed to have existed
at that time. But the real story is exactly to the contrary, and has many
surprises in it because of the anticipations of very recent advances which
it represents.[12]

It would be surprising, then, if we were to find no attention paid to
dentistry during the Middle Ages. As a matter of fact, a number of the old
surgeons include in their textbooks of surgery the discussion of oral
surgery. Aëtius evidently knew much about the hygiene of the teeth, and
discusses extraction and the cure of fistulæ of the gums as well as the
surgical treatment of many other lesions of the mouth. Paul of Ægina in
the century after Aëtius has even more details; and while they both
quote mainly from older authors, there seems no doubt that they
themselves must have had considerable practical experience in the
treatment of the teeth and had made not a few observations. The Arabians
took up the subject, and discussed dental diseases and their treatment
rationally and in considerable detail. Abulcassis particularly has much
that is of significance and interest. We have pictures of two score of
dental instruments that were used by him. 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 the dental arches. Orthodontia
is usually thought of as of much later origin, yet no one who knows
Abulcassis's work can speak of efforts at straightening the teeth as
_invented_ after his time.

[Illustration: SURGICAL INSTRUMENTS OF THE ARABS, ACCORDING TO ABULCASIM

_After plates in Gurlt's "Geschichte der Chirurgie"_

    1. A pincher for extracting foreign bodies from the ear

    2. An ear syringe for injections

    3. A tongue depressor

    4. Concave scissors for the removal of tonsils

    5. Curved pinchers for foreign bodies in the throat

    6 to 29. Instruments for the treatment of the teeth

    19 and 20. Forceps

    21 to 25. Levers and hooks for the removal of roots

    26. Strong pinchers for the same

    27. A tooth saw 28 and 29. Files for the teeth]

The great surgeons of the later Middle Ages in their textbooks of surgery
usually include remarks on oral surgery, and suggest treatment for the
various diseases of the teeth. Guy de Chauliac in "La Grande Chirurgie"
lays down certain rules for the preservation of the teeth, and shows that
the ordinary causes of dental decay were well recognized in his time.
Emphasis was laid by him on not taking foods too hot or too cold, and
above all on the advisability of not having either hot or cold food
followed by something very different from it in temperature. The breaking
of hard things with the teeth was warned against as responsible for such
fissures in the enamel as gave opportunity for the development of decay.
The eating of sweets, and especially the sticky sweets, preserves, and the
like, were 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.

Chauliac is particularly emphatic in his insistence on not permitting
alimentary materials to remain in the cavities, and suggests that if
cavities between the teeth tend to retain food material they should even
be filled in such a way as to prevent these accumulations. His directions
for cleansing the teeth were rather detailed. His favourite 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 favourite 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-bones, small white seashells, 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 favourite liquid dentifrice contained the following ingredients: Half
a pound each of sal ammoniac and rock salt, and a quarter of a pound of
saccharin 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 colour 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 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 very similar to those
we make use of for removing tartar.

Guy de Chauliac was also interested in mechanical dentistry and the
artificial replacement of lost teeth; and, indeed, dental prosthesis
represents, as treated by him, a distinct anticipation of dental
procedures usually thought quite modern.

When teeth become loose he advises that they be fastened to the healthy
ones with a gold chain. Guerini, in his "History of Dentistry"
(Philadelphia, 1907), suggests that he evidently means a gold wire. If the
teeth fall out Chauliac recommends that they be replaced by the teeth of
another person, or with artificial teeth made from ox-bone, 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
Abulcassis 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.

Guerini called particular attention to the fact that Chauliac recognized
the dentists as specialists. He observes that operations on the teeth are
in a class by themselves, and belong to the _dentatores_ to whom they had
been entrusted. He remarks, however, that the operations on the mouth
should be performed under the direction of a surgeon. It is in order to
give surgeons the general principles by means of which they may be able
to judge of the advisability or necessity for dental operations, that his
brief presentation of the subject is made. 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 and
ointments, rubbings, fumigations, cauterizations, fillings, filings," as
well as the various dental operations. He says that the _dentator_ must be
provided with appropriate instruments, among which he named scrapers,
rasps, straight and curved, spatumina, elevators, simple and with two
branches, toothed tenacula, and many different forms of probes and
cannulas. He should have also small scalpels, tooth trephines, and files.

After Guy de Chauliac, the most important contributor to dentistry is
Giovanni of Arcoli--or simply Arcolano, but sometimes better known by his
Latin name Johannes Arculanus--who was Professor of Medicine and Surgery
at Bologna just before and after the middle of the fifteenth century. He
is sometimes treated in history as belonging rather to the Renaissance,
but he owed his training to the Middle Ages and was teaching before they
closed, so he has a place in Medieval Medicine. Guerini, in his "History
of Dentistry," says that Arculanus treats the subject of dentistry rather
fully and with great accuracy. The Italian historian makes a summary of
Arculanus's rules for dental hygiene which shows how thoroughly he
appreciated the care of the teeth. The medieval surgeon arranged his rules
in ten distinct canons, 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, 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, or 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, 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 dentifrices 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.

Shortly after Arculanus, when the Middle Ages are over--if they end with
the middle of the fifteenth century, though perhaps not if the later date
of the discovery of America is to be taken as the medieval terminal--John
de Vigo has in a few lines a very complete description of the method of
filling teeth with gold-leaf which deserves to be quoted. Only that it was
a common practice he would surely have described it more in detail,
though he could have added nothing to the significance of what he has to
say: "By means of a drill or file the putrefied or corroded part of the
teeth should be completely removed. The cavity left should then be filled
with gold-leaf."

Much more is known about the medieval anticipation of other
specialities--those of the throat and nose, and eye and ear--and the
surprise is with regard to dentistry, which is usually quite unknown. The
fact, however, that dentistry developed so much more than is usually
thought prepares the mind for the anticipations in other departments.
Following that of dentistry should come naturally the mouth and throat,
and it happens that the men whose writings in dentistry are known also
touched on these subjects.

The medical writers of the early Middle Ages, particularly Aëtius,
Alexander of Tralles, and Paul of Ægina, have not a little to say with
regard to affections of the throat and nose, and the eye and ear.
Alexander's chapter on the Treatment of Affections of the Ear, Gurlt
considers ample evidence of large practical experience and power of
observation. Alexander describes the ordinary mode of getting water out of
the external auditory canal by standing on the leg corresponding to the
side in which the water is, and kicking out with the opposite leg.
Foreign bodies should be removed by an ear spoon, or a small instrument
wrapped in wool and dipped in sticky material. He suggests sneezing with
the head leaning toward the side on which the foreign body is present.
Insects or worms that find their way into the ear may be killed by
injections of dilute acid and oil or other substances.

Paul of Ægina has a very practical technique for the removal of fish-bones
or other objects caught in the throat. He also gives the detailed
technique of opening the larynx or trachea, with the indications for this
operation. He also describes how wounds of the neck should be sewed after
attempts at suicide. In a word, the more one knows of these old-time
medieval writers of the sixth and seventh centuries the clearer it becomes
that they had learned their lessons well from the ancients, and passed on
an excellent tradition to their colleagues of succeeding generations. If
these lessons were not properly taken, it was because the disturbance of
civilization caused by the coming down of the Teutonic invaders into Italy
took away interest in the things of the mind and of the body, until the
coming of another upward turn in progress.

Arculanus has some very interesting paragraphs with regard to the
treatment of conditions in the nose. 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 fine scissors; or with a
narrow file just small enough to permit 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 hæmorrhage, or if there is fear of it, the instruments with
which the section 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 of the 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 (Æginetas),
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 pulle

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