In the course of their conquests, however, the Mohammedan Arabs captured the Greek cities of Asia Minor. They were brought closely in contact with Greek culture, Greek literature, and Greek thought. As has always been the case, captive Greece took its captors captive. What happened to the Romans earlier came to pass also among the Arabs. Inspired by Greek philosophy, science, and literature, they became ardent devotees of science and the arts. While not inventing or discovering anything new, like the Romans they carried on the old. Damascus, Basra, Bagdad, Bokhara, Samarcand all became centres of culture and of education. Large sums were paid for Greek manuscripts, and for translations from them. Under the famous Harun al-Raschid, at the end of the eighth century, whose name is better known to us than that of any others, because of the stories of his wandering by night among his people in order to see if justice were done, three hundred scholars were sent at the cost of the Caliph to the various parts of the world in order to bring back treasures of science, and especially of geography and medicine. It is an interesting historical reflection that the Japanese and Chinese are doing the same thing now.

The Arabs were very much taken by the philosophy of Aristotle, and it became the foundation of all their education. Greek thought, as always, inspired its students to higher things. Soon everywhere in the dominions of the Caliphs, philosophy, science, art, literature, and education nourished. Medicine was taken up with the other sciences and cultivated assiduously. Freind, in his "Historia Medicinae," says that the writings of the old Greeks which treated of medicine were saved from destruction with the other books at Alexandria, for the desire of health did not have less strength among the Arabs than among other nations. Since these books taught them how to preserve health, and were not otherwise contrary to the laws of the Prophet, that served to bring about their preservation. Freind also calls attention to the fact that grammars and books which treated of the science of language were likewise saved from destruction. Besides the library, the Arabs, after their conquest of Alexandria in the eighth century, came under the influence of the university still in existence there.

In the West, in Spain, the Arabs enjoyed the same advantages as regards contact with culture and education as their conquest of the Eastern cities and Alexandria brought them in the East. While it is not generally realized, Spain was, as we have pointed out, the province of the Roman Empire in the West that advanced most in culture before the breaking up of the Empire. The Silver Age of Latin literature owes all of its geniuses to Spain. Lucan, the Senecas, Martial, Quintilian, are all Spaniards. Spain itself was a most flourishing province, and under the Spanish Caesars, from the end of the first to about the end of the second century, increased rapidly in population. Spain was the leader in these prosperous times, and the tradition of culture maintained itself. When Spain became Christian the first great Christian poet, Prudentius, born about the middle of the fourth century, came from there. He has been called the Horace and Virgil of the Christians.

The coming down of the barbarians from the North disturbed Spain's prosperity and the peace and culture of her inhabitants, but it should not be forgotten that the first medieval popularization of science, a sort of encyclopedia of knowledge, the first of its kind after that of Pliny in the classical period, came from St. Isidore of Seville, a Spanish bishop.

There has been considerable tendency to insist that Spanish culture and intellectuality owe nearly all to the presence of the Moors in Spain. This can only be urged, however, by those who know nothing at all of the Spanish Caesars, the place of Spain in the history of the Roman Empire, and the continuance of the culture that then reached a climax of expression during succeeding centuries. On the contrary, the Moors who came to Spain owe most of their tendency to devote themselves to culture and education to the state of affairs existent in Spain when they came. There is no doubt that they raised standards of education and of culture above the level to which they had sunk under the weight of the invading barbarians from the North, and Spain owes much to the wise ruling and devotion to the intellectual life of her Moorish invaders. All the factors, however, must be taken together in order to appreciate properly the conditions which developed under the Arabs in both the East and the West. The Arabs invented little that was new in science or philosophy; they merely carried on older traditions. It is for that that the modern time owes them a great debt of gratitude.

RHAZES

The most distinguished of the Arabian physicians was the man whose rather lengthy Arabian name, beginning with Abu Bekr Mohammed, finished with el-Razi, and who has hence been usually referred to in the history of medicine as Rhazes. He was born about 850 at Raj, in the Province of Chorasan in Persia. He seems to have had a liberal early education in philosophy and in philology and literature. He did not take up medicine until later in life, and, according to tradition, supported himself as a singer until he was thirty years of age. Then he devoted himself to medical studies with the ardor and the success so often noted in those whose opportunity to study medicine has been delayed. His studies were made at Bagdad, where Ibn Zein el-Taberi was his teacher. He returned to his native town and was for some time the head of the hospital there. Later he was called by the Sultan to Bagdad to take charge of the renovated and enlarged hospital of the capital. His medical career, then, is not unlike that of many another successful physician, especially of the modern time. At Bagdad he had abundant opportunities for study, and the ambition to make medicine as well as to make money and gain fame.

His studies in science were all founded on Aristotle. Though he was called the Galen of his time, and looked up to the Greek physician as his master, even the authority of Galen did not override that of the Stagirite in his estimation. One of his aphorisms is said to have been, "If Galen and Aristotle are of one mind on a subject, then surely their opinion is true. When they differ, however, it is extremely difficult for the scholar to decide which opinion should be accepted." He drew many pupils to Bagdad, and, when one knows his teaching, this is not surprising. Some of his aphorisms are very practical. While the expressions just quoted with regard to Galen and Aristotle might seem to indicate that Rhazes was absolutely wedded to authority, there is another well-known maxim of his which shows how much he thought of the value of experience and observation. "Truth in medicine," he said, "is a goal which cannot be absolutely reached, and the art of healing, as it is described in books, is far beneath the practical experience of a skilful, thoughtful physician." Some of his other medical aphorisms are worth noting. "At the beginning of a disease choose such remedies as will not lessen the patient's strength." "When you can heal by diet, prescribe no other remedy, and, where simple remedies suffice, do not take complicated ones."

Rhazes knew well the value of the influence of mind over body even in serious organic disease, and even though death seemed impending. One of his aphorisms is: "Physicians ought to console their patients even if the signs of impending death seem to be present. For the bodies of men are dependent on their spirits." He considered that the most valuable thing for the physician to do was to increase the patient's natural vitality. Hence his advice: "In treating a patient, let your first thought be to strengthen his natural vitality. If you strengthen that, you remove ever so many ills without more ado. If you weaken it, however, by the remedies that you use you always work harm." The simpler the means by which the patient's cure can be brought about, the better in his opinion. He insists again and again on diet rather than artificial remedies. "It is good for the physician that he should be able to cure disease by means of diet, if possible, rather than by means of medicine." Another of his aphorisms seems worth while quoting: "The patient who consults a great many physicians is likely to have a very confused state of mind."

Some idea of Rhazes' strenuous activity as a writer on medical subjects may be obtained from the fact that thirty-six of his works are still extant, and there are nearly two hundred others of which only the titles have been preserved. Some of these are doubtless the works of pupils and students of succeeding generations, published under his name to attract attention. His principal work is "Continens," or "Comprehensor," which owes its title to the fact that it was meant to contain the whole practice of medicine and surgery. It includes references to the writings of all previous distinguished medical writers, from Hippocrates to Honein Ben Ishac, also known as Johannitius, a Christian Arabian physician, one of Rhazes' teachers. The most frequently quoted of these authorities are Galen, Oribasius, Aetius, and Paul of AEgina. The work, however, is not made up entirely of quotations, but contains many observations made by the author himself. Gurlt says that the foundation of the theoretic medicine of Rhazes is the system of Galen, while in practice he seems to cling more to the aphorisms of Hippocrates. He has many practical points which show that he thought for himself. For instance, in wounds of the abdomen, if the intestines are extruded and cannot be replaced, he suggests the suspension of the patient by his hands and feet in a bath in order to facilitate their return. If they do not go back readily, compresses dipped in warm wine should be used. Cancer he declares to be almost incurable. He has much to say about the bites of animals and their tendency to be poisonous, knew rabies very well, and knew also that the bites of men might have similar serious consequences.

