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diff --git a/43300-0.txt b/43300-0.txt new file mode 100644 index 0000000..1534ac3 --- /dev/null +++ b/43300-0.txt @@ -0,0 +1,5846 @@ +*** START OF THE PROJECT GUTENBERG EBOOK 43300 *** + +Note: Project Gutenberg also has an HTML version of this + file which includes the original illustrations. + See 43300-h.htm or 43300-h.zip: + (http://www.gutenberg.org/files/43300/43300-h/43300-h.htm) + or + (http://www.gutenberg.org/files/43300/43300-h.zip) + + + Images of the original pages are available through + Internet Archive. See + http://archive.org/details/medievalmedicine00wals + + + + + +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 pulled on backward and forward after the fashion of +a saw. Arculanus remarks, evidently with the air of a man who has tried it +and not been satisfied, that this operation is quite uncertain, and seems +to depend a great deal on chance, and much reliance must not be placed on +it. Arculanus suggests a substitute method by which latent polyps--or +occult polyps, as he calls them--may be removed. + +Among the affections of the upper air passages mentioned by Arculanus are +various forms of sore throat, which he calls Synanche or Cynanche, or +angina. A milder form of the affection was called Parasynanche. The +medieval teaching with regard to an angina that was causing severe +difficulty of breathing was to perform tracheotomy. Arculanus goes into +some detail with regard to affections of the uvula, which was made much +more responsible for throat affections than at the present time. The +popular tradition in our time of the uvula and its fall is evidently a +remnant of the medieval teaching with regard to it. Arculanus's +description of the removal of the uvula, or at least of the tip of it, +gives a very good idea of how thorough the teaching of surgical technique +was in his time. His directions are: "Seat the patient upon a stool in a +bright light, while an assistant holds the head; after the tongue has been +firmly depressed by means of a speculum, let the assistant hold this +speculum in place. With the left hand then insert an instrument, a stilus, +by which the uvula is pulled forward; and then remove the end of it by +means of a heated knife or some other process of cauterization. The mouth +should afterwards be washed out with fresh milk." + +The application of a cauterizing solution by means of a cotton swab +wrapped round the end of a sound may be of service in patients who refuse +the actual cautery. To be successful, he insists that the application must +be firmly made and must be frequently repeated. + +With regard to ophthalmology the older history has always been thoroughly +appreciated. Even as early as the time of Hammurabi (2200 B.C.) some +rather extensive and interesting surgery of the eye was practised, for the +fees for these operations are mentioned in the code. All of the early +medieval writers on medicine and surgery--Aëtius, Alexander of Tralles, +and Paul of Ægina--have paragraphs at least, and sometimes more, with +regard to eye operations and the care of the eyes. + +Operations above all for cataract have been practised from very early +times, and are mentioned also by many medieval writers on medicine and +surgery. It is not surprising, then, to find that the medieval surgeons +particularly discussed a number of eye diseases and the operations for +them. Pope John XXI., who before he became Pope was known as _Petrus +Hispanus_ (the Spaniard), and who had been a professor of surgery and a +papal physician, wrote a book on eye diseases in the latter half of the +thirteenth century, which has come down to us. He had much to say of +cataract, dividing it into traumatic and spontaneous, and suggesting +operation by needling, a gold needle being used for that purpose. Pope +John describes a form of hardness of the eye which would seem to be what +we now call glaucoma, and has a number of external applications for eye +diseases. Most of his collyria had some bile in them, the bile of various +kinds of animals and birds being supposed to be progressively more +efficient for the cure of external affections of the eye. This very +general use of bile, or of an extract of the livers of animals or fishes, +seems to be a heritage from biblical times, when old Toby was cured of his +blindness by the gall of the fish.[13] The Pope ophthalmologist (see +_Opthalmology_, Milwaukee, January, 1909) recommended the urine of infants +as an eye-wash, experience having evidently shown that this fluid, which +is usually bland and unirritating, a solution of salts of a specific +gravity such that it would not set up osmotic processes in the eye, was +empirically of value. In the Middle Ages the idea of using it would be +much less deterrent, because it was quite a common practice for physicians +to taste urine in order to test it for pathological conditions. + +Spectacles were rather commonly used in the Middle Ages, probably having +been invented in the second half of the thirteenth century by Salvino de +Armato of Florence. Bernard de Gordon mentions them under the name _oculus +berellinus_ early in the fourteenth century. They were originally made +from a kind of smoky crystal, _berillus_, whence the German name _Brillen_ +and the French _besicles_ (Garrison). Guy de Chauliac suggests that when +collyria failed to improve the sight spectacles should be employed. Almost +needless to say, this use of spectacles meant very much for the comfort +and convenience of old people. Up to that time most of those who reached +the age of three-score would be utterly unable to read, and would have to +depend either on others or on their memory for teaching and many other +purposes. External eye troubles, as those due to trichiasis and to various +disturbances of the lachrymal apparatus, were treated by direct mechanical +means. Some very ingenious suggestions and manipulations were made with +regard to them. + + + + +CHAPTER IX + +MEDICAL EDUCATION FOR WOMEN + + +Among the rather startling surprises that have developed, as the growth of +our knowledge of medieval history, through consultation of the documents +in recent years, is constantly contradicting traditions founded on lack of +information, perhaps the greatest has been to learn that women were given +opportunities for the higher education at practically all of the Italian +universities, and that they became not only students, but professors, at +many of these institutions. No century from the twelfth down to the +nineteenth was without some distinguished women professors at Italian +universities, and in the later Middle Ages there was a particularly active +period of feminine education. + +The most interesting feature of this development for us is that the +application of women to medical studies from the twelfth to the fourteenth +centuries was not only not discouraged, but was distinctly encouraged, and +we find evidence that a number of women studied and taught medicine, +wrote books on medical subjects, were consulted with regard to +medico-legal questions, and in general were looked upon as medical +colleagues in practically every sense of the word. The very first medical +school that developed in modern times, that of Salerno, which came into +European prominence in the eleventh century, was quite early in its +history opened to women students, and a number of women professors were on +its faculty. + +Considering the modern idea that ours is the first time when women have +ever had any real opportunity for the higher education, and above all +professional education, it is a source of no little astonishment to find +that at Salerno not only an opportunity was afforded to women to study +medicine, but the department of women's diseases was handed over entirely +to them, and as a consequence we have a Salernitan School of Women +Physicians, some of whom wrote textbooks on the subject relating to this +speciality. De Renzi, in his "Storia della Scuola di Salerno," has brought +to light many details of the history of this phase of medical education +for women at the first important medical school that developed in modern +Europe. The best known of these medieval women physicians was Trotula, to +whom is attributed a series of books on medical subjects--though +doubtless some of these were due rather to disciples, but became +identified with the more famous master, as so often happened with medieval +books. Trotula's most important book bears two sub-titles: "Trotula's +Unique Book for the Curing of Diseases of Women, Before, During, and After +Labour," and the other sub-title, "Trotula's Wonderful Book of Experiences +(_experimentalis_) in the Diseases of Women, Before, During, and After +Labour, with Other Details Likewise Relating to Labour." + +Probably the most interesting passage in her book for the modern time is +that with regard to a torn perineum and its repair, even when prolapse of +the uterus is a complication. The passage, which may be found readily in +De Renzi or in Gurlt, runs: + + "Certain patients, from the severity of the labour, run into a rupture + of the genitalia. In some even the vulva and anus become one foramen, + having the same course. As a consequence, prolapse of the uterus + occurs, and it becomes indurated. In order to relieve this condition, + we apply to the uterus warm wine in which butter has been boiled, and + these fomentations are continued until the uterus becomes soft, and + then it is gently replaced. After this we sew the tear between the + anus and vulva in three or four places with silk thread. The woman + should then be placed in bed, with the feet elevated, and must retain + that position, even for eating and drinking, and all the necessities + of life, for eight or nine days. During this time, also, there must be + no bathing, and care must be taken to avoid everything that might + cause coughing, and all indigestible materials." + +There is a passage almost more interesting with regard to prophylaxis of +rupture of the perineum. Trotula says: "In order to avoid the aforesaid +danger, careful provision should be made, and precautions should be taken +during labour after the following fashion: A cloth folded in somewhat +oblong shape should be placed on the anus, and during every effort for the +expulsion of the child, that should be pressed firmly, in order that there +may not be any solution of the continuity of tissue." + +There are records of other women professors of Salerno, though none of +them as famous as Trotula. A lady of the name of Mercuriade is said to +have written "On Crises in Pestilent Fever," and as she occupied herself +with surgery as well as medicine, there is also a work on "The Cure of +Wounds." Rebecca Guarna, who belonged to the old Salernitan family of that +name, a member of which in the twelfth century was Romuald, priest, +physician, and historian, wrote "On Fevers," "On the Urine," and "On the +Embryo." Abella acquired a great reputation with her work "On Black Bile," +and curiously enough on "The Nature of Seminal Fluid." From these books +it is clear that, while as professors they had charge of the department of +women's diseases, they studied all branches of medicine. There are a +number of licences preserved in the Archives of Naples in which women are +accorded the privilege of practising medicine, and apparently these +licences were without limitation as to the scope of practice. The preamble +of the licence, however, suggests the eminent suitability of women +treating women's diseases. It ran as follows: + + "Since, then, the law permits women to exercise the profession of + physicians, and since, besides, due regard being had to purity of + morals, women are better suited for the treatment of women's diseases, + after having received the oath of fidelity, we permit," etc. + +The story of medical education for women with the free opportunity for +practice, and above all the recognition accorded by making them professors +at the University of Salerno, will seem all the more surprising to those +who recall that the Benedictines largely influenced the foundation at +Salerno, and were important factors in its subsequent growth and +management. Ordinarily it would be presumed that monastic influence would +be distinctly against permitting women to secure such opportunities for +education, and, above all, encouraging their occupation with medical +practice. As a matter of fact, it seems indeed to have been monastic +influence which secured this special development. The Benedictines were +already habituated to the idea that women were quite capable, if given the +opportunity, of taking advantage of the highest education; and besides, +they were accustomed to see them occupied, and successfully, with the care +of the ailing. When St. Benedict established the monks of the West in +retreats, where the men of the earlier Middle Ages could secure, in the +midst of troubled times and with men in the cities utterly neglectful of +intellectual interests, a refuge from the disturbed life around them, and +an opportunity for intellectual development, his sister Scholastica +afforded similar opportunities for such women as felt that they were +called rather to the intellectual and spiritual life than to the taking up +of the burden of domestic duties and a wife's labours. + +In these Benedictine convents for women, as they spread throughout +Italy--and afterwards