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diff --git a/43300.txt b/43300.txt deleted file mode 100644 index 2c9e5ac..0000000 --- a/43300.txt +++ /dev/null @@ -1,6238 +0,0 @@ -The Project Gutenberg eBook, Medieval Medicine, by James J. (James Joseph) -Walsh - - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - - - - -Title: Medieval Medicine - - -Author: James J. (James Joseph) Walsh - - - -Release Date: July 25, 2013 [eBook #43300] - -Language: English - -Character set encoding: ISO-646-US (US-ASCII) - - -***START OF THE PROJECT GUTENBERG EBOOK MEDIEVAL MEDICINE*** - - -E-text prepared by Chris Curnow and the Online Distributed Proofreading -Team (http://www.pgdp.net) from page images generously made available by -Internet Archive (http://archive.org) - - - -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 Aetios Amidenus--that is, Aetios of Amida--born in the town of that -name in Mesopotamia on the Upper Tigris (now Diarbekir), who flourished in -the sixth century. Aetios, or in the Latin form Aetius, 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 Aetius 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 Aegina--Aeginetus 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, Aetios 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 Graecia. 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 Graecisms 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. Aetius, Alexander of Tralles, and Paul of -Aegina 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. Aetius, 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 -vertebrae--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." - -Aetius 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. Aetius 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 Aegina) 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 Aetius." - -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 haemoptysis, 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 faeces, 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 Aegina, 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 haemorrhage from the uterus, the -bleeding might be stopped by putting ligatures around the limbs. This -same method has been suggested for severe haemorrhage 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 gynaecology. - -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 -Graecia. 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 Graecisms, 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 Irae_, -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. Aegidius 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 (LUeBECK) - -_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 -Medicinae," 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 Medicinae," and we -have a "Flos Medicinae" 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 Medicinae," 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, Aegineta, 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 Averroes, 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. Bartholomaeus 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)--Aetius, Alexander of Tralles, and Paul of Aegina--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 -Graecisms 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. Haemorrhages 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 aera corrumpentibus, ut sunt allia, cepe, et -hujusmodi, et colloquio mulieris menstruosae, et manus ejus debent esse -mundae_, 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 aestate 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 fistulae 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 fistulae, 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 anaesthesia. 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, - Pare, 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 anaesthetic 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. - -Anaesthesia 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 anaesthesia. -Mandragora was the base of most of these anaesthetics, 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 anaesthesia 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 Pare, 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 anaesthesia practised by the -surgeons of his time, especially in cases of amputation, is particularly -interesting to us because the anaesthetic 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 Suedhoff -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 Suedhoff 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 Pare 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 haemorrhage. In the old days of - septic surgery, secondary haemorrhage 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 - haemorrhage 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 haemorrhage. 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 haemorrhage 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, -haemorrhage, 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. Aetius evidently knew much about the hygiene of the teeth, and -discusses extraction and the cure of fistulae of the gums as well as the -surgical treatment of many other lesions of the mouth. Paul of Aegina in -the century after Aetius 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 -(_limosite 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 Aetius, -Alexander of Tralles, and Paul of Aegina, 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 Aegina 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 haemorrhage, 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 Aegina (Aeginetas), -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--Aetius, Alexander of Tralles, -and Paul of Aegina--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 -Medicinae," and the second "Liber Compositae Medicinae." 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 Medicins," 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 fiance, 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 Heloise-Abelard 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 Caesarea 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 Luebeck 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. Luebeck 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 -Aegineta (Aeginetus), 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 Aegina 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 Aretaeus, 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 memoire_)." - -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 Aegineta 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' Encyclopaedia" 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 encyclopaedia 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 encyclopaedist 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 -Salpetriere 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 - - Aegidius, 64 - - Aegina, Paul of, 6, 27, 33, 138, 146, 149, 184, 186 - - Aeginetus. _See_ Aegina, Paul of - - Aetius, 4, 28, 138, 146 - - Aetius, 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 - - Anaesthesia, 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 - - Aretaeus, 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 - - Bartholomaeus 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 - - Fistulae, 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 - - - Haemoptysis, 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 Luebeck, 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 Medicinae," 73 - - Linear cicatrices, 101 - - Lister, Lord, 103 - - Louis IX., 110 - - Luebeck, 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 Aegina, 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; - Haec 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 anaethesia 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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