It is impossible to give any adequate idea of the thoroughly practical character of Rhazes' medical writing in a few lines, but it may suffice to say that there is scarcely any feature of modern medicine and surgery that he does not touch, and oftener than not his touch is sure and rational and frequently much better than the advice of successors long after him in the same matters. An example or two will suffice to illustrate this. In the treatment of nasal polyps he says that whenever drug treatment of these is not successful, they should be removed with a snare made of hair. For fall of the uvula he suggests gargles, but when these fail he advises resection and cauterization. Among the affections of the tongue he numbers abscess, fissure, ulcer, cancer, ranula, shortening of the ligaments, hypertrophy, erythema of the mucous membrane, and inflammatory swelling. In general his treatment of the upper respiratory tract is much farther advanced than we might think possible at this time. He advises tracheotomy whenever there is great difficulty of respiration, and describes how it should be done. After the dyspnea has passed the edges of the wound should be brought together with sutures. It is not surprising, then, to find that the treatment of fractures and luxations is eminently practical, and, indeed, on any subject that he touches he throws practical light.

In the introduction to his edition of the works of Ambroise Pare, Malgaigne says that the first reference to a metal band in connection with trusses is to be found in Rhazes. Hernia was, of course, one of the serious ailments that, because of its superficial character, was rather well understood, and so it is not surprising to find that much of our modern treatment of it was anticipated. The manipulations for taxis, the use of a warm bath for the relaxation of the patient by means of heat and by putting the head and feet higher than the abdomen while in the bath, and the employment of various kinds of trusses to prevent strangulation of the hernia recur over and over again, in the authors of the Middle Ages. Many of the suggestions are to be found in the early Greek authors, but subsequent writers give a certain personal expression to them which shows how much they had learned by personal observation in the employment of various methods.

Pagel, in Puschmann's "Handbook of the History of Medicine," declares that Rhazes' most important work for pure medicine is his monograph on smallpox. Its principal value is due to the fact that, though he has consulted old authorities carefully, his discussion of the disease is founded almost entirely on his own experience. His description of the various stages of the disease, of the forms of the eruption, and of the differential diagnosis, is very accurate. He compares the course of the fever with that of other fevers, and brings out exactly what constitutes the disease. His suggestions as to prognosis are excellent. Those cases, he declares, are particularly serious in which the eruption takes on a dark, or greenish, or violet color. The prognosis is also unfavorable for those cases which, having considerable fever, have only a slight amount of rash. His treatment of the disease in young persons was by venesection and cool douches. Cold water and acid drinks should be administered freely, so that sweat and other excretions may carry off poisonous materials. Care must be taken to watch the pulse, the breathing, the appearance of the feet, the evacuations from the bowels, and to modify therapy in accordance with these indications. The eruption is to be encouraged by external warmth and special care must be taken with regard to complications in the eyes, the ears, the nose, the mouth, and the pharynx.

A fact that will, perhaps, give the best idea to modern readers of the place of Rhazes in the history of medicine is that Vesalius considered it worth his while to make a translation of his principal work. Unfortunately that translation has not come down to us. When Vesalius, pestered by the controversies that had come upon him because of his venturing to make his observations for himself, accepted the post of physician to the Emperor Charles V, he burnt a number of his manuscripts. Among these were his translation of Rhazes and some annotations on Galen, which, as he says himself, had grown into a huge volume. The Galenists were bitterly decrying his refusal to accept Galen on many points, and both of these works would have added fuel to the flame of controversy. He deemed it wiser, then, not to give any further opportunities for rancorous criticism, and, feeling presumably that in his new and important post it was not worth while to bother further over the matter, he burnt them. He tells the reason in his letters to Joachin Roelant: "When I was about to leave Italy to go to Court, since a number of the physicians whom you know had made the worst kind of censure of my books, both to the Emperor himself, and to other rulers, I burned all the manuscripts that were left, although I had never suffered a moment under the displeasure of the Emperor because of these complaints, and in spite of the fact that a number of friends who were present urged me not to destroy them."

Vesalius' translation of Rhazes was probably undertaken because he recognized in him a kindred spirit of original investigation and inquiry, whose work, because it was many centuries old, would command the weight of an authority and at the same time help in the controversy over Galenic questions. This, of itself, would be quite enough to make the reputation of Rhazes, even if we did not know from the writings themselves and from the admiration of many distinguished men as well as the incentive that his works have so often proved to original observation, that he is an important link in the chain of observers in medicine, who, though we would naturally expect them to be so frequent, are really so rare.

ALI ABBAS

Rhazes lived well on into the tenth century. His successor in prestige, though not his serious rival, was Ali Ben el-Abbas, usually spoken of in medical literature as Ali Abbas, a distinguished Arabian physician who died near the end of the tenth century. He wrote a book on medicine which, because of its dedication to the Sultan, to whom he was body-physician, is known as the "Liber Regius," or "Royal Book of Medicine." This became the leading text-book of medicine for the Arabs until replaced by the "Canon of Avicenna" some two centuries later. The "Liber Regius" was an extremely practical work and, like most of the Arabian books of the early times, is simple and direct, quite without many of the objectionable features that developed later in Arabian medicine. It is valuable mainly for its contributions to diet and the fact that Ali Abbas tested many of his medicines on ailing animals before applying them to men. Of course, it owes much to earlier writers on medicine, and especially to Paul of AEgina.

An example of its practical value is to be found in his description of the treatment of a wound of the brachial artery, when, as happened often in venesection from the median basilic vein, it was injured through carelessness or inadvertence. If astringent or cauterizing methods do not stop the bleeding, the artery should be exposed, carefully isolated, tied in two places above and below the wound, and then cut across between them. He has many similar practical bits of technique. For instance, in pulling a back tooth he recommends that the gums be incised so as to loosen them around the roots, and then the tooth itself may be drawn with a special forceps which he calls a molar forceps. In ascites he recommends that when other means fail an opening should be made three finger-breadths below the navel with a pointed phlebotomy knife, and a portion of the fluid allowed to evacuate itself. A tube should then be inserted, but closed. The next day more of the fluid should be allowed to come away, and then the tube removed and the abdomen wrapped with a firm bandage.

It is easy to understand that Ali Abbas' book should have been popular, and the more we know of it the easier it is to explain why Constantine Africanus should have selected it for translation. It contains ten theoretic and ten practical books, and gives an excellent idea of the medical knowledge and medical practice of the time. Probably the fact that Constantine had translated it led to its early printing, so that we have an edition of it published at Venice in 1492, and another at Lyons in 1523. During the Middle Ages the book was often spoken of as "Regalis Dispositio," the "Royal Disposition of Medicine."

MOORISH PHYSICIANS

After Rhazes, the most important contributors to medical literature from among the Arabs, with the single exception of Avicenna, were born in Spain. They are Albucasis or Abulcasis, the surgeon; Avenzoar, the physician, and Averroes, the philosophic theorist in medicine. Besides, it may be recalled here that Maimonides, the great Jewish physician, was born and educated at Cordova, in Spain. It might very well be a surprise that these distinguished men among the Arabs should have flourished in Spain, so far from the original seat of Arabian and Mohammedan dominion in the East, where, owing to conditions in the modern time, the English-speaking world particularly is not likely to assume that the environment was favorable for the development of science and philosophy. Anyone who recalls, however, the history of Spanish intellectual influence in the Roman Empire, as we have traced it at the beginning of this chapter, will appreciate how favorable conditions were in Spain for the fostering of intellectual development. With the disturbances that had come from political strife and the invasion of the barbarians in Italy, Spain had undoubtedly come to hold the primacy in the intellectual life of Europe at the time when the Arabs took possession of the peninsula.