throughout Germany, and France, and England, though +the fact is often ignored--the intellectual life was pursued as faithfully +as the spiritual. Besides, there gathered around the convent gates as +around the monasteries the farmers who worked their estates, and who found +it so good "to live under the crozier," as the rule of the Abbot or +Abbess was called, and who always suffered severely whenever, by +confiscation or war or like disturbances, the monastic lands passed into +the hands of laymen. For their own large numbers as well as for their +peasantry, and for the travellers who stayed in their guest-houses, the +nuns had to provide medical attendance; and the infirmarians of the +convents, situated as they were so often far from cities or towns, +acquired considerable medical knowledge and came to apply it with +excellent success. The traditions were gathered from many quarters, and +passed on for centuries from one house to another; and they gathered +simples and treated the ordinary ailments, and nursed the ailing into +moods of greater courage and states of mind that predisposed to recovery. + +Probably the most important book on medicine that we have from the twelfth +century is written by a Benedictine Abbess, since known as St. Hildegarde. +She was born of noble parents at Boeckelheim in the county of Sponheim, +about the end of the eleventh century. She was educated at the Benedictine +cloister of Disibodenberg, and when her education was finished she entered +the house as a religious, and at the age of about fifty she became abbess. +Her writings, reputation for sanctity, and her wise rule, eminently +sympathetic as she was, attracted so many new members to the community +that the convent became overcrowded. Accordingly, with eighteen of her +nuns, Hildegarde withdrew to a new convent at Rupertsburg, which English +and American travellers will doubtless recall because it is not far from +Bingen on the Rhine, made famous in the later time by Mrs. Hemans's poem. +Here she came to be a sort of centre for the intellectual life of her +period. According to traditions, some of which are dubious, she was in +active correspondence with nearly every important personage of her +generation. She was an intimate friend of St. Bernard of Clairvaux, who +was himself perhaps the most influential man of Europe in this century. +Her correspondence was enormous, and she was consulted from all sides +because her advice on difficult problems of any and every kind was +considered so valuable. + +In spite of all this time-taking correspondence she found leisure to write +a series of books, most of them on mystical subjects, but two of them, +strange as it may seem, on medicine. The first is called "Liber Simplicis +Medicinæ," and the second "Liber Compositæ Medicinæ." These books were +written as a contribution of her views with regard to the medical +knowledge of her time, but were evidently due, partly at least, to the +Benedictine traditions of interest in medicine. Dr. Melanie Lipinska in +her "Histoire des Femmes Médicins," a thesis presented for the doctorate +in medicine at the University of Paris in 1900, which was subsequently +awarded a special prize by the French Academy, reviews Hildegarde's work +critically from the medical standpoint. She does not hesitate to declare +the Abbess Hildegarde the most important medical writer of her time. +Reuss, the editor of the works of Hildegarde as they are published in +Migne's "Patrologia," the immense French edition of all the important +works of the Fathers, Doctors, and Saints of the Church, says: + + "Among all the saintly religious who have practised medicine or + written about it in the Middle Ages, the most important is without any + doubt St. Hildegarde...." With regard to her book he says: "All those + who wish to write the history of the medical and natural sciences must + read this work, in which this religious woman, evidently well grounded + in all that was known at that time in the secrets of nature, discusses + and examines carefully all the knowledge of the time." He adds: "It is + certain that St. Hildegarde knew many things that were unknown to the + physicians of her time." + +Some of Hildegarde's expressions are startling enough because they +indicate discussion of, and attempts to elucidate, problems which many +people of the modern time are likely to think occurred only to the last +few generations. For instance, in talking about the stars and describing +their course through the firmament, she makes use of a comparison that +seems strangely ahead of her time. She says: "Just as the blood moves in +the veins, causing them to vibrate and pulsate, so the stars move in the +firmament, and send out sparks as it were of light, like the vibrations of +the veins." This is, of course, not an anticipation of the discovery of +the circulation of the blood, but it shows how close were men's ideas to +some such thought five centuries before Harvey's discovery. For Hildegarde +the brain was the regulator of all the vital qualities, the centre of +life. She connects the nerves in their passage from the brain and the +spinal cord through the body with manifestations of life. She has a series +of chapters with regard to psychology, normal and morbid. She talks about +frenzy, insanity, despair, dread, obsession, anger, idiocy, and innocency. +She says very strongly in one place that "when headache and migraine and +vertigo attack a patient simultaneously, they render a man foolish and +upset his reason. This makes many people think that he is possessed of a +demon, but that is not true." These are the exact words of the saint as +quoted in Mlle. Lipinska's thesis. + +With this story of St. Hildegarde in mind, and the recall of other +educational developments among the Benedictine nuns, it is easy to +understand the developments that took place at Salerno, where monastic +influence was so prominent. Just as the medical, and above all the +surgical, traditions of Salerno found their way to Bologna at the +beginning of the thirteenth century, so also did the regulations regarding +standards in medical education, and with them medical education for women. +There are definite historical documents which show that women not only +studied but taught in the medical department of Bologna. The name of one +of them at least is very well known. She was Alessandra Giliani, and, +strange as it might appear, was one of the prosectors in anatomy of +Mondino, the founder of teaching by human dissection. According to the +"Cronaca Persicetana," quoted by Medici in his "History of the Anatomical +School at Bologna": + + "She became most valuable to Mondino because she would cleanse most + skilfully the smallest vein, the arteries, all ramifications of the + vessels, without lacerating or dividing them, and to prepare them for + demonstration she would fill them with various coloured liquids, + which, after having been driven into the vessels, would harden without + destroying the vessels. Again, she would paint these same vessels to + their minute branches so perfectly, and colour them so naturally, + that, added to the wonderful explanations and teachings of the master, + they brought him great fame and credit." + +This passage with its description, as coming from a woman, of a very early +anticipation of our most modern anatomical technique--injection, +hardening, and colouring, so as to imitate nature for the making of +anatomical preparations, for class and demonstration purposes--is all the +more interesting because the next great improvement in anatomical +teaching, the use of wax models of dissected specimens coloured to imitate +nature, came also from a woman, Madame Manzolini, also of Bologna. +Feminine instinct aroused women to use their inventive ability to do away +with the necessity for always recurring to the deterrent material of fresh +dissections, and yet securing such preparations as would make teaching not +less but more effective. + +Some doubt has been thrown on certain details of the story of Alessandra +Giliani, but the memorial tablet erected at the time of her death in the +Hospital Church of Santa Maria de Mareto in Florence gives all the +important facts, and tells the story of the grief of her fiancé, who was +himself Mondino's other assistant. Like her, he died young also, when +there were high hopes of his ability, and there is more than the suspicion +that these two untimely deaths may have been due to dissecting wound +infections. She died "consumed by her labours," so that it may have been +phthisis; but he was taken by "a swift and lamentable death." + +Nicaise, in the Introduction to his edition of Guy de Chauliac's "Grande +Chirurgie" (Paris, 1893), has a brief review of the history of women in +medicine, with special reference to France. He supplies practically all +the information available in very short compass, as well as the references +where more details can be obtained. + + "Women continued to practise medicine in Italy for centuries, and the + names of some who attained great renown have been preserved for us. + Their works are still quoted from in the fifteenth century. + + "There was none of them in France who became distinguished, but women + could practise medicine in certain towns at least on condition of + passing an examination before regularly appointed masters. An edict of + 1311, at the same time that it interdicts unauthorized women from + practising surgery, recognizes their rights to practise the art if + they have undergone an examination before the regularly appointed + master surgeons of the corporation of Paris. An edict of King John, + April, 1352, contains the same expressions as the previous edict. Du + Bouley, in his 'History of the University of Paris' gives another + edict by the same king, also published in the year 1352, as a result + of the complaints of the faculties at Paris, in which there is also + question of women physicians. This responded to a petition: 'Having + heard the petition of the Dean and Masters of the Faculty of Medicine + at the University of Paris, who declare that there are very many of + both sexes, some of the women with legal title to practise and some + of them merely old pretenders to a knowledge of medicine, who come to + Paris in order to practise, be it enacted,' etc. (The edict then + proceeds to repeat the terms of previous legislation in this matter.) + + "Guy de Chauliac speaks also of women who practised surgery. They + formed the fifth and last class of operators in his time. He complains + that they are accustomed to too great an extent to give over patients + suffering from all kinds of maladies to the will of Heaven, founding + their practice on the maxim, 'The Lord has given as he has pleased; + the Lord will take away when he pleases; may the name of the Lord be + blessed.' + + "In the sixteenth century, according to Pasquier, the practice of + medicine by women almost entirely disappeared. The number of women + physicians becomes more and more rare in the following centuries, just + in proportion as we approach our own time. Pasquier says that we find + a certain number of them anxious for knowledge, and with a special + penchant for the study of the natural sciences and even of medicine, + but very few of them take up practice." + +There seems, however, to have been not nearly so much freedom or so much +encouragement for women in medicine in France as in Italy. Indeed, in the +whole matter of education for women, medieval France has but little to +record compared to Italy's significant chapter in the history of feminine +education. One reason for this was doubtless the Hélöise-Abélard incident +early in the history of the University of Paris. This seems to have +discouraged efforts in the direction of the securing of the higher +education for women in most of the Western Universities. Oxford was a +daughter university of Paris, and Cambridge of Oxford, and they and all +the other universities of the West were more deeply influenced in their +customs and organization by Paris than by Italy, and as a consequence we +hear little of feminine education in the West generally. One result of +this has been the existence of a feeling that, since women had very few +opportunities for the higher education in Western Europe, they must have +had them nowhere else. This presumption forms the basis of not a little +misunderstanding of the Middle Ages in our time. It often takes but a +little incident to set the current of history in a very different +direction from that in which it might have gone, and this seems to have +been the case as regards the higher education for women in France and +Spain and England. + + + + +CHAPTER X + +MEDIEVAL HOSPITALS + + +Our recent experience makes it easy to understand that such magnificent +advance in surgery as has been described in the preceding chapters would +have been quite impossible unless there were excellent hospitals in the +medieval period. Good surgery demands good hospitals, and indeed +inevitably creates them. Whenever hospitals are in a state of neglect, +surgery is hopeless. We have, however, abundant evidence of the existence +of fine hospitals in the Middle Ages, quite apart from this assumption of +them, because of the surprising surgery of the period. Historical +traditions from the earlier as well as the later medieval times +demonstrate a magnificent development of hospital organization. While +there had been military hospitals and a few civic institutions for the +care of citizens in Roman times, and some hospital traditions in the East +and in connection with the temples in Egypt, hospital organization as we +know it is Christian in origin; and particularly the erection of +institutions for the care of the ailing poor came to be looked upon very +early as a special duty of Christians. Even the Roman Emperor, Julian the +Apostate, declared that the old Olympian religion would inevitably lose +its hold on the people, unless somehow it could show such care for others +in need as the Christians exhibited wherever they obtained a foothold. It +was not, however, until nearly the beginning of the Middle Ages that the +Christians were in sufficient numbers in the cities, and were free enough +from interference by government, to take up seriously the problem of +public hospital organization. The rapidity of the development, once +external obstacles were removed, shows clearly how close to the heart of +Christianity was the subject of care for the ailing poor. St. Basil's +magnificent foundation at Cæsarea in Cappadocia, called the _Basilias_, +which took on the dimensions of a city (termed Newtown) with regular +streets, buildings for different classes of patients, dwellings for +physicians and nurses and for the convalescent, and apparently even +workshops and industrial schools for the care and instruction of +foundlings and of children that had been under the care of the monastery, +as well as for what we would now call reconstruction work, shows how far +hospital organization, even in the latter part of the fourth century, had +developed. + +About the year 400 Fabiola at Rome, according to St. Jerome, "established +a Nosocomium to gather in the sick from the streets, and to nurse the +wretched sufferers wasted from poverty and disease." A little later +Pammachius, a Roman Senator, founded a Xenodochium for the care of +strangers which St. Jerome praises in one of his letters. At the end of +the fifth century Pope Symmachus built hospitals in connection with the +three most important churches of Rome, St. Peter's, St. Paul's, and St. +Lawrence's. During the Pontificate of Vigilius, Belisarius founded a +Xenodochium in the _Via Lata_ at Rome, shortly after the middle of the +sixth century. Christian hospitals were early established in the cities of +France; and not long after the conversion of England, in that country. + +In connection with these hospitals, it is rather easy to understand the +fine development of surgery by early Christian physicians which we have +traced. The later medieval period of hospital building, however, is of +particular interest in the history of medicine, because we have such +details of it as show its excellent adaptation to medical and surgical +needs. According to Virchow, in his article on the History of German +Hospitals, which is to be found in the second volume of his collected +"Essays on Public Medicine and the History of Epidemics,"[14] the story +of the foundation of these hospitals of the Middle Ages, even those of +Germany, centres around the name of one man, Pope Innocent III. Virchow +was not at all a papistically inclined writer, so that his tribute to the +great Pope who solved so finely the medico-social problems of his time +undoubtedly represents a merited recognition of a great social development +in history. + + "The beginning of the history of all these German hospitals is + connected with the name of that Pope who made the boldest and + farthest-reaching attempt to gather the sum of human interests into + the organization of the Catholic Church. The hospitals of the Holy + Ghost were one of the many means by which Innocent III. thought to + hold humanity to the Holy See. And surely it was one of the most + effective. Was it not calculated to create the most profound + impression to see how the mighty Pope, who humbled emperors and + deposed kings, who was the unrelenting adversary of the Albigenses, + turned his eyes sympathetically upon the poor and the sick, sought the + helpless and the neglected upon the streets, and saved the + illegitimate children from death in the waters! There is something at + once conciliating and fascinating in the fact that, at the very time + when the fourth crusade was inaugurated through his influence, the + thought of founding a great organization of an essentially humane + character, which was eventually to extend throughout all + Christendom, was also taking form in his soul; and that in the same + year (1204) in which the new Latin Empire was founded in + Constantinople, the newly erected hospital of the Holy Spirit, by the + old bridge on the other side of the Tiber, was blessed and dedicated + as the future centre of this organization." + +According to tradition, just about the beginning of the thirteenth century +Pope Innocent resolved to build a hospital in Rome. On inquiry, he found +that probably the best man to put in charge of hospital organization was +Guy or Guido of Montpellier, of the Brothers of the Holy Ghost, who had +founded a hospital at Montpellier which became famous throughout Europe +for its thorough organization. Accordingly he summoned Guido to Rome, and +gave into his hands the organization of the new hospital, which was +erected on the other side of Tiber in the Borgo not far from St. Peter's. +Indeed, Santo Spirito Hospital, as it came to be called, was probably the +direct successor of the hospital which Pope Symmachus (488-514) had had +built in connection with St. Peter's not long after the beginning of the +Middle Ages. It is easy to understand that at the time when magnificent +municipal structures, cathedrals, town halls, abbeys, and educational +institutions of various kinds were being erected, with exemplary devotion +to art and use, the Hospital of Santo Spirito under the special patronage +of the Pope was not unworthy of its time.[15] We know very little, +however, about the actual structure. + +[Illustration: THIRTEENTH-CENTURY HOSPITAL INTERIOR (TONERRE) + +_From "The Thirteenth: Greatest of Centuries," by J. J. Walsh_] + +Then, as now, Bishops made regular visits at intervals _ad limina_--that +is, to the Pope as Chief Bishop of the Church; and according to tradition +Pope Innocent called their attention particularly to this hospital of +Santo Spirito, one of his favourite institutions, and suggested that every +diocese in Christendom ought to have such a refuge for the ailing poor. +The consequence was the erection of hospitals everywhere throughout +Europe. Virchow has told the story of these hospital foundations of the +Holy Ghost, as they were called, and makes it very clear that probably +every town of 5,000 inhabitants everywhere throughout Europe at this time +had a hospital. The traditions with regard to France are quite as complete +as those that concern Germany and the great hospitals of London--St. +Thomas's; St. Bartholomew's, which had been a priory with a house for the +care of the poor, but was now turned into a hospital; Bethlehem, +afterwards Bedlam; Bridewell, and Christ's Hospital, the first of which +afterwards became a prison, while Christ's Hospital, though retaining its +name, became a school. The Five Royal Hospitals, as they were called, +were either founded, or received a great stimulus and thorough +reorganization, during the thirteenth century. + +It would be easy to suppose these hospitals were rather rude structures, +inexpertly built, poorly arranged, and above all badly lighted and +ventilated. They might be expected to furnish protection from the elements +for the poor, but scarcely more, and probably became in the course of time +hotbeds of infection because of their lack of air and uncleanness. As a +matter of fact, they were almost exactly the opposite of any such +supposition. Those in the larger towns at least were model hospitals in +many ways, and ever so much better than many hospital structures erected +in post-medieval centuries. Indeed, the ordinary impression as to the +medieval hospitals, and their lack of suitability to their purpose, would +apply perfectly to the hospitals of the latter half of the eighteenth and +the early nineteenth centuries. It is because our generation still has the +memory of these hospitals of the past generation, and assumes that if +these were so bad, the hospitals of an earlier time must have been worse +and the hospitals of the medieval period must have been intolerable, that +the derogatory tradition with regard to medieval hospitals and many other +medical subjects maintained itself until the coming of real information +with regard to them. + +The ecclesiastical architecture of the later Middle Ages was not only +beautiful, but it was eminently suitable for its purpose, and above all +provided light and air. The churches, the town halls, the monasteries and +abbeys, were models in their kind, and it would have been quite surprising +if the hospitals alone had been unworthy products of that great +architectural period. As abundant remains serve to show even to the +present time, they were not. The hospitals built in the thirteenth century +particularly usually were of one story, had high ceilings with large +windows, often were built near the water in order that there might be +abundance of water for cleansing purposes, and also so that the sewage of +the hospital might be carried off, had tiled floors that facilitated +thorough cleansing, and many other provisions that the architects of our +time are reintroducing into hospital construction. They were a complete +contrast to the barrack-like hospitals with small windows, narrow +corridors, cell-like rooms, which were built even two generations ago, and +which represented the lowest period in hospital building for seven +centuries. + +[Illustration: LEPER HOSPITAL OF ST. BARTHOLOMEW, OXFORD + +_From "Medieval Hospitals," by Miss R. M. Clay_] + +Viollet le Duc, in his "Dictionary of Architecture," has given a picture +of the interior of one of these medieval hospitals, that of Tonnerre in +France, erected by Marguerite of Bourgogne, the sister of St. Louis, in +1293, which we reproduce here. Mr. Arthur Dillon, discussing this +hospital from the standpoint of an architect, says: + + "It was an admirable hospital in every way, and it is doubtful if we + to-day surpass it. It was isolated, the ward was separated from the + other buildings, it had the advantages we so often lose of being but + one story high, and more space was given to each patient than we can + now afford. + + "The ventilation by the great windows and ventilators in the ceiling + was excellent; it was cheerfully lighted, and the arrangement of the + gallery shielded the patients from dazzling light and from draughts + from the windows, and afforded an easy means of supervision; while the + division by the roofless, low partitions isolated the sick, and + obviated the depression that comes from the sight of others in pain. + + "It was, moreover, in great contrast to the cheerless white wards of + to-day. The vaulted ceiling was very beautiful; the woodwork was + richly carved, and the great windows over the altars were filled with + coloured glass. Altogether, it was one of the best examples of the + best period of Gothic architecture." + +The hospital ward itself was 55 feet wide and 270 feet long and had a high +arched ceiling of wood. The Princess herself lived in a separate building, +connected with the hospital by a covered passage. The kitchen and +storehouse for provisions were also in separate buildings. The whole +hospital plant was placed between the branches of a small stream +conducted around it, which served to temper the atmosphere, and was a +source of water supply at one end of the grounds and helped in the +disposal of sewage from the other end. + +A hospital of the Holy Ghost which may be taken as the type of such +structures is still standing at Lübeck in Germany, and was, like the +hospital at Tonnerre, also built during the thirteenth century. It was +erected as the result of the movement initiated by Pope Innocent's +foundation of the Santo Spirito at Rome. The picture of this, in my +"Thirteenth Century," will serve to show what Holy Ghost hospitals in +important cities at least were like. Lübeck was one of the rich Hansa +towns in the thirteenth century, but there were many others of equal +importance, or very nearly so, and all of these towns were rivals in the +architectural adornment of their municipalities, and particularly in the +erection of cathedrals, town halls, guild halls, and other buildings for +the use of citizens. + +The older portion of the Hospital of St. Jean at Bruges also gives an +excellent idea of a later medieval hospital as it was constructed in a +populous commercial town. Bruges, almost needless to say, was one of the +most important cities of Europe in the fourteenth century. The Hospital of +St. Jean, then, was built, like the cathedral and churches and the town +hall, so as to be worthy of the city's prestige. The older part, which is +now used for a storeroom, has the characteristics of the best medieval +hospitals. The ward was one story in height, the windows were large, high +in the walls, and the canals that flowed around the hospital made pleasant +vistas for the patient, while the gardens attached were eminently suitable +for convalescents. The phases of hospital