ABULCASIS

The most important of the Arabian surgeons of the Middle Ages is Albucasis or Abulcasis, also Abulkasim, who was born near Cordova, in Spain. The exact year of his birth is not known, but he flourished in the second half of the tenth century. He is said to have lived to the age of 101. The name of his principal work, which embraces the whole of medicine, is "Altasrif," or "Tesrif," which has been translated "The Miscellany." Most of what he has to say about medical matters is taken from Rhazes. His work on surgery, however, in three books, represents his special contribution to the medical sciences. It contains a number of illustrations of instruments, and is the first illustrated medical book that has come to us. It was translated into Latin, and was studied very faithfully by all the surgeons of the Middle Ages. Guy de Chauliac has quoted Albucasis about two hundred times in his "Chirurgia Magna." Even as late as the beginning of the sixteenth century Fabricius de Acquapendente, the teacher of Harvey, confessed that he owed most to three great medical writers, Celsus (first century), Paul of AEgina (seventh century), and Abulcasis (tenth century).

Abulcasis insisted that for successful surgery a detailed knowledge of anatomy was, above all, necessary. He said that the reason why surgery had declined in his day was that physicians did not know their anatomy. The art of medicine, he added further, required much time. Unfortunately, to quote Hippocrates, there are many who are physicians in name only, and not in fact, especially in what regards surgery. He gives some examples of surgical mistakes made by his professional brethren that were particularly called to his attention. They are the perennially familiar instances of ignorance causing death because surgeons were tempted to operate too extensively.

His description of the procedure necessary to stop an artery from bleeding is an interesting example of his method of teaching the practical technique of surgery. Apply the finger promptly upon the opening of the vessel and press until the blood is arrested. Having heated a cautery of the appropriate size, take the finger away rapidly and touch the cautery at once to the end of the artery until the blood stops. If the spurting blood should cool the cautery, take another. There should be several ready for the purpose. Take care, he says, not to cauterize the nerves in the neighborhood, for this will add a new ailment to the patient's affection. There are only four ways of arresting arterial hemorrhage. First, by cautery; second, by division of the artery, when that is not complete—for then the extremities contract and the blood clots—or by a ligature, or by the application of substances which arrest blood flow, aided by a compressive bandage. Other means are inefficient, and seldom and, at most, accidentally successful. His instruction for first aid to the injured in case of hemorrhage in the absence of the physician, is to apply pressure directly upon the wound itself.

The development of the surgical specialties among the Arabs is particularly interesting. Abulcasis has much to say about nasal polyps. He divided them into three classes: (1) cancerous, (2) those with a number of feet, and (3) those that are soft and not living,—these latter, he says, are neither malignant nor difficult to treat. He recommends the use of a hook for their removal, or a snare for those that cannot be removed with that instrument. His instructions for the removal of objects from the external ear are interestingly practical. He advises the use of bird lime on the end of a sound to which objects will cling, or, where they are smaller, suction through a silver or copper canula. Hooks and pincettes are also suggested. Insects should be removed with a hook, or with a canula, or, having been killed by warm oil, removed by means of a syringe. Some of his observations with regard to genito-urinary surgery are quite as interesting. He even treated congenital anomalies. He suggests cutting of the meatus when narrowed, dilatation of strictures with lead sounds, and even suggests plans of operations to improve the condition in hypospadias. He gives the signs for differentiation between epitheliomata and condylomata, and distinguishes various forms of ulceration of the penis.

Abulcasis discusses varicose veins in very much the same spirit as a modern surgeon does. They occur particularly in people who work much on their feet, and especially who have to carry heavy burdens. They should not be operated on unless they produce great discomfort, and make it impossible for the sufferer to make his living. They may be operated on by means of incision or extirpation. Incision consists of cutting the veins at two or three places when they have been made prominent by means of tight bandages around the limb. The blood should be allowed to flow freely out of the cut ends, and then a bandage applied. For extirpation, the skin having been shaved beforehand, the vein should be made prominent, and then carefully laid bare. When freed from all adhesions, it should be lifted out on a hook, and either completely extirpated or several rather long pieces removed. He lays a good deal of stress on the necessity for freeing the vein thoroughly and lifting it well out of tissues before incising it. In old cases special care must be taken not to tear the vein.

Minute details of technique are often found in these old authors. Abulcasis, for instance, treats of adherent fingers with up-to-date completeness. They can occur either congenitally or from injury, as, for instance, burning. They should be separated, and then separation maintained by means of bandages or by the insertion between them of a thin lead plate, which prevents their readhesion. Adhesions of the fingers with the palm of the hand, which Abulcasis has also seen, should be treated the same way.

At times there is surprise at finding some rare lesion treated with modern technique, and a hint at least of our modern apparatus. Fracture of the pubic arch, for instance, is described in Abulcasis quite as if he had had definite experience with it. When this occurs in a woman, the reposition of the bone is often greatly facilitated by a cotton tampon in the vagina. This tampon must be removed at every urination. There is another way, however, of better securing the same purpose of counterpressure. One may take a sheep's bladder into the orifice of which a tube is fastened. One should introduce the bladder into the vagina, and then blow strongly through the tube, until the bladder becomes swollen and fills up the vaginal cavity. The fracture will, as a rule, then be readily reduced. Here is, of course, not alone the first hint of the colpeurynter, but a very practical form of the apparatus complete. Old-time physicians used the bladders of animals very generally for nearly all the medical purposes for which we now use rubber bags.

AVICENNA

Undoubtedly the most important of Abulcasis' contemporaries is the famous physician whose Arabic name, Ibn Sina, was transformed into Avicenna. He was born toward the end of the tenth century in the Persian province of Chorasan, at the height of Arabian influence, and is sometimes spoken of as the chief representative of Arabian medicine, of as much importance for it as Galen for later Greek medicine. His principal book is the so-called "Canon." It replaced the compendium "Continens" of Rhazes, and, in the East, continued until the end of the fifteenth century to be looked upon as the most complete and best system of medicine. Avicenna came to be better known in the West than any of the other Arabian writers, and his name carried great weight with it. There are very few subjects in medicine that did not receive suggestive, if not always adequate, treatment at the hands of this great Arabian medical thinker of the eleventh century. He copied freely from his predecessors, but completed their work with his own observations and conclusions. One of his chapters is devoted to leprosy alone. He has definite information with regard to bubonic plague and the filaria medinensis. Here and there one finds striking anticipations of what are supposed to be modern observations. Nothing was too small for his notice. One portion of the fourth book is on cosmetics, in which he treats the affections of the hair and of the nails. He has special chapters with regard to obesity, emaciation, and general constitutional conditions. His book, the "Antidotarium," is the foundation of our knowledge of the drug-giving of his time.

Some idea of the popularity and influence of Avicenna, five centuries after his time, can be readily derived from the number of commentaries on him issued during the Renaissance period by the most distinguished medical scholars and writers of that time. Hyrtl, in his "Das Arabische und Hebraeische in der Anatomie," quotes some of them,—Bartholomaeus de Varignana, Gentilis de Fulgineis, Jacobus de Partibus, Didacus Lopez, Jacobus de Forlivio, Ugo Senesis, Dinus de Garbo, Matthaeus de Gradibus, Nicolaus Leonicenus, Thaddaeus Florentinus, Galeatus de Sancta Sophia. A more complete list, with the titles of the books, may be found in Haller's "Bibliotheca Anatomica." For over three centuries after the foundation of medical schools in Europe (and even after Mondino's book had been widely distributed), Avicenna was still in the hands of all those who had an enthusiasm for medical science.