building down the centuries can +be studied at St. Jean, and, strange as it may seem, the oldest portion of +the hospital, that of the medieval period, provided the most light and air +for the patients and the best opportunity for thorough cleansing, as well +as for occupation of the patients' minds with details of the construction +that were visible from any part of the ward. + +The hospitals of the Middle Ages are particularly interesting, because +they represent a solution of the social problems other than merely the +relief of pain and suffering, or the care of the needy who have none to +care for them. They represent a ready, constantly near opportunity for the +better-to-do classes to exercise charity toward those who needed it most. +The hospitals were always in the busiest portions of the towns, and were +often visited by the citizens, both men and women. Dr. John S. Billings, +in his description of "The Johns Hopkins Hospital" (Baltimore, 1890), +touched upon this spirit of the hospital movement of the Middle Ages in a +very appropriate way when he said: + + "When the medieval priest established in each great city of France a + Hotel Dieu, a place for God's hospitality, it was in the interest of + charity as he understood it, including both the helping of the sick + poor, and the affording of those who were neither sick nor poor an + opportunity and a stimulus to help their fellow-men; and doubtless the + cause of humanity and religion was advanced more by the effect on the + givers than on the receivers." + +A rather significant historical detail with regard to medieval hospitals +is the foundation of a special order to take care of the hospitals in +which St. Anthony's Fire, or what we know as erysipelas, was treated. +Apparently this indicated the recognition of the contagiousness of this +disease by the medieval people. Pope Honorius III. approved the foundation +of an order of nurses particularly devoted to the care of patients +suffering from this affection. Other religious congregations for the same +works seem to have been established. We did not recognize the +contagiousness of the disease until the last generation. Undoubtedly these +special foundations made it possible to control many of the epidemics of +erysipelas that used to make surgical care in our hospitals in the modern +time such a difficult matter. Even as late as our Civil War here in +America, erysipelas was the special dread of the hospital surgeon. +Oliver Wendell Holmes pointed out that erysipelas might readily be carried +to the parturient woman with the production of child-bed fever. It is +interesting to realize, then, the attempt of the medieval period to +segregate the disease. + +[Illustration: THE HARBLEDOWN HOSPITAL, NEAR CANTERBURY + +_From "Medieval Hospitals," by Miss R. M. Clay_ + +"On the outskirts of a town, seven hundred years ago, the eye of the +traveller would have been caught by a well-known landmark--a group of +cottages, with an adjoining chapel, clustering round a green enclosure. At +a glance he would recognize it as the lazar-house, and would prepare to +throw an alms to the crippled and disfigured representative of the +community."] + +Besides hospitals, a series of lazarettos--that is, of buildings for the +segregation of lepers--were erected in the various countries of Europe +during the medieval period. Just about the end of the Crusades it was +discovered that leprosy had become very common throughout Europe. It is +often said that leprosy was introduced at this time, but it had evidently +been in the West for many centuries before. Gregory of Tours mentions +leper hospitals as early as 560, and the disease evidently continued to +progress, in spite of these special hospitals, until in the thirteenth +century it became clear that strenuous efforts would have to be made to +wipe out the disease. Accordingly, leproseries were erected in connection +with practically every town in Europe at this time. Baas estimates that +there were some 19,000 of them in Europe altogether. Virchow has listed a +large number of the leper hospitals of the German cities, quite enough to +show that probably no organized community was without one. + +As a consequence of this widespread movement of enforced segregation, +leprosy gradually died out in Europe, remaining only here and there in +backward localities. The disease was probably as common during the later +Middle Ages as tuberculosis is among us at the present time. The recently +discovered relations between the bacterial cause of the two diseases may +give rise to the question as to whether we shall succeed as well with the +great social and hygienic problem that confronts our generation, of +lowering the death-rate from "the great white plague," as the medieval +generations did with their chronic folk-disease, leprosy. It would be "a +consummation devoutly to be wished." We are now beginning to have as many +sanatoria for tuberculosis in proportion to the population as they had of +leproseries. These leproseries, or lazarettos, as they were called, were +not at all the dreadful places that the imagination has been wont to +picture them in recent years; on the contrary they were, as a rule, +beautifully situated on a side-hill to favour drainage, consisted of a +series of dwellings with a chapel in their midst surrounded by trees, and +encompassed by what was altogether a park effect. Miss Clay, in "Medieval +Hospitals," has given a picture of one of them, which we reproduce, +because it serves to contradict the popular false notion with regard to +the bare and ugly and more or less jail-like character of these +institutions. + + + + +CHAPTER XI + +MEDIEVAL CARE OF THE INSANE + + +Quite contrary to the usual impression, rather extensive and well-managed +institutions for the care of the insane came into existence during the +Middle Ages, and continued to fulfil a very necessary social and medical +duty. For the unspeakable neglect of the insane which is a disgrace to +civilization, we must look to the centuries much nearer our own than those +of the Middle Ages. Above all, the Middle Ages did not segregate the +insane entirely from other ailing patients until their affections had +become so chronic as to be certainly incurable, and they took the insane +into ordinary hospitals to care for them at the beginning of their +affection. This mode of procedure has many advantages, mainly in getting +the patients out of unfavourable environments and putting them under +skilled care early in their affections, so that a definite effort is being +made to restore what is called the psychopathic ward in the general +hospitals in our time. Only a careful study of the details of actual +historical references to the medieval care of the insane will serve to +contradict unfortunate traditions which have gathered around the subject +entirely without justification in real history. + +The traditions of medical knowledge with regard to the insane inherited by +the early Middle Ages from the ancients were of the best, and the books +written at this time have some interesting material on the subject. Paulus +Aëgineta (Aëginetus), who wrote in the seventh century--and it must not be +forgotten that already at this time some 200 years of the Middle Ages have +passed--has some excellent directions with regard to the care and +treatment of patients suffering from melancholia and mania. He says, in +his paragraph on the cure of melancholy: "Those who are subject to +melancholy from a primary affection of the brain are to be treated with +frequent baths and a wholesome and humid diet, together with suitable +exhilaration of mind, and without any other remedy unless, when from its +long continuance, the offending humour is difficult to evacuate, in which +case we must have recourse to more powerful and complicated plans of +treatment." He then gives a series of directions, some of them quite +absurd to us, apparently in order to satisfy those who feel that they must +keep on doing something for these cases, though evidently his own opinion +is expressed in the first portion of the paragraph, and in the simple +laxative treatment that he outlines. "These cases are to be purged first +with dodder of thyme (_epithymus_) or aloes; for if a small quantity of +these be taken every day it will be of the greatest service, and open the +bowels gently." + +His directions as to diet for those suffering from melancholia are all in +the line of limiting the consumption of materials that might possibly +cause digestive disturbance, for evidently his experience had taught him +that the depression was deeper whenever indigestion occurs. He says: "The +diet for melancholics shall be wholesome and moderately moistening; +abstaining from beef, roe's flesh, dried lentils, cabbages, snails, thick +and dark coloured wines, and in a word from whatever things engender black +bile." Mania was to be treated very nearly like melancholia, with special +warnings as to the necessity for particular care of these patients. "But +above all things they must be secured in bed, so that they may not be able +to injure themselves or those who approach them; or swung within a wicker +basket in a small couch suspended from on high." This last suggestion +would seem to be eminently practical, especially for young people who are +not too heavy, and enforces the idea that the physicians of this time were +thinking seriously of their problems of care for the insane and +exercising their ingenuity in inventions for their benefit. + +Paul of Ægina seems, then, to have thought that mania and melancholia were +definitely related to each other, and to have held a similar opinion in +this regard to Aretæus, who declared that melancholia was an incipient +mania. Both had evidently noted that in most cases there were melancholic +and maniacal stages in the same patient. These early medieval students of +mental disease, then, anticipated to a rather startling extent our most +recent conclusions with regard to the essential insanities. They would +have been much readier to agree with Kraepelin's term, manic-depressive +insanity, than with the teaching of the hundred years before our time, +which so absolutely separated these two conditions. + +All this represents an organized knowledge of insanity that could not be +acquired by chance, nor by a few intermittent observations on a small +number of patients, but must have been due to actual, careful, continued +observation of many of them over a long period. Here is the presumptive +evidence for the existence of special institutions for their care at this +period in the Middle Ages. This presumption is confirmed by Ducange in his +"Commentary on Byzantine History," in which he tells of the existence of a +_morotrophium_, or house for lunatics, at Byzantium in the fourth +century, and one is known to have existed at Jerusalem late in the fifth +century. Further confirmation of the existence of special arrangements and +institutions for the care of the insane even thus early in the Middle Ages +is obtained from the _regula monachorum_ of St. Jerome, which enjoins upon +the monks the duty of making careful provision for the isolation and +proper treatment of the sick both in mind and body, whilst they were +enjoined to leave nothing undone to secure appropriate care and speedy +recovery of such patients.[16] + +Among the first Christian institutions for the care of the ailing founded +by private benevolence, a refuge for the insane was undoubtedly built in +England before the seventh century. Burdett says that: "How far the two +institutions established in England prior to A.D. 700 were entitled to be +considered asylums, we have discovered insufficient evidence to enable us +to decide." He evidently inclines to the opinion, however, that provision +was made in them for the care of those ailing in mind as well as in body. + +There is a rather well-grounded tradition that Sigibaldus, the +thirty-sixth bishop of Metz during the papacy of Leo IV., about A.D. 850, +erected two monasteries and paid special attention to the sick in body +and mind. There are records that the insane in Metz were placed under the +guardianship of persons regularly appointed. The attendants in the +hospitals had to take a special oath of allegiance to the King, and that +they would fulfil their duties properly. + +There is definite evidence of Bethlehem in London, afterwards known as +Bedlam, containing lunatics during the thirteenth century, for there is +the report of a Royal Commission in the next century stating that there +were six lunatics there who were under duress. Burdett says that Bedlam +has been devoted exclusively to the treatment of lunatics from some years +prior to 1400 down to the present time, so that it takes precedence in +this matter of the asylum founded in Valencia in Spain, which Desmaisons +has erroneously held as the first established in Europe. Esquirol states +that the Parliament of Paris ordered the general hospital, that of the +Hotel Dieu, to provide a place for the confinement of lunatics centuries +before this; and while definite evidence is lacking, there seems no doubt +that in most places there were, as we have said, what we would call +psychopathic wards in connection with medieval hospitals. + +Early in the fifteenth century there are a number of bequests made to +Bedlam which specifically mention the care of the insane. Indeed, "the +poor madmen