AVENZOAR

Another of the distinguished Arabian physicians was Avenzoar—the transformation of his Arabic family name, Ibn-Zohr. He was probably born in Penaflor, not far from Seville. He died in Seville in 1162 at the age, it is said, of ninety-two years. He was the son of a physician descended from a family of scholars, jurists, physicians, and officials. He received the best education of the time not only in internal medicine, but in all the specialties, and must be counted among the greatest of the Spanish Arabian physicians. He was the teacher of Averroes, who always speaks of him with great respect. He is interesting as probably being the first to suggest nutrition per rectum. A few words of his description show how well he knew the technique. His apparatus for the purpose consisted of the bladder of a goat or some similar animal structure, with a silver canula fastened into its neck, to be used about as we use a fountain syringe. Having first carefully washed out the rectum with cleansing and purifying clysters, he injected the nutriment—eggs, milk, and gruels—into the gut. His idea was that the intestine would take this, and, as he said, suck it up, carrying it back to the stomach, where it would be digested. He was sure that he had seen his patients benefited by it.

Some light on his studies of cases that would require such treatment may be obtained from what he has to say about the handling of a case of stricture of the esophagus. He says that this begins with some discomfort, and then some difficulty of swallowing, which is gradually and continuously increased until finally there comes complete impossibility of swallowing. It was in these cases that he suggested rectal alimentation, but he went farther than this, and treated the stricture of the esophagus itself.

The first step in this treatment is that a canula of silver or tin should be inserted through the mouth and pushed down the throat till its head meets an obstruction, always being withdrawn when there is a vomiting movement, until it becomes engaged in the stricture. Then freshly milked milk, or gruel made from farina or barley, should be poured through it. He says that in these cases the patient might be put in a warm milk or gruel bath, since there are some physicians who believe that through the lower parts of the body, and also through the pores of the whole body, nutrition might be taken up. While he considers that this latter method should be tried in suitable cases, he has not very much faith in it, and says that the reasons urged for it are weak and rather frivolous. It is easy to understand that a man who has reached the place in medicine where he can recommend manipulative treatments of this kind, and discuss nutritional modes so rationally, knew his practical medicine well, and wrote of it judiciously.

AVERROES

Among the distinguished contributors to medicine at this time, though more a philosopher than a physician, is the famous Averroes, whose full Arabic name among his contemporaries was Abul-Welid Mohammed Ben Ahmed Ibn Roschd el-Maliki. Like Avenzoar, of whom he was the intimate personal friend, and Abulcasis and Maimonides, he was born in the south of Spain. He was in high favor with the King of Morocco and of Spain, El-Mansur Jacub, often known as Almansor, who made him one of his counsellors. His works are much more important for philosophy than for medicine, and his philosophical writings gave him a place only second to that of Aristotle in the Western world during the Middle Ages. Averroism is still a subject of at least academic interest, and Renan's monograph on it and its author was one of the popular books of the latter half of the nineteenth century in philosophic circles. In spite of his friendship with the Moorish King and with Avenzoar, he fell under the suspicion of free thinking and was brought to trial with a number of personal friends, who occupied high positions in the Moorish government. He escaped with his life, but only after great risks, and he was banished to a suburb of Cordova, in which only Jews were allowed to live. By personal influence he succeeded in securing the pardon of himself and friends, and then was summoned to the court of the son and successor of El-Mansur in Morocco. He died, not long after, in 1198.

Altogether there are some thirty-three works of Averroes on philosophy and science. Only three of these are concerned with medicine. One is the "Colliget," so-called, containing seven books, on anatomy, physiology, pathology, diagnostics, materia medica, hygiene, and therapy. Then there is a commentary on the "Cantica of Avicenna," and a tractate on the "Theriac." Averroes' idea in writing about medicine was to apply his particular system of philosophy to medical science. His intimate relations with other great physicians of the time, and in particular his close friendship with Avenzoar, enabled him to get abundant medical information in faultless order so far as knowledge then went, but his theoretic speculations, instead of helping medicine, as he thought they would, and as philosophers have always been inclined to think as regards their theoretic contributions, were not only not of value, but to some extent at least hindered human progress by diverting men from the field of observation to that of speculation. It is interesting to realize that Averroes did in his time what Descartes did many centuries later, and many another brilliant thinker has done before and since.

ARABIAN INFLUENCE

The fame of these great thinkers and writers in philosophy and in medicine came to be known not only through the distribution of their books long after their death, but during their lifetime, and in immediately subsequent generations, ardent seekers after knowledge, who were themselves afterwards to become famous by their teaching and writing, found their way into the Arabian dominions in order to take advantage of the educational opportunities afforded. These were better than they could secure at home in Christian countries, because the process of bringing culture and devotion to literature and science into the minds of the Northern nations, who had replaced the old Romans in Europe, was not yet completed. Bagdad and Cordova were the two favorite places of educational pilgrimage. The names that are most familiar among the scholars in the Middle Ages in Europe are those of whom it is recorded that they made long journeys in order to get in touch with what the Arabs had preserved of the old Greek civilization and culture. Among them are such men as Michael Scot or Scotus, Matthew Platearius, who was afterwards a great teacher at Salerno; Daniel Morley, Adelard of Bath, Egidius, otherwise known as Gilles de Corbeil; Romoaldus, Gerbert of Auvergne, who later became Pope under the name of Sylvester II; Gerard of Cremona, and the best known of them all, at least in medicine, Constantine Africanus, whose wanderings, however, were probably not limited to Arabian lands, but who seems also to have been in Hindustan.

We are rather prone to think that this great spirit of going far afield for knowledge's sake is recent, or, at least, quite modern. As a matter of fact, one finds it everywhere in history. Long before Herodotus did his wanderings there were many visitors who went to Egypt, and many more later who went to Crete, and many more a few centuries later who went to the shores of Asia Minor seeking for the precious pearl of knowledge, and sometimes finding it without finding the even more precious pearl of wisdom, "whose worth is from the farthest coasts."

To the Arabs we owe the foundation of a series of institutions for the higher learning, like those which had existed around them in Asia Minor and in Egypt at the time they made their conquests. Alexandria, Pergamos, Cos, Cnidos, Tarsus, and many other Eastern cities had had what we would call at least academies, and many of them deserved the name of universities. The Arabs continued the tradition in education that they found, and established educational institutions which attracted wide attention. As we have said, the two most famous of these were at Bagdad and at Cordova. Mostanser, the predecessor of the last Caliph of the family of the Abbassides, built a handsome palace, in which the academy of Bagdad was housed. It is still in existence, and gives an excellent idea of the beneficent interest of this monarch and of other of the Abbasside rulers in education. Its fate at the present time is typical of the attitude of the Mohammedans towards education. Though the building is still standing, the institution of learning is no longer there. As Hyrtl remarks, it is not ideas that are exchanged in it now, but articles of commerce. It has become the chief office of the Turkish customs department in Bagdad.

These institutions of the higher learning, founded by the Arabs, at first as rather strict imitations of the museums or academies of Egypt and Asia Minor, gradually changed their character under the Arabs. Their courses became much more formal, examinations became much more important. Scholarship was sought not so much for its own sake, as because it led to positions in the civil service, to the favor of princes, and, in general, to reputation and pecuniary reward. Formal testimonials proclaiming education, signed by the academic authorities, were introduced and came to mean much. Lawyers could not practise without a license, physicians also required a license. These formalities were adopted by the Western medieval universities to a considerable degree and have been perpetuated in the modern time. Undoubtedly they did much to hamper real education among the Arabs by setting in place of the satisfaction of learning for its own sake and the commendation of teachers the formal recognition of a certain amount of work done as recognized by the educational authorities. There was always a tendency among the Arabs to formulate and formalize, to over-systematize what they were at; to think that new knowledge could be obtained simply by speculating over what was already acquired, and developing it. There are a number of comparisons between this and later periods of education that might be suggested if comparisons were not odious.

The influence of Arabian medicine on modern medicine can, perhaps, best be judged from the number of words in our modern nomenclature, which, though bearing Latin forms, often with suggestion of Greek origins, still are not derived from the old Latin or Greek authors, but represent Arabic terms translated into Latin during the Renaissance period. Hyrtl, without pretence of quoting them all, gives a list of these which is surprising in its comprehensiveness. For instance, the mediastinum, the sutura sagittalis, the scrobiculus cordis, the marsupium cordis, the chambers of the heart, the velum palati, the trochanter, the rima glottidis, the fontanelles, the alae of the nose, all have their present names, not from original Latin expressions, but from the translation of Arabic terms. For all such words the Greeks and Romans have quite other expressions, in which the sense of our modern terms is not contained. This has given rise to many misunderstandings, and to many attempts in the modern times to return to the classic terminology rather than preserve what in many cases are the barbarisms introduced through the Arabic, but it is doubtful whether any comprehensive reform in the matter can be effected, so strongly entrenched in medical usage have these terms now become.

Freind, in his "History of Medicine," already cited, calls attention to the fact that the Arabs had an unfortunate tendency to change by addition or subtraction of their own views the authors that they studied, and wished to translate to others. This seems to have been true even of some of the most distinguished of them. Of course, the idea of preserving an author's text untouched, and making it clear just where note and commentary came in, had not yet come to men's view, but quite apart from this the Arabs apparently often tried to gain acceptance for their own ideas by having them masquerade as the supposed ideas of favorite classic authors.

Another unfortunate tendency among the Arabs was their liking for the discussion of many trivial questions. Hyrtl, in his volume on "Arabian and Hebrew Words in Anatomy,"[6] declares that it is almost incredible how earnestly some trivial questions in anatomy and physiology were discussed by the Arabs. He gives some examples. Why does no hair grow on the nose of men? Why does the stomach not lie behind the mouth? Why does the windpipe not lie behind the esophagus? Why are the breasts not on the abdomen? Why are not the calves on the anterior portion of the legs? Even such men as Rhazes and Avicenna discuss such questions.

It was this tendency of the Arabs that passed over to the Western Europeans with Arabian commentaries on philosophy and science, and brought so many similar discussions in the scholastic period. These trivialities have usually been supposed to originate with the scholastics themselves, for they are not to be found in the Greek authors on whom the scholastics were writing commentaries, but they are typically Oriental in character, and it must be remembered that during the twelfth and early thirteenth centuries, at least, Greek philosophy found its way largely into Europe in Arab versions, and these characteristically Arabian additions of the discussion of curious trivial questions came with them and produced an imitative tendency among the Europeans.

As a rule the more careful has been the study of Arabian writers in the modern time, particularly by specialists, the clearer has it become that they lacked nearly all originality. Especially were they faulty in their observations; besides, they had a definite tendency to replace observation by theory, a fatal defect in medicine. The fine development of surgery that came at the end of the Arabian period of medicine in Europe could never have come from the Arabs themselves. Gurlt has brought this out particularly, but it will not be difficult to cite many other good authorities in support of this opinion.

Hyrtl, in his "Thesis on the Rarer Old Anatomists,"[7] says that "the Arabs paid very little attention to anatomy, and, of course, because of the prohibition in the Koran, added nothing to it. Whatever they knew they took from the Greeks, and especially Galen. Not only did they not add anything new to this, but they even lost sight of much that was important in the older authors. The Arabs were much more interested in physiology; they could study this by giving thought to it without soiling their hands. They delighted in theory, rather than in observation."

While we thus discuss the lack of originality and the tendency to over-refinement among the Arabian medical writers, it must not be thought that we would make little of what they accomplished. They not only preserved the old medical writers for us, but they kept alive practical medicine with the principles of the great Greek thinkers as its basis. There are a large number of writers of Arabian medicine whose names have secured deservedly a high place in medical history. If this were a formal history of Arabian medicine, their careers and works would require discussion. For our purpose, however, it seems better to confine attention to a few of the most prominent Arabian writers on medicine, because they will serve to illustrate how thoroughly practical were the Arabian physicians and how many medical problems that we are prone to think of as modern they occupied themselves with, solving them not infrequently nearly as we do in the modern time.



VI

THE MEDICAL SCHOOL AT SALERNO

The Medical School at Salerno, probably organized early in the tenth century, often spoken of as the darkest of the centuries, and reaching its highest point of influence at the end of the twelfth century, is of great interest in modern times for a number of reasons. First it brought about in the course of its development an organization of medical education, and an establishment of standards that were to be maintained whenever and wherever there was a true professional spirit down to our own time. They insisted on a preliminary education of three years of college work, on at least four years of medical training, on special study for specialist's work, as in surgery, and on practical training with a physician or in a hospital before the student was allowed to practise for himself. At Salerno, too, the department of women's diseases was given over to women professors, and we have the text-books of some of these women medical teachers. The license to practise given to women, however, seems to have been general and did not confine them merely to the care of women and children. We have records of a number of these licenses issued to women in the neighborhood of Salerno. This subject of feminine medical education at Salerno, because of its special interest in our time, will have a chapter by itself.

These are the special features of medical education in our own time that we are rather prone to think of as originating with ourselves and as being indices of that evolution of humanity and progress in mankind which are culminating in our era. It is rather interesting, then, to study just how these developments came about and what the genesis of this great school was. The books of its professors were widely read, not only in their own generation but for centuries afterwards. With the invention of printing at the time of the Renaissance most of them were printed and exerted profound influence over the revival of medicine which took place at that time. Salerno became the first of the universities in the modern sense of the word. Here there gathered round the medical school, first a preparatory department representing modern college work, and then departments of theology and law, though this latter department particularly was never quite successful. The fact that the first university, that of Salerno, should have been organized round a medical school, the second, that of Bologna, around a law school, and the third, that of Paris, around a school of theology and philosophy, would seem to represent the ordinary natural process of development in human interests. First man is interested in himself and in his health, then in his property, and finally in his relations to his fellow-man and to God.

Though much work has been done on the subject in recent years, it is not easy to trace the origin of the medical school at Salerno. The difficulty is emphasized by the fact that even the earliest chroniclers whose accounts we have were not sure as to its origin, and even had some doubt about the age of the school. Alphanus, usually designated Alphanus I because there are several of the name, who is one of the earliest professors whose name and fame have come down to us, gives us the only definite detail as to the age of the school. He was a Benedictine monk, distinguished as a literary man, known both as poet and physician, who was afterwards raised to the Bishopric of Salerno. As a bishop he was one of the beneficent patrons, to whom the school owed much. He lived in the tenth century, and states that medicine flourished in the town before the time of Guimarus II, who reigned in the ninth century. In the ancient chronicle of Salerno, re-discovered by De Renzi and published in his "Collectio Salernitana," it is definitely recorded that the medical school was founded by four doctors,—a Jewish Rabbi Elinus, a Greek Pontus, a Saracen Adala, an Arab, and a native of Salerno, each of whom lectured in his native language. There are many elements in this tradition, however, that would seem to indicate its mythical origin and that it was probably invented after the event to account for the presence of teachers in all these languages and the coming of students from all over the world. The names, for instance, are apparently corruptions of real names, as can be readily recognized. Elinus, the Jew, is probably Elias or Eliseus, Adala is a corruption of Abdallah, and Pontus, as pointed out by Puschmann in his "History of Medical Education," should probably be Gario-Pontus.