of Bethlehem" seem to have been favourite objects of charity. +The care of the insane there seems to have touched a responsive chord in +many hearts. Mayor Gregory describes in his "Historical Collections" +(about 1451) this London asylum and its work of mercy, and from him we +have evidence of the fact that some of the patients were restored to +reason after their stay in the asylum. He has words of praise for how +"honestly" the patients were cared for; but recognizes, of course, that +some could not be cured. In his quaint old English he emphasizes +particularly the church feature of the establishment. + + "A chyrche of Owre Lady that ys namyde Bedlam. And yn that place ben + founde many men that ben fallyn owte of hyr wytte. And fulle honestely + they ben kepte in that place; and sum ben restoryde unto hyr witte and + helthe a-gayne. And sum ben a-bydyng there yn for evyr, for they ben + falle soo moche owte of hem selfe that hyt ys uncurerabylle unto man." + +In her chapter on Hospitals for the Insane in "Medieval Hospitals of +England,"[17] Miss Clay gives a number of details of the care of the +insane in England, and notes that the Rolls of Parliament (1414) mention +"hospitals ... to maintain men and women who had lost their wits and +memory"; manifestly they had some experience which differentiated cases +of aphasia from those of insanity. She says that outside of London "it was +customary to receive persons suffering from attacks of mania into general +infirmaries. At Holy Trinity, Salisbury, not only were sick persons and +women in childbirth received, but mad people were to be taken care of +(_furiosi custodiantur donec sensum adipiscantur_). This was at the close +of the fourteenth century. In the petition for the reformation of +hospitals (1414), it is stated that they existed partly to maintain those +who had lost their wits and memory (_hors de leur sennes et mémoire_)." + +Further evidence of the presence of the insane with other patients is to +be found in the fact that in certain hospitals and almshouses it was +forbidden to receive the insane, showing that in many places that must +have been the custom. Miss Clay notes: + + "Many almshouse-statutes, however, prohibited their admission. A + regulation concerning an endowed bed in St. John's, Coventry (1444), + declared that a candidate must be 'not mad, quarrelsome, leprous, + infected.' At Ewelme 'no wood man' [crazy person] must be received; + and an inmate becoming 'madd, or woode,' was to be removed from the + Croydon almshouse." + +Desmaisons is responsible for the tradition which declares there were no +asylums for the insane until the beginning of the fifteenth century, and +that then they were founded by the Spaniards under the influence of the +Mohammedans. Lecky, in his "History of European Morals," has contradicted +this assertion of Desmaisons', and declares that there is absolutely no +proof for it. Burdett, in his "History of Hospitals," vol. i., p. 42, says +with regard to this question: + + "Again, Desmaisons states that the 'origin of the first establishment + exclusively devoted to the insane dates back to A.D. 1409. This date + constitutes an historic fact, the importance of which doubtless needs + no demonstration. Its importance stands out all the more clearly when + we calculate the lapse of time between the period just spoken of + (1409) and that in which Spain's example' (Desmaisons is here + referring to the Valencia asylum as the first in Europe) 'found so + many followers.' Now, as a matter of fact, an asylum exclusively for + the use of the mentally infirm existed at Metz in the year A.D. 1100, + and another at Elbing, near Danzic, in 1320. Again, there was an + ancient asylum, according to Dugdale, known as Berking Church + Hospital, near the Tower of London, for which Robert Denton, chaplain, + obtained a licence from King Edward III. in A.D. 1371. Denton paid + forty shillings for this licence, which empowered him to found a + hospital in a house of his own, in the parish of Berking Church, + London, 'for the poor priests, and for men and women in the said city + who suddenly fall into a frenzy and lose their memory, who were to + reside there till cured; with an oratory to the said hospital to the + invocation of the Blessed Virgin Mary.'" + +The passages from Aëgineta at the beginning of this chapter represent a +thorough understanding of mental diseases often supposed not to exist at +this time. Often it is presumed that this thorough appreciation of +insanity gradually disappeared during subsequent centuries, and was not +revived until almost our own time. It is quite easy, however, to +illustrate by quotations from the second half of the Middle Ages a like +sensible treatment of the subject of insanity by scientific and even +popular writers. How different was the attitude of mind of the medieval +people toward lunacy from that which is usually assumed as existing at +that time may be gathered very readily from the paragraph in +"Bartholomeus' Encyclopædia" with regard to madness. I doubt whether in a +brief discussion so much that is absolutely true could be better said in +our time. Insanity, according to old Bartholomew, was due to some poison, +autointoxication, or strong drink. The treatment is prevention of injury +to themselves or others, quiet and peaceful retirement, music, and +occupation of mind. The paragraph itself is worth while having near one, +in order to show clearly the medieval attitude toward the insane of even +ordinarily well-informed folk, for Bartholomew was the most read book of +popular information during the Middle Ages. + +Bartholomew himself was only a compiler of information--a very learned +man, it is true, but a clergyman-teacher, not a physician. Translations of +his book were probably more widely read in England, in proportion to the +number of the reading public, than any modern encyclopædia has ever been. +He said: + + "Madness cometh sometime of passions of the soul, as of business and + of great thoughts, of sorrow and of too great study, and of dread: + sometime of the biting of a wood-hound [mad dog], or some other + venomous beast; sometime of melancholy meats, and sometime of drink of + strong wine. And as the causes be diverse, the tokens and signs be + diverse. For some cry and leap and hurt and wound themselves and other + men, and darken and hide themselves in privy and secret places. _The + medicine of them is, that they be bound, that they hurt not themselves + and other men. And namely such shall be refreshed, and comforted, and + withdrawn from cause and matter of dread and busy thoughts. And they + must be gladded with instruments of music and some deal be occupied._" + (Italics ours.) + +Bartholomew recognizes the two classes of causes of mental disturbance, +the mental and the physical, and, it will be noted, has nothing to say +about the spiritual--that is, diabolic possession. Writing in the +thirteenth century, diabolism was not a favourite thought of the men of +his time, and Bartholomew omits reference to it as a cause of madness +entirely. Food and drink, and especially strong spirituous liquor, are set +down as prominent causes. It may seem curious in our time that the bite of +a mad dog, or a "wood hound," as Bartholomew put it, should be given so +important a place; but in the absence of legal regulation rabies must have +been rather common, and the disease was so striking from the fact that its +onset was often delayed for a prolonged interval after the bite, that it +is no wonder that a popular encyclopædist should make special note of it. + +The effect of alcohol in producing insanity was well recognized during the +Middle Ages, and many writers have alluded to it. Pagel, in the chapters +on Medieval Medicine in Puschmann's "Handbook," says that Arculanus, of +whom there is mention in the chapter on Oral Surgery and the Minor +Surgical Specialities, has an excellent description of alcoholic insanity. +The ordinary assumption that medieval physicians did not recognize the +physical factors which lead up to insanity, and practically always +attributed mental derangement to spiritual conditions, especially to +diabolic possession, is quite unfounded so far as authoritative physicians +were concerned. Their suggestions as to treatment, above all in their care +for the general health of the patient and the supplying of diversion of +mind, was in principle quite as good as anything that we have been able to +accomplish in mental diseases down to the present time. Their insanity +rate, and above all their suicide rate, was much lower than ours, for life +was less strenuous and conscious, and though men and women often had to +suffer from severe physical strains and stresses, their free outdoor life +made them more capable of standing them. + +The history of human care for the insane, it is often said by those who +are reviewing the whole subject briefly, may be represented by the steps +in progress from the presumption of diabolical possession, and exorcism +for its relief, to intelligent understanding, sympathetic treatment, and +gentle surveillance, with the implication that this has all been a gradual +evolution. There is no doubt that during the Middle Ages even physicians +often thought of possession by the devil as the cause of irrational states +of mind. Not only some of the genuinely insane--though not all, be it +noted--but also sufferers from dreads and inhibitions of various kinds, +the victims of tics and uncontrollable habits, especially the childish +repetition of blasphemous words, and sufferers from other psychoses and +neuroses, were considered to be the victims of diabolic action. Exorcism +then became a favourite form of treatment of all these conditions, but +its general acceptance came about because it was so often successful. The +mental influence of the ceremonies of exorcism was often quite as +efficient in the cure of these mental states as mesmerism, hypnotism, +psycho-analysis, and other mental influences in the modern time. + +It may particularly be compared in this regard to psycho-analysis in our +own day, for this cures patients by making them feel that they have been +the victims of some very early evil impression, usually sexual in +character, which has continued unconsciously to them to colour all their +subsequent mental life. Some of the curious theories of secondary +personality, the subliminal self and what has recently been called "our +hidden guest," represent in other terms what the medieval observers and +thinkers expressed in their way by an appeal to diabolic influence. They +felt that there was a spirit influencing these patients quite independent +of themselves in some way, and their thoroughgoing belief in a personal +devil led them to think that there must be some such explanation of the +phenomena. Even great scientists in the modern time who have studied +psychic research have not been able to get away entirely from the feeling +that there is something in such possession, and have admitted that there +may be even alien influence by an evil spirit. The more one studies the +question from all sides, and not merely from a narrow materialistic +standpoint, the less one is ready to condemn the medievalists for their +various theories of diabolic possession. The Christian Church still +teaches not only its possibility but its actual occurrence. + +Such conservative thinkers as Sir Thomas More, one of England's greatest +Lord Chancellors, the only one who ever cleared the docket of the Court of +Chancery, continued to believe in it nearly a century after the Middle +Ages had closed, but above all is quite frank in the expression of his +opinion that some of the mutism, the tics, and bad habits, and repeated +blasphemies, attributed to it, may be cured by soundly thrashing the young +folks who are subject to them. Neurological experts will recall similar +experiences in the modern time. Charcot's well-known story of the little +boy whose _tic_ was the use of the word uttered by the corporal at +Waterloo, and was cured by being soundly licked by some playmates at the +Salpêtrière gate, is a classic. Some of the medieval cruelty represented +unfortunate developments from the observations that had been made that a +number of the impulsive neuroses and psychoneuroses could be favourably +modified, or even entirely corrected, by attaching to the continuance of +the habit a frequently repeated memory of distinctly unpleasant +consequences that had come upon the patient because of it. Our experience +in the recent war called to attention a great many cases of mutism, +functional blindness, tremors, and incapacities of all kinds, some of +which were cured by painful applications of electricity. The medieval use +of the lash for such cases can be better understood now as the result of +this very modern set of clinical observations. + +In the meantime it must not be forgotten that the people of the Middle +Ages, even when they thought of insane and psychoneurotic persons as the +subjects of diabolic possession, felt themselves under the necessity of +providing proper physical care for these victims of disease or evil +spirits, and as we know actually made excellent provision for them. Not +only were the insane given shelter and kept from injuring themselves and +others, but in many ways much better care was provided for them than has +been the custom down almost to our own