While we do not know exactly when the medical school at Salerno was founded, we know that a hospital was established there as early as 820. It was founded by the Archdeacon Adelmus, and was placed under the control of the Benedictines after it was realized that a religious order, by its organization, was best fitted for carrying on such charitable work continuously. Other infirmaries and charitable institutions, mainly under control of the religious, sprang up in Salerno. It was the presence of these hospitals in a salubrious climate that seems first to have attracted the attention of patients and then of physicians from all over Europe and even adjacent Africa and Asia. Puschmann says that it is uncertain whether clinical instruction was imparted in these institutions or not, but the whole tenor of what we know about the practical character of the teaching at Salerno and of the fine development of professional medicine there, would seem to argue that probably those who came to study medicine here were brought directly in contact with patients.

As early as the ninth century Salerno was famous for its great physicians. We know the names of at least two physicians, Joseph and Joshua, who practised there about the middle of the ninth century. Ragenifrid, a Lombard by his name, was private physician to Prince Wyamar of Salerno in the year 900. The fact that he was from North Italy indicates that already foreigners were being attracted, but more than this that they were obtaining opportunities unhampered by any Chauvinism. From early in the tenth century physicians from Salerno were frequently brought to foreign courts to become the attending physicians to rulers. Patients of the highest distinction from all over Europe began to flock to Salerno, and we have the names of many of them. In the tenth century Bishop Adalberon, when ailing, went there, though he found no cure for his ills. Abbot Desiderius, however, the great Benedictine scholar of the time, who afterwards became Pope Victor III, regained his health at Salerno under the care of the great Constantine Africanus, who was so much impressed by the gentle kindness and deep learning and the example of the saintly life of his patient that not long after he went to Monte Cassino to become a Benedictine under Desiderius, who was abbot there. Duke Guiscard sent his son Bohemund to Salerno for the cure of a wound received in battle, which had refused to heal under the ordinary surgical treatment of the time. William the Conqueror, early in the eleventh century and while still only the Duke of Normandy, is said to have passed some time at Salerno for a similar reason.

The most interesting feature of the medical life at Salerno at this time is the relations between the clergy and the physicians. In the sketch of the life of Constantine Africanus, which follows this chapter, there is some account of the friendship between Abbot Desiderius of Monte Cassino and Constantine Africanus, and the latter's withdrawal from his professorship to become a Benedictine. One of the physicians of the early tenth century who stood high in favor with Prince Gisulf was raised to the Bishopric of Salerno. This was Alphanus, whom we have already mentioned as a chronicler, a monk, a poet, a physician, and finally the Bishop of Salerno.

The best proof of how thorough was the medical education at Salerno and how much influence it exerted even over public opinion is to be found in the regulation of the practice of medicine, which soon began, and the insistence upon proper training before permission to practise medicine was granted. The medical school at Salerno early came to be a recognized institution in the kingdom of the Two Sicilies, representing a definite standard of medical training. It is easy to understand that the attraction which Salerno possessed for patients soon also brought to the neighborhood a number of irregular physicians, travelling quacks, and charlatans. Wealthy patients were coming from all over the world to be treated at Salerno. Many of them doubtless were sufferers from incurable diseases and nothing could be done for them. Often they would be quite unable to return to their homes and would be surely unwilling to give up all hope if anybody promised them anything of relief. There was a rich field for the irregular, and of course, as always, he came. Salerno had already shown what a good standard of medical education should be, and it is not surprising, then, that the legal authorities in this part of the country proceeded to the enforcement of legal regulations demanding the attainment of this standard, in order that unfit and unworthy physicians might not practise medicine to their own benefit but to the detriment of the patients.

Accordingly, as early as the year 1140, King Ruggiero (Roger) of the Two Sicilies promulgated the law: "Whoever from this time forth desires to practise medicine must present himself before our officials and judges, and be subject to their decision. Anyone audacious enough to neglect this shall be punished by imprisonment and confiscation of goods. This decree has for its object the protection of the subjects of our kingdom from the dangers arising from the ignorance of practitioners."

Just about a century later the Emperor Frederick II, the Hohenstaufen, in the year 1240, extended this law, emphasized it, and brought it particularly into connection with the great medical school of the Two Sicilies, of which territory he was the ruler. This law has often been proclaimed as due to his personality rather than to his times,—as representing his very modern spirit and his progressive way of looking at things. There is no doubt that certain personal elements for which he should be given due credit are contained in the law. To understand it properly, however, one must know the law of King Roger of the preceding century; and then it is easy to appreciate that Frederick's regulation is only such a development of the governmental attitude toward medical practice as might have been expected during the century since Roger's time. It has sometimes been suggested that this law made by the Emperor Frederick, who was so constantly in bitter opposition to the Papacy, was issued in despite of the Church authorities and represents a policy very different from any which they would have encouraged. The early history of Salerno, even briefly as we have given it, completely contradicts any such idea. The history of medical regulation at the beginning of the next century down at Montpellier moreover, where the civil authorities being weak the legal ordering of the practice of medicine was effectively taken up by the Church, and the authority for the issuance of licenses to practise was in the hands of the bishops of the neighborhood, shows clearly that it is not because of any knowledge of the real medical history of the times that such remarks are made, but from a set purpose to discredit the Church.

The Emperor Frederick's law deserves profound respect and consideration because of the place that it holds in the legal regulation of the practice of medicine. Anyone who thinks that evolution must have brought us in seven centuries much farther in this matter than were the people of the later Middle Ages should read this law attentively. Everyone who is interested in medical education should have a copy of it near him, because it will have a chastening effect in demonstrating not only how little we have done in the modern time rather than how much, but above all how much of decadence there was during many periods of the interval. The law may be found in the original in "The Popes and Science" (Fordham University Press, N.Y., 1908). Three years of preliminary university education before the study of medicine might be taken up, four years of medical studies proper before a degree was given, a year of practice with a regularly licensed physician before a license to practise could be obtained, a special course in anatomy if surgery were to be practised; all this represents an ideal we are striving after at the present time in medical education. Besides this, Frederick's law also regulates medical fees, requires gratuitous attendance on the poor for the privilege of practice accorded by the license, though the general fees are of a thoroughly professional character and represent for each visit of the physician about the amount of daily wage that the ordinary laborer of that time earned. Curiously enough, this same ratio of emolument has maintained itself. This law was also a pure drug law, regulating the practice of pharmacy, and the price as well as the purity of drugs, and the relations of physicians, druggists, and the royal drug inspectors whose business it was to see that only proper drugs were prepared and sold.

All this is so much more advanced than we could possibly have imagined, only that the actual documents are in our possession, that most people refuse to let themselves be persuaded in spite of the law that it could have meant very much. Especially as regards medical education are they dubious as to conditions at this time. To them it seems that it can make very little difference how much time was required for medical study or for studies preliminary to medicine, since there was so little to be learned. The age was ignorant, men knew but little, and so very little could be imparted no matter how much time was taken.