time. They had many fewer insane to +care for; life was not so strenuous, or rather fussy, as it is in our +time; large city life had not developed, and simple existence in the +country was the best possible prophylactic against many of the mental +afflictions that develop so frequently in the storm and stress of +competitive industrial city existence. This prophylaxis was accidental, +but it was part of the life of the time that needs to be appreciated, +since it represents one of the helpful hints that the Middle Ages can +give us for the reduction of our own alarmingly increasing insanity rate. + +They had no large asylums such as we have now, but neither did they have +any poor-houses; yet we have come to recognize how readily they solved the +social evils of poverty. The almshouses at Stratford, with their +accommodations for an old man and his wife living together, are a typical, +still extant example of this. Each small community cared for its own +sufferers. They did not solve their social problems in the mass fashion +which we have learned is so liable to abuse, but each little town cared to +a great extent for its own mentally ailing. They were able to do this +mainly because hospitals were rather frequent; and psychic cases were, at +the beginning, cared for in hospitals, and when in milder state their near +relatives were willing to take more bother in caring for them than in our +time. Delirious states due to fever had not yet been definitely +differentiated from the acute insanities, and all these cases then were +taken in by the hospitals. This was an excellent thing for patients, +because they came under hospital care early; and one of the developments +that must come in our modern hospitals is a psychopathic ward in every one +of them, for patients will be saved the worst developments of their +affection. + +The better-to-do classes found refuges for their non-violent insane in +certain monasteries and convents, or in parts of monastic establishments +particularly set aside for this purpose. When the patient was of the +higher nobility, he was often put in charge of a monk or of several +religious, and confined in a portion of his own or a kinsman's castle and +cared for for years. There are traditions of similar care for the +peasantry who were connected with monastic establishments, and sometimes +small houses were set apart for their use on the monastery grounds. As +cities grew in extent, certain hospitals received mental patients as well +as the physically ailing, keeping them segregated. After a time some of +these hospitals were entirely set aside for this purpose. Bedlam in +England, which had been the old Royal Bethlehem Hospital for the care of +all forms of illness, came to be just before the end of the thirteenth +century exclusively for the care of the insane. In Spain particularly the +asylums for the insane were well managed, and came to be models for other +countries. This development in Spain is sometimes attributed to the Moors, +but there is absolutely no reason for this attribution, except the desire +to minimize Christianity's influence, even though this effort should +attempt the impossible feat of demonstrating Mohammedanism as an organizer +of charity and social service. + +Some of the developments of their care for the insane in the Middle Ages +are very interesting. Before this period closed, there was a custom +established at Bedlam by which those who had been insane but had become +much better were allowed to leave the institution. This was true, even +though apparently there might be no friends to care for them particularly, +or to guarantee their conduct or their return, in case of redevelopment of +their symptoms. This amounted practically to the open-door system. The +authorities of the hospital, however, made one requirement. Those who had +been insane and were allowed to leave Bedlam were required to wear a badge +or plate on the arm, indicating that they had been for some time in this +hospital for the insane. These people came to be known as Bedlamites, or +Bedlams, or Bedlamers, and attracted so much sympathy from the community +generally that some of the ne'er-do-wells, the tramps and sturdy vagrants +who have always been with the world as a problem quite as well as the +insane, obtained possession of these insignia by fraud or stealth, and +imposed on the charity of the people of the time. + +It is easy to understand that wherever these patients were recognized by +their badges as having been for a time in an asylum for the insane, they +were treated quite differently from ordinary people. Though allowed to +leave the asylum, and left, as it were, without surveillance, they were +really committed to the care of the community generally. No one who knows +the history is likely to irritate a person who has been insane, nor are +such people treated in the same spirit as those who are supposed to have +been always normal, but out of pity and sympathy they are particularly +cared for. They are not expected to live the same workaday existence as +mentally healthy individuals, but their pathway in life is smoothed as +much as possible. Many an unfortunate incident in modern times is due to +the fact that a previous inmate of an asylum is irritated beyond his power +to control himself in the ordinary affairs of life by those who know +nothing of his previous mental weakness. It is not unlikely that our +open-door system will have to be supplemented by some such arrangement as +this medieval requirement of a badge, and that we can actually get +suggestions from the medieval people with regard to the care of the insane +that will be valuable for us. + +Another very interesting development of care for the mentally afflicted +was the organization of institutions like the village of Gheel in Belgium, +in which particularly children who were of low-grade mentality were cared +for. This was practically the origin of what has come in our time to be +called the colony system of caring for defectives. We now have colonies +for imbeciles of various grades, and village systems of caring for them. +At Gheel the system developed, it might be said, more or less +accidentally, but really quite naturally. St. Dympna was an Irish +girl-martyr whose shrine, said to be on the site of her martyrdom, existed +in the village of Gheel. Her intercession was said to be very valuable in +helping children of low-grade mentality. These were brought to the shrine, +sometimes from a long distance, and when the prayers of relatives were not +answered immediately the children were often left near the shrine in the +care of some of the villagers, to have the benefit of the martyr's +intercession for a prolonged period. As a consequence of this custom, many +of the houses of the village came to harbour one or more of these mentally +defectives, who were cared for by the family as members of it. + +The religious feelings, and particularly the impression that the +defectives were under the special patronage of the patron saint of the +village, not only kept them from being abused or taken advantage of in any +way, but made them an object of special care. They were given various +simple tasks to perform, and the public spirit of the community cared for +them. It was only with the development of modern sophistication that the +tendency to take advantage of social defectives came and special +government regulations had to be made and inspectors appointed. This +system of caring for these defective children, however, was eminently +satisfactory. Other villages took up the work, especially in the Low +Countries and in France. The village and colony system of caring for the +insane, which we are now developing with so much satisfaction, was +entirely anticipated under the most favourable circumstances, and with +religious sanctions, during the Middle Ages. Not a few of the defectives, +when they grew up, came to be attached in various humble occupations to +monastic establishments. Here they were out of the current of the busy +life around them, and were cared for particularly. They were not +overworked but asked to do what they could, and given their board and +clothes and the sympathetic attention of the religious. There are many +more of such cases at the present time than are at all appreciated. They +emphasize how much of this fraternal care there must have been in the +Middle Ages. + +Between the village system of caring for defectives, and the germ of the +colony idea in their recognition of the value of the country or small town +as a dwelling-place for those suffering from backwardness of mind or +chronic bodily ills that disturb mentality, and the "open-door system" for +the insane, as practised at Bedlam and other places, the Middle Ages +anticipated some of the best features of what is most modern in our care +for mental patients. Their use of severe pain as a corrective for the +psychoneuroses, even when they thought of them in connection with diabolic +possession, is another striking instance of their very practical way of +dealing with these patients in a manner likely to do them most good. We +have had to make our own developments in these matters, however, before we +could appreciate the true value of what they were doing in the Middle +Ages. + + + + +APPENDIX I + + +Law of the Emperor Frederick II. (1194-1250) regulating the practice of +Medicine.[18] + +"While we are bent on making regulations for the common weal of our loyal +subjects we keep ever under our observation the health of the individual. +In consideration of the serious damage and the irreparable suffering which +may occur as a consequence of the inexperience of physicians, we decree +that in future no one who claims the title of physician shall exercise the +art of healing or dare to treat the ailing, except such as have beforehand +in our University of Salerno passed a public examination under a regular +teacher of medicine and been given a certificate, not only by the +professor of medicine, but also by one of our civil officials, which +declares his trustworthiness of character and sufficiency of knowledge. +This document must be presented to us, or in our absence from the kingdom, +to the person who remains behind in our stead in the kingdom, and must be +followed by the obtaining of a licence to practise medicine either from +us or from our representative aforesaid. Violation of this law is to be +punished by confiscation of goods and a year in prison for all those who +in future dare to practise medicine without such permission from our +authority. + +"Since the students cannot be expected to learn medical science unless +they have previously been grounded in logic, we further decree that no one +be permitted to take up the study of medical science without beforehand +having devoted at least three full years to the study of logic.[19] After +three years devoted to these studies he (the student) may, if he will, +proceed to the study of medicine, provided always that during the +prescribed time he devotes himself also to surgery, which is a part of +medicine. After this, and not before, will he be given the licence to +practise, provided he has passed an examination, in legal form, as well as +obtained a certificate from his teacher as to his studies in the preceding +time. After having spent five years in study he shall not practise +medicine until he has during a full year devoted himself to medical +practice with advice and under the direction of an experienced physician. +In the medical schools the professors shall during these five years devote +themselves to the recognized books, both those of Hippocrates as well as +those of Galen, and shall teach not only theoretic but also practical +medicine. + +"We also decree as a measure intended for the furtherance of public health +that no surgeon shall be allowed to practise, unless he has a written +certificate, which he must present to the professor in the medical +faculty, stating that he has spent at least a year at that part of +medicine which is necessary as a guide to the practice of surgery, and +that, above all, he has learned the anatomy of the human body at the +medical school, and is fully equipped in this department of medicine, +without which neither operations of any kind can be undertaken with +success nor fractures be properly treated. + +"In every province of our kingdom which is under our legal authority, we +decree that two prudent and trustworthy men, whose names must be sent to +our court, shall be appointed and bound by formal oath, under whose +inspection electuaries and syrups and other medicines be prepared +according to law and be sold only after such inspection. In Salerno in +particular we decree that this inspectorship shall be limited to those who +have taken their degree as masters in physic. + +"We also decree by the present law that no one in the kingdom except in +Salerno or in Naples [in which were the two universities of the kingdom] +shall undertake to give lectures on medicine or surgery, or presume to +assume the name of teacher, unless he shall have been very thoroughly +examined in the presence of a government official and of a professor in +the art of medicine. [No setting up of medical schools without the proper +authority.] + +"Every physician given a licence to practise must take an oath that he +shall faithfully fulfil all the requirements of the law, and in addition +that whenever it comes to his knowledge that any apothecary has for sale +drugs that are of less than normal strength, he shall report him to the +court, and besides that he shall give his advice to the poor without +asking for any compensation. A physician shall visit his patient at least +twice a day and at the wish of his patient once also at night, and shall +charge him, in case the visit does not require him to go out of the +village or beyond the walls of the city, not more than one-half tarrene in +gold for each day's service.