This is, I fear, a common impression, but an utterly false one. The preliminary training that is the undergraduate work at the universities consisted of the Seven Liberal Arts—the trivium and quadrivium, which embraced logic, rhetoric, grammar, metaphysics, under which was included not a little of physics, cosmology in which some biology was studied, as well as psychology and mathematics, astronomy, and music. This was a thoroughly rounded course in intellectual training. No wonder that Professor Huxley said in his Inaugural Address as Rector of Aberdeen, "I doubt if the curriculum of any modern university shows so clear and generous a comprehension of what is meant by culture as this old trivium and quadrivium does." There is no doubt at all about the value of the undergraduate training, nor of the scholarship of the men who were turned out under the system, nor of their ability to concentrate their minds on difficult subjects—a faculty that we strive to cultivate in our time and do not always congratulate ourselves on securing to the degree, at least, that we would like.

As to the medical teaching, AEgidius, often called Gilles of Corbeil, who was a graduate of Salerno and afterward became the physician-in-ordinary to Philip Augustus, King of France, thought that he could not say too much for the training in medicine that was given at this first of the medical schools. One thing is sure, the professors were eminently serious, the work taken up was in many ways thoroughly scientific, and some of the results of the medical investigations of that early day are interesting even now. The descriptions of diseases that we have from the Salernitan school are true to nature and are replete with many original observations. Puschmann says: "The accounts given of intermittent fever, pneumonia, phthisis, psoriasis, lupus, which they called the malum mortuum, of ulcers on the sexual organs, among which it is easy to recognize chancre, and of the disturbances of the mental faculties, especially deserve mention." They seem to have been quite expert in their knowledge of phthisis. In the treatment of it they laid great stress upon the giving up of a strenuous life, the living a rather easy existence in the open air, and a suitable diet. When the commencement of consumption was suspected, the first prescription was a good course of strengthening nourishment for the patient. On the other hand, they declared that the cases in which diarrhea supervened during consumption soon proved fatal. In general, with regard to people who were liable to respiratory diseases, they insisted upon life in an atmosphere of equable temperature. Though the custom was almost unheard of in the Salerno of that time, and indeed at the present time there is very little heating during the winter in southern Italy, they insisted that patients who were liable to pulmonary affections should have their rooms heated.

On the other hand, they suggested the cooling of the air of the sick-room, as we have noted in the chapter on Constantine Africanus, and Afflacius recommended the employment of an apparatus from which water trickled continuously in drops to the ground and then evaporated. Baths and bleeding were employed according to definite indications and diet was always a special feature. They had a number of drugs and simples, and the employment of some of them is interesting. Iron was prescribed for enlargement of the spleen. The internal use of sea sponge, in which of course there is a noteworthy proportion of iodine, was recommended for relief from the symptoms of goitre by reducing its size. Iodine has been used so much ever since in this affection, even down to our own day, that this employment of one of its compounds is rather striking. Massage of the goitre was also recommended, and this mode of treatment was commonly employed for a number of ailments.

Probably the best idea that can be obtained in brief space of the achievements of the University of Salerno is to be found in Pagel's appreciation of Salerno's place in the history of medicine in his chapters on "Medicine in the Middle Ages" in Puschmann's "Handbuch der Geschichte der Medizin" (Berlin, 1902). He said: "If we take up now the accomplishments of the school of Salerno in the different departments there is one thing that is very remarkable. It is the rich independent productivity with which Salerno advanced the banners of medical science for hundreds of years almost as the only autochthonous centre of medical influence in the whole West. One might almost say that it was like a versprengten Keim—a displaced embryonic element—which, as it unfolded, rescued from destruction the ruined remains of Greek and Roman medicine. This productivity of Salerno, which may well be compared in quality and quantity with that of the best periods of our science, and in which no department of medicine was left without some advance, is one of the striking phenomena of the history of medicine. While positive progress was not made, there are many noteworthy original observations to be chronicled. It must be acknowledged that pupils and scholars set themselves faithfully to their tasks to further as far as their strength allowed the science and art of healing. In the medical writers of the older period of Salerno who had not yet been disturbed by Arabian culture or scholasticism, we cannot but admire the clear, charmingly smooth, light-flowing diction, the delicate and honest setting forth of cases, the simplicity of their method of treatment, which was to a great extent dietetic and expectant, and while we admire the carefulness and yet the copiousness of their therapy, we cannot but envy them a certain austerity in their pharmaceutic formulas and an avoidance of medicamental polypragmasia. The work in internal medicine was especially developed. The contributions to it from a theoretic and a literary standpoint, as well as from practical applications, found ardent devotees."

Less than this could scarcely have been expected from the medical school which brought such an uplift of professional dignity and advance in the standards of medical education that are to be noticed in connection with Salerno. Registration, licensure, preliminary education, adequate professional studies, clinical experience under expert guidance, even special training for surgical work, all came in connection with this great medical school. Such practical progress in medical education could not have been made but by men who faced the problems of the practice of medicine without self-deception and solved them as far as possible by common-sense, natural, and rational methods.

It is usually said that at Salerno surgery occupied an inferior position. It is true that we have less record of it in the earlier years of Salerno than we would like to see. It was somewhat handicapped by the absence of human dissection. This very important defect was not due to any Church opposition to anatomy, as has often been said, but to the objection that people have to seeing the bodies of their friends or acquaintances used for anatomical purposes. In the comparatively small towns of the Middle Ages there were few strangers, and therefore very seldom were there unclaimed bodies. The difficulty was in the obtaining of dissecting material. We had the same difficulty in this country until about two generations ago, and the only way that bodies could be obtained regularly was by "resurrecting" them, as it was called, from graveyards. In the absence of human subjects, anatomy was taught at Salerno upon the pig. The principal portion of the teaching in anatomy consisted of the demonstration of the organs in the great cavities of the body and their relations, with some investigations of their form and the presumed functions of the corresponding organs in man. Copho's well-known "Anatomy of the Pig" was a text-book written for the students of Salerno. In spite of its limitations, it shows the beginnings of rather searching original inquiry and even some observations in pathological anatomy. It is simple and straightforward and does not profess to be other than it is, though it must be set down as the first reasonably complete contribution to comparative anatomy.

When their surgery came to be written down, however, it gave abundant evidence of the thoroughness with which this department of medicine had been cultivated by the Salernitan faculty. We have the text-book of Roger, with the commentary of Rolando, and then the so-called commentary of the Four Masters. These writings were probably made rather for the medical school at Bologna than that of Salerno, though there is no doubt that at least Roger and Rolando received their education at Salerno and embodied in their writings the surgical traditions of that school. While I have preferred, in order to have a connected story of surgical development, to treat of their contributions to their specialty under the head of the "Great Surgeons of the Medieval Universities," it seems well to point out here that they must be considered as representing especially the surgical teaching of the older medical school of Salerno. There are many interesting features of the old teaching that they have embodied in their books. For instance, at Salerno both sutures and ligatures were employed in order to prevent bleeding. We are rather accustomed to think of such uses of thread, and especially the ligature, as being much later inventions. The fact of the matter is, however, that ligatures and sutures were reinvented over and over again and then allowed to go out of use until someone who had no idea of their dangers came to reinvent them once more.[8]

Much is often said about the place of Arabian surgery and medicine at this time, and the influence that they had over the medical teaching and thinking of the period. To trust many of the shorter histories of medicine the Arabs must be given credit for more of the medical thought of this time than any other medical writers or thinkers. It is forgotten, however, apparently, that in the southern part of Italy, where Salerno was situated, Greek influence never died out. This had been a Greek colony in the olden time and continued to be known for many centuries after the Christian era as Magna Graecia. Greek medicine, then, had more influence here than anywhere else. As a matter of fact, the beginnings of Salernitan teaching are all Greek and not at all Arabian. This is as true in surgery as in medicine. I have quoted Gurlt in the chapter on "Great Surgeons of the Medieval Universities," insisting that the Salernitan school owed nothing at all to Arabian surgery. Salernitan medicine was, during the twelfth century, just as free from Arabian influence. When Arabian medicine makes itself felt, as pointed out by Pagel in his "Geschichte der Heilkunde im Mittelalter,"[9] far from exerting a beneficial influence, it had a rather unfortunate effect. It led especially to an oversophistication of medicine from the standpoint of drug therapeutics. The Arabian physicians trusted nature very little. In this they were like our forefathers of medicine one hundred years ago, of whom Rush was the typical representative—so history repeats itself.