[20] From a patient whom he visits outside of +the village or the wall of the town, he has a right to demand for a day's +service not more than three tarrenes, to which may be added, however, his +expenses, provided that he does not demand more than four tarrenes +altogether. + +"He (the regularly licensed physician) must not enter into any business +relations with the apothecary nor must he take any of them under his +protection nor incur any money obligations in their regard. Nor must any +licensed physician keep an apothecary's shop himself. Apothecaries must +conduct their business with a certificate from a physician according to +the regulations and on their own credit and responsibility, and they shall +not be permitted to sell their products without having taken an oath that +all their drugs have been prepared in the prescribed form, without any +fraud. The apothecary may derive the following profits from his sales: +Such extracts and simples as he need not keep in stock for more than a +year, before they may be employed, may be charged for at the rate of three +tarrenes an ounce. Other medicines, however, which in consequence of the +special conditions required for their preparation or for any other reason, +the apothecary has to have in stock for more than a year, he may charge +for at the rate of six tarrenes an ounce. Stations for the preparation of +medicines may not be located anywhere but only in certain communities in +the kingdom as we prescribe below. + +"We decree also that the growers of plants meant for medical purpose shall +be bound by a solemn oath that they shall prepare their medicines +conscientiously according to the rules of their art, and so far as it is +humanly possible that they shall prepare them in the presence of the +inspectors. Violations of this law shall be punished by the confiscation +of their movable goods. If the inspectors, however, to whose fidelity to +duty the keeping of the regulations is committed, should allow any fraud +in the matters that are entrusted to them, they shall be condemned to +punishment by death." + + + + +APPENDIX II + + +Bull of Pope John XXII., issued February 18, 1321, as a charter for the +Medical Department of the University of Perugia.[21] + +"While with deep feelings of solicitous consideration we mentally revolve +how precious the gift of science is and how desirable and glorious is its +possession, since through it the darkness of ignorance is put to flight +and the clouds of error completely done away with so that the trained +intelligence of students disposes and orders their acts and modes of life +in the light of truth, we are moved by a very great desire that the study +of letters in which the priceless pearl of knowledge is found should +everywhere make praiseworthy progress, and should especially flourish more +abundantly in such places as are considered to be more suitable and +fitting for the multiplication of the seeds and salutary germs of right +teaching. Whereas some time ago, Pope Clement of pious memory, our +predecessor, considering the purity of faith and the excelling devotion +which the city of Perugia, belonging to our Papal states, is recognized to +have maintained for a long period towards the Church, wishing that these +might increase from good to better in the course of time, deemed it +fitting and equitable that this same city, which had been endowed by +Divine Grace with the prerogatives of many special favours, should be +distinguished by the granting of university powers, in order that by the +goodness of God men might be raised up in the city itself pre-eminent for +their learning, decreed by the Apostolic authority that a university +should be situated in the city and that it should flourish there for all +future time with all those faculties that may be found more fully set +forth in the letter of that same predecessor aforesaid. And, whereas, we +subsequently, though unworthy, having been raised to the dignity of the +Apostolic primacy, are desirous to reward with a still richer gift the +same city of Perugia for the proofs of its devotion by which it has proven +itself worthy of the favour of the Apostolic See, by our Apostolic +authority and in accordance with the council of our brother bishops, we +grant to our venerable brother, the Bishop of Perugia, and to those who +may be his successors in that diocese, the right of conferring on persons +who are worthy of it the licence to teach (the Doctorate) in canon and +civil law, according to that fixed method which is more fully described +and regulated more at length in this our letter. + +"Considering, therefore, that this same city, because of its convenience +and its many favouring conditions, is altogether suitable for students and +wishing on that account to amplify the educational concessions hitherto +made because of the public benefits which we hope will flow from them, we +decree by Apostolic authority that if there are any who in the course of +time shall in that same university attain the goal of knowledge in medical +science and the liberal arts and should ask for licence to teach in order +that they may be able to train others with more freedom, that they may be +examined in that university in the aforesaid medical sciences and in the +arts and be decorated with the title of Master in these same faculties. We +further decree that as often as any are to receive the decree of Doctor in +medicine and arts, as aforesaid, they must be presented to the Bishop of +Perugia, who rules the diocese at the time, or to him whom the bishop +shall have appointed for this purpose, who having selected teachers of the +same faculty in which the examinations are to be made, who are at that +time present in the university to the number of at least four, they shall +come together without any charge to the candidate and, every difficulty +being removed, should diligently endeavour that the candidate be examined +in science, in eloquence, in his mode of lecturing, and anything else +which is required for promotion to the degree of doctor or master. With +regard to those who are found worthy, their teachers should be further +consulted privately, and any revelation of information obtained at such +consultations as might redound to the disadvantage or injury of the +consultors is strictly forbidden. If all is satisfactory the candidates +should be approved and admitted and the licence to teach granted. Those +who are found unfit must not be admitted to the degree of doctor, all +leniency or prejudice or favour being set aside. + +"In order that the said university may in the aforesaid studies of +medicine and the arts so much more fully grow in strength, according as +the professors who actually begin the work and teaching there are more +skilful, we have decided that until four or five years have passed some +professors, two at least, who have secured their degree in the medical +sciences at the University of Paris, under the auspices of the Cathedral +of Paris, and who shall have taught or acted as masters in the +before-mentioned University of Paris, shall be selected for the duties of +the masterships and the professorial chairs in the said department in the +University of Perugia, and that they shall continue their work in this +last-mentioned university until noteworthy progress in the formation of +good students shall have been made. + +"With regard to those who are to receive the degree of doctor in medical +science, it must be especially observed that all those seeking the degree +shall have heard lectures in all the books of this same science which are +usually required to be heard by similar students at the University of +Bologna or of Paris, and that this shall continue for seven years. Those, +however, who have elsewhere received sufficient instruction in logic or +philosophy having applied themselves to these studies for five years in +the aforesaid universities, with the provision, however, that at least +three years of the aforesaid five or seven year term shall have been +devoted to hearing lectures in medical science in some university and +according to custom, shall have been examined under duly authorized +teachers and shall have, besides, read such books outside the regular +course as may be required, may, with due observation of all the +regulations which are demanded for the taking of degrees in Paris or +Bologna, also be allowed to take the examination at Perugia." + + + + +INDEX + + + Abdallah, 41 + + Abdominal wounds, 98 + + Abella, 157 + + Abulcasis, 35, 78 + + Abul Farag, 33 + + Adalbert of Mainz, 63 + + Adale, 41 + + Ægidius, 64 + + Ægina, Paul of, 6, 27, 33, 138, 146, 149, 184, 186 + + Æginetus. _See_ Ægina, Paul of + + Ætius, 4, 28, 138, 146 + + Aëtius, 27 + + Albert the Great, 110 + + Albertus Magnus, 14, 18 + + Alcohol, 194 + + Alessandra Giliani, 164 + + Alexander of Tralles, 4, 27, 29, 146 + + Alexandria, 33 + + Ali Abbas, 35 + + Alphanus, 41 + + Anæsthesia, 100, 104, 105, 120 + + Anselm of Havelberg, 63 + + Anthemios, 5 + + Antiseptic surgery, 104 + wine as, 101 + + Arabian culture, 8 + surgeons, 149 + + Arabians, 139 + + Arabs, 46 + + Archbishop of Lyons, 63 + + Arculanus, 147, 150 + + Ardern, John, 85, 123, 127 + + Aretæus, 186 + + Argelata, Pietro d', 125 + + Aristotle, 18 + study of, 16 + + Armato, Salvino de, 152 + + Arnold de Villanova, 66 + aphorisms of, 67 + + Arsenic in syphilis, 124 + + Artificial teeth, 142 + + Asepsis, 95, 101 + + Asylums, 191 + + Aue, Hartmann von der, 64 + + Aurelius Celsus, 26 + + Authorities of medieval physicians, 20 + + Authority, influence of, 12 + + Autointoxication, 83 + + Avenzoar, 35, 77 + + Averroes, 35 + + Avicenna, 35, 47, 76, 149 + + + Baas, 181 + + Bachtischua, 7 + + Bacon, Roger, 14, 110 + + Bandages, stiffened, 123 + + Barber surgeons, 115 + + Bartholomæus Anglicus, 81 + + Bartholomew on causes of insanity, 192 + + Basil Valentine, 84 + + Baths, 32 + for melancholia, 184 + + Bedlam, 188 + + Bedlamites, 201 + + Belisarius, Hospital of, 171 + + Benedictine convents, 159 + + Bernard de Gordon, 70, 72, 153 + + Bernard of Morlaix, 49 + + Bile in eye diseases, 152 + + Bladders of animals, 78 + + Bleeding, 55, 84 + + Blood-letting, 32 + + Bologna, 40 + + Bones, number of, 54 + + Bougies, 123 + + Branca, 106 + Antonio, 107 + + Bruno da Longoburgo, 96 + + Brunschwig, Hieronymus, 135 + + Bubonic plague, 77 + + + Calomel, 85 + + Care of the insane, 34, 183, 189 + + Care of the sick, 24, 25 + + Cassiodorus, 25 + + Cataract, 151 + + Cautery, 100, 126 + + Celsus, Aurelius, 26 + + Charter of the University of Perugia, 212 + + Chauliac, Guy de, 11, 66, 71, 72, 105, 109, 118, 123, 139, 140, 153, 167 + + Christian hospitals, 24 + + Cleanliness, 95 + + Clyster apparatus, 127 + + Cold compresses, 30 + + Compilation, 3 + + Constantine, 36, 45 + + Contrecoup, 92 + + Convents, Benedictine, 159 + + Corbeil, Gilles de, 64 + + Cosmetics, 77 + + Crusades, 89, 181 + + + Dental instruments, 143 + + Dentistry, 138 + + Depressed fractures, 93 + + De Renzi, 37, 41, 44, 45, 47, 76, 155, 156 + + Diabolic possession, 195, 196 + + Diet, 31, 36 + for melancholies, 185 + + Dioscorides, 26 + + Dioscoros, 5 + + Diphtheria, 27, 128 + + Diseases of nervous system, 30 + of women, 156 + + Drainage, 97 + tubes, 125 + + Duke, Robert, 46 + + Duns Scotus, 110 + + Dura mater, infection of, 93 + + + Ebers Papyrus, 137 + + Education, characters of medieval, 12 + + Elias, 41 + + Elinus, 41 + + English, King of the, 40 + + Epileptic conditions, 30 + + Exorcism, 195 + + Eye diseases, bile in, 152 + wash, urine of infants as, 152 + + + Fabiola, Hospital of, 171 + + Fee, law as to, 44 + + Fever, 32 + + Filaria medinensis, 77 + + Fistulæ, 100 + + Fistulas, 127 + + Four masters of Salerno, 47, 91 + + Fracture of the skull, 91 + of the thigh, extension in, 123 + + Fractures of the skull, 94 + depressed, 93 + + Frederick II., 42 + law of, 43, 206 + + + Gaddesden, John of, 70, 119 + + Galen, 18, 19, 26, 47, 72, 116 + + Gariopontus, 41 + + Gerssdorff, Hans von, 135 + + Gilbert, 69 + + Giovanni of Arcoli, 143 + + Glaucoma, 152 + + Gonorrhoea, 123 + + Gregory, Major, 189 + of Tours, 181 + + Guarna, Rebecca, 157 + + Guerini, 142, 143 + + Guido of Montpellier, 64 + + Gurlt, 9, 47, 69, 90, 93, 95, 96, 99, 106, 110, 113, 121, 146, 156 + + Guy de Chauliac. _See_ Chauliac + + Guy of Montpellier. _See_ Montpellier + + + Hæmoptysis, 30 + + Hangman's rope, 28 + + Hare-lip, 134 + + Hartmann von der Aue, 64 + + Headache, 30 + + Hemicrania, 30 + + Herbs, 26 + + Hernia, 68 + operations too frequent, 122 + radical cure of, 121 + reduction of, 122 + + Hernias, 99 + + Herodotus, 137 + + Hippocrates, 26, 47 + + Holy Ghost Hospital, 172 + + Hospital, 64, 65 + at Lübeck, 178 + for lunatics, 187 + of Bedlam, 188 + of Belisarius, 171 + of Fabiola, 171 + of Pope Symmachus, 171 + of St. Basil, 170 + of St. Jean, 178 + of Tonnerre, 176 + + Hospitals, 169 + Christian, 24 + for lepers, 181 + of the Holy Ghost, 172 + royal, 174 + + Hotel Dieu, 188 + + "Hudibras," 107 + + Hugh of Lucca, 96, 104 + + Humours, 54 + + Hymns, Latin, 48 + + Hysteria, 34 + + + Indian surgeons, 106 + + Infection of dura mater, 93 + + Infirmaries in monasteries, 24 + + Inhalations, steam, 29 + + Insane, care of the, 34, 183, 189 + + Insanity, 194 + lash for, 198 + + Intestine, suture of, 134 + + Intestines, wounds of, 99 + + Italy the postgraduate medical centre, 118 + + + John of Salisbury, 64 + of Gaddesden, 70, 119 + + + King of the English, 49 + + + Laceration of the middle meningeal artery, 92 + + Lanfranc, 11, 80, 96, 110 + + Lash for insanity, 198 + + Latin hymns, 48 + + Law as to fee, 44 + of Frederick II., 43, 206 + + Lepers, hospitals for, 181 + + Ligatures, 125 + + "Lilium Medicinæ," 73 + + Linear cicatrices, 101 + + Lister, Lord, 103 + + Louis IX., 110 + + Lübeck, hospital at, 178 + + Lunatics, hospital for, 187 + + Lucca, Hugh of, 96, 104 + + Lyons, Archbishop of, 63 + + + Manzolini, Madame, 165 + + Mad dog, 68, 80 + + Magnetism, 15 + + Maimonides, 35, 79 + + Medical oath, 44 + schools at universities, 74 + superstitions, 22 + + Medici, 164 + + Medicine and surgery, relations of, 115 + popular, 22 + + Medieval education, characters of, 12 + medicine, periods of, 21 + textbooks, 88 + + Melancholics, diet for, 185 + + Mental defectives, colonies for, 202 + + Meningeal artery, laceration of, 92 + + Mercuriade, 157 + + Mercury, use of, 123 + + Mesue, 47 + + Methrodoros, 5 + + Metrorrhagia, 33 + + Middle Ages, limits of, vii + + Milk, 29, 52 + bath, 78 + + Monasteries, infirmaries in, 24 + + Mondeville, Henri de, 11, 66, 114, 116 + + Mondino, 96, 164 + + Monte Cassino, 39 + + Montpellier, Guy de, 10, 61, 173 + + Moorish physicians, 62 + + Morbus Gallicus, 124 + + Morley, Henry, 17 + + Morgagni, 84 + + Muratori, 76 + + + Nasal cautery, 148 + polypi, 147 + speculum, 149 + + Nature study, 13 + + Needling for cataract, 151 + + Nefretykes, 85 + + Nerve suture, 113 + + Nervous system, 30 + + Nicaise, 166 + + Nose, surgery of the, 106 + + Number of bones, 54 + of veins, 54 + + Nurses, order of, 180 + + Nutrition _per rectum_, 77 + + + Oath, medical, 44 + + Oesophagus tube, 123 + + Ophthalmology, 151 + + Opium, 29 + + Order of nurses, 180 + + Ordronaux, 47, 50 + + Oribasius, 28 + + Orthodontia, 139 + + + Pagel, 56, 127, 194 + + Pammachius, 171 + + Paris, 40, 110 + + Passavant, Jean, 111 + + Paul of Ægina, 6, 27, 33, 138, 146 + + Peregrinus, 15 + + Perineum, rupture of, 157 + + Perugia, Charter of the University, 212 + + Pfolspeundt, Heinrich von, 133, 134 + + Physician, conduct of the, 58 + + Physicians, Moorish, 62 + + Pitard, Jean, 114 + + Plague, bubonic, 77 + + Plastic surgery, 106, 134 + + Polypi, nasal, 147 + + Pontus, 41 + + Pope Symmachus, Hospital of, 171 + + Popular medicine, 22 + + Power, D'Arcy, 127 + + Psycho-analysis, 196 + + Pure drug law, 43 + + Pus, 103 + + Puschmann, 56 + + Putrefaction, 97 + + + Rabies, 81, 128 + + Rectal feeding, 78 + surgery, 127 + + Red light treatment, 70, 82 + + Regimen, 48, 49 + sanitatis, 47 + + Renal disease, 85 + + Rhazes, 35, 148 + + Roger, 42, 56, 70, 90, 103 + + Roland, 56, 103 + + Rolando, 91 + + Roman medicine, origin of, 2 + + "Rosa Anglica," 70 + + Rupture of the perineum, 157 + + + St. Basil, Hospital of, 170 + + St. Benedict, 24 + + St. Bernard, 63 + of Clairvaux, 161 + + St. Hildegarde, 160 + + St. Jean, Hospital of, 178 + + Saintsbury, Professor, 48 + + Salerno, 7, 37, 75, 155 + curriculum at, 38 + + Salerno, school of, 57 + + Salicet, William of, 96, 105 + + Salisbury, John of, 64 + + Salvino de Armato, 152 + + Santa Sophia, architect of, 5 + + School of Salerno, 57 + + Scotus, Duns, 40 + + Sects in surgery, 116 + + Sick, care of the, 24, 25 + + Skin of the snake, 28 + + Skull, fractures of, 91, 94 + opening the, 92 + + Smallpox, 35, 70 + + Snake, skin of, 28 + + Sore throat, 31 + + Spectacles, 73, 152 + + Steam inhalations, 29 + + Stiffened bandages, 123 + + Students, 65 + + Superstitions, medical, 22 + + Surgeon, training of, 117 + + Surgeons, Arabian, 140 + barber, 11 + Indian, 106 + temperance in, 97 + + Surgery, antiseptic, 104 + of the nose, 106 + plastic, 106, 134 + rectal, 127 + sects in, 116 + + Surgical specialities, 136 + + Syphilis, 123 + arsenic treatment of, 124 + + + Tagliacozzi, 107 + + Taranta, Valesco de, 71 + + Tartar, removal of, 141 + + Teeth, artificial, 142 + cleaning of, 140 + filling of, 145 + preservation of, 139, 144 + straightening of, 139 + + Temperaments, 54 + + Temperance in surgeons, 97 + + Testicle excision in hernia operations, 121 + + Tetanus, 130 + + Textbooks, medieval, 88 + + Theodoric, 70, 96, 102, 113 + + Therapeutics, 23 + + Thigh, fracture of, 123 + + Thomas Aquinas, 110 + + Thyroid gland, 28 + + Tonnerre, Hospital of, 176 + + Tooth-powder, 140 + + Tracheotomy, 147, 150 + + Trallianus, 4 + + Trephining, 93, 94 + + Trichiasis, 153 + + Trotula, 155 + + Truss, 73, 122 + + + Union by first intention, 100 + + Universities, medical schools at, 74 + + Urine of infants as eye-wash, 152 + + Use of mercury, 123 + + Uvula, affections of the, 150 + + + Valentine, Basil, 84 + + Valesco de Taranta, 71 + + Veins, number of, 54 + + Vicious sexual habits, 28 + + Vigo, John de, 145 + + Viollet le Duc, 176 + + Virchow, 171, 174, 181 + + + William of Salicet, 96, 105 + + Wine as antiseptic, 101 + + Women, diseases of, 156 + in medicine, 10 + physicians, 166 + professors, 155 + students, 155 + + Wood dogge, 129 + + Wood-hound, 193 + + Wounds, abdominal, 98 + dry treatment of, 125 + of intestines, 99 + treatment of, 98 + + + Yperman, 123, 131 + + +PRINTED IN GREAT BRITAIN BY BILLING AND SONS, LTD., GUILDFORD + + + + +FOOTNOTES: + +[1] Fordham University Press, New York, 1911. + +[2] _Popular Science Monthly_, May, 1911. + +[3] Philadelphia: Lippincott, 1871. + +[4] The Latin lines run thus: + + Si vis incolumem, si vis te reddere sanum, + Cures tolle graves, iras crede profanum. + Parce mero--coenato parum, non sit tibi vanum + Surgere post epulas; somnum fuge meridianum; + Ne mictum retine, nec comprime fortiter anum; + Hæc bene si serves, tu longo tempore vives. + +[5] English translations of the _Regimen_ were made in 1575, 1607, and +1617. The two latter were printed; the former exists in manuscript in the +Library of Corpus Christi College, Oxford. The opening lines of the +edition of 1607 deserve to be noted because they are the origin of an +expression that has been frequently quoted since. + + The Salerne Schoole doth by these lines impart + All health to England's King, and doth advise + From care his head to keepe, from wrath his harte. + Drink not much wine, sup light, and soone arise. + When meat is gone long sitting breedeth smart; + And after noone still waking keepe your eies, + When mou'd you find your selfe to nature's need, + Forbeare them not, for that much danger breeds, + _Use three physitians still--first Dr. Quiet, + Next Dr. Merry-man, and third Dr. Dyet_. + +[6] Some of these old medical traditions come down to us from many more +centuries than we have any idea of until we begin to trace them. +Ordinarily it is presumed that the advice with regard to the taking of +small amounts of fluid during meals comes to us from the modern +physiologists. In "The Babees Book," a volume on etiquette for young folks +issued in the thirteenth century, there is among other advices, as, for +instance, "not to laugh or speak while the mouth is full of meat or +drink," and also "not to pick the teeth with knife or straw or wand or +stick at table," this warning: "While thou holdest meat in mouth beware to +drink; that is an unhonest chare; and also physick forbids it quite." It +was "an unhonest chare" because the drinking-cups were used in common, and +drinking with meat in the mouth led to their soiling, to the disgust of +succeeding drinkers. All the generations ever since have been in slavery +to the expression that "physic forbids it quite," and now we know without +good reason. + +[7] The book called "The Hundred Merry Jests" suggests that the wagtail is +light of digestion because it is ever on the wing, and therefore had, as +it were, an essential lightness. + +[8] International Clinics, vol. iii., series 28. + +[9] "Historical Relations of Medicine and Surgery down to the Sixteenth +Century." London, 1904. + +[10] The subsequent disuse of anæthesia seems an almost impossible mystery +to many, but the practically total oblivion into which the practice fell +is incomprehensible. This is emphasized by the fact that while it dropped +out of medical tradition, the memory of it remained among the poets, and +especially among the dramatists. Shakespeare used the tradition in "Romeo +and Juliet." Tom Middleton, in the tragedy of "Women Beware Women" (Act +IV., Scene i., 1605), says: + + "I'll imitate the pities of old surgeons + To this lost limb, who, ere they show their art, + Cast one asleep, then cut the diseased part." + +[11] "Physicke is so studied and practised with the Egyptians that every +disease hath his several physicians, who striveth to excell in healing +that one disease and not to be expert in curing many. Whereof it cometh +that every corner of that country is full of physicians. Some for the +eyes, others for the head, many for the teeth, not a few for the stomach +and the inwards." + +[12] The Ebers Papyrus shows that special attention was paid to diseases +of the eyes, the nose, and throat, and we have traditions of operations +upon these from very early times. Conservative surgery of the teeth, and +the application of prosthetic dental apparatus, being rather cosmetic than +absolutely necessary, might possibly be expected not to have developed +until comparatively recent times; but apart from the traditions in Egypt +with regard to this speciality, which are rather dubious, we have abundant +evidence of the definite development of dentistry from the long ago. The +old Etruscans evidently paid considerable attention to prosthetic +dentistry, for we have specimens from the Etruscan tombs which show that +they did bridge work in gold, supplied artificial teeth, and used many +forms of dental apparatus. At Rome the Laws of the Twelve Tables (_circa_ +450 B.C.) forbade the burying of gold with a corpse except such as was +fastened to the teeth, showing that the employment of gold in the mouth +for dental repair must have been rather common. We have specimens of gold +caps for teeth from the early Roman period; and there is even a +well-confirmed tradition of the transplantation of teeth, a practice which +seems to have been taken up again in the later Middle Ages, and then +allowed to lapse once more until our own time. + +[13] Dr. Petells, discussing this use of livers (_Janus_, 1898), says that +there has been some tendency to revert to the idea of biliary principles +as of value in external eye diseases. + +[14] "Gesammelte Abhandlungen aus dem Gebiete der Oeffentliche Medizin," +Hirschwald, Berlin, 1877. + +[15] See Walsh, "The Thirteenth, Greatest of Centuries," New York, seventh +edition, 1914. + +[16] Burdett, "Hospitals and Asylums of the World." + +[17] London, 1909. + +[18] To be found in Huillard-Brehollis' "Diplomatic History of Frederick +II. with Documents" (issued in twelve quarto volumes, Paris, 1851-1861). + +[19] Under logic at this time was included the study of practically all +the subjects that are now included under the term the seven liberal arts. +Huxley, in his address before the University of Aberdeen, on the occasion +of his inauguration as rector of that university, said: "The scholars (of +the early days of the universities, first half of the thirteenth century) +studied grammar, rhetoric, arithmetic and geometry, astronomy, theology +and music." He added: "Thus their work, however imperfect and faulty, +judged by modern lights, it may have been, brought them face to face with +all the leading aspects of the many-sided mind of man. For these studies +did really contain, at any rate in embryo--sometimes, it may be, in +caricature--what we now call philosophy, mathematical and physical science +and art. And I doubt if the curriculum of any modern university shows so +clear and generous a comprehension of what is meant by culture as the old +trivium and quadrivium does." Science and Education Essays, p. 197. New +York, D. Appleton and Co. 1896. + +[20] A tarrenus or tarrene in gold was equal to about thirty cents of our +money. Money at that time had from ten to fifteen times the purchasing +power that it has at the present time. An ordinary workman at this time in +England received about four pence a day, which was just the price of a +pair of shoes, while a fat goose could be bought for two and a half pence, +a sheep for one shilling and two pence, a fat hog for three shillings, and +a stall-fed ox for sixteen shillings (Act of Edward III. fixing prices). + +[21] The University of Perugia had already achieved a European reputation +for its Law School, and this Papal document was evidently meant to +maintain standards, and keep the new Medical School up to the best +criteria of the times. The original Latin of this document, as well as of +the Law of Frederick II., may be found in Walsh, "The Popes and Science," +Fordham University Press, New York, 1908. They are quoted directly from +the official collection of Papal Bulls. + + + + +_IN THE SAME SERIES_ + + +PASTEUR & AFTER PASTEUR + +By STEPHEN PAGET, F.R.C.S. + +HON. 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