Before the introduction of Arabian medicine the Salernitan school of medicine was noted for its common-sense methods and its devotion to all the natural modes of healing. It looked quite as much to the prevention of disease as its treatment. Diet and air and water were always looked upon as significant therapeutic aids. With the coming of Arabian influence there began, says Pagel, "as the literature of the times shows very well, that rule of the apothecary in therapeutics which was an unfortunate exaggeration. Now all the above-mentioned complicated prescriptions came to be the order of the day. Apparently the more complicated a prescription the better. Dietetics especially was relegated to the background. Salerno, at the end of the twelfth century, had already reached its highest point of advance in medicine and was beginning to decline. Decadence was evident in so far as all the medical works that we have from that time are either borrowings or imitations from Arabian medicine with which eventually Salernitan medical literature became confounded. Only a few independent authors are found after this time." This is so very different from what is ordinarily presumed to have been the case and openly proclaimed by many historians of medicine because apparently they would prefer to attribute scientific advance to the Arabs than to the Christian scholars of the time, that it is worth while noting it particularly.

Salerno was particularly rich in its medical literary products. Very often we have not the names of the writers. Apparently there is good reason to think that a number of the professors consulted together in writing a book, and when it was issued it was considered to be a text-book of the Salernitan school of medicine rather than of any particular professor. This represents a development of co-operation on the part of colleagues in medical teaching that we are likely to think of as reserved for much later times.

The most important medical writing that comes to us from Salerno, in the sense at least of the work that has had most effect on succeeding generations, has been most frequently transcribed, most often translated and committed to memory by many generations of physicians, is the celebrated Salernitan medical poem on hygiene. The title of the original Latin was "Regimen Sanitatis Salernitanum." It was probably written about the beginning of the twelfth century. A century or so later it came to be the custom to call medical books after flowers, and so we had the "Lilium Medicinae" and the "Flos Medicinae" down at Montpellier, and this became the "Flos Medicinae" of Salerno. Pagel calls it the quintessence of Salernitan therapeutics.

For many centuries portions at least of this Latin medical poem were as common in the mouths of physicians all over Europe as the aphorisms of Hippocrates or the sayings of Galen. Probably this enables us to understand the great reputation that the Salernitan school enjoyed and the influence that it wielded better than anything else. The poem is divided into ten principal parts, containing altogether about 3,500 lines. The first part on hygiene has 855 lines in eight chapters. The second part on materia medica, though containing only four chapters, has also about 800 lines. Anatomy and physiology are crowded into about 200 lines, etiology has something over 200, semiotics has about 250, pathology has but thirty lines more or less, and therapeutics about 400; nosology has about 600 more, and finally there is something about the physician himself, and an epilogue. As Latin verses go, when written for such purposes, these are not so bad, though some of them would grate on a literary ear. The whole work makes a rather interesting compendium of medicine, with therapeutic indications and contra-indications, and whatever the physician of the medieval period needed to have ready to memory. Some of its prescriptions, both in the sense of formulae and of directions to the patient, have quite a modern air.

One very interesting contribution to medical literature that comes to us from Salerno bears the title, "The Coming of a Physician to His Patient, or An Instruction for the Physician Himself." We have had a number of such works published in recent years, but it is a little surprising to have the subject taken up thus early in the history of modern professional life. It is an extremely valuable document, as demonstrating how practical was the teaching at Salerno. The work is usually ascribed to Archimattheas, and it certainly gives a vivid picture of the medical customs of the time. The instruction for the immediate coming of the physician to his patient runs as follows: "When the doctor enters the dwelling of his patient, he should not appear haughty, nor covetous, but should greet with kindly, modest demeanor those who are present, and then seating himself near the sick man accept the drink which is offered him (sic) and praise in a few words the beauty of the neighborhood, the situation of the house, and the well-known generosity of the family,—if it should seem to him suitable to do so. The patient should be put at his ease before the examination begins and the pulse should be felt deliberately and carefully. The fingers should be kept on the pulse at least until the hundredth beat in order to judge its kind and character; the friends standing round will be all the more impressed because of the delay and the physician's words will be received with just that much more attention."

The old physician evidently realized very well how much influence on the patient's mind meant for the course of the disease. For instance, he recommends that the patient should be asked to confess and receive the sacraments of the Church before the doctor sees him, for if mention is afterwards made of this the patient may believe that it is because the doctor thinks that there is no hope for him. For the purpose of producing an effect upon the patient's mind, the old physician does not hesitate even to suggest the taking advantage of every possible source of information, so as to seem to know all about the case. "On the way to see the sick person he [the physician] should question the messenger who has summoned him upon the circumstances and the conditions of the illness of the patient; then, if not able to make any positive diagnosis after examining the pulse and the urine, he will at least excite the patient's astonishment by his accurate knowledge of the symptoms of the disease and thus win his confidence."

At the end of these preliminary instructions there is a rather diplomatic—to say the least—bit of advice that might perhaps to a puritanic conscience seem more politic than truthful. Since the old professor insists so much on not disturbing the patient's mind by a bad prognosis or any hint of it, and since even some exaggeration of what he might think to be the serious outlook of the case to friends would only lead to greater care of the patient, there is probably much more justification for his suggestion than might be thought at first glance. He says, "When the doctor quits the patient he should promise him that he will get quite well again, but he should inform his friends that he is very ill; in this way, if a cure is affected, the fame of the doctor will be so much the greater, but if the patient dies people will say that the doctor had foreseen the fatal issue."

The story of the medical school of Salerno, even thus briefly and fragmentarily told, illustrates very well how old is the new in education,—even in medical education. There is scarcely a phase of modern interest in medical education that may not be traced very clearly at Salerno though the school began its career a thousand years ago, and ceased to attract much attention over six hundred years ago. We owe most of our knowledge of the details of its organization and teaching to De Renzi. Without the devotion of so ardent a scholar it would have been almost impossible for us to have attained so complete a picture of Salernitan activities. As it is, as a consequence of his work we are able to see this first of modern medical schools developing very much as do our most modern medical schools. There has been an accumulation of medical information in the thousand years, but the ways and modes of facing problems and many of the solutions of them do not differ from what they were in the distant past. The more we know about any particular period, the more is this brought home to us. It is for this that study of particular periods and institutions of the olden time, as of Salerno, grows increasingly interesting, because each new detail helps to fill in sympathetically the new-old picture of human activity as it may be seen at all times.



VII

CONSTANTINE AFRICANUS

Probably the most important representative of the medical school at Salerno, certainly the most significant member of its faculty, if we consider the wide influence for centuries after his time that his writings had, was Constantine Africanus. He is interesting, too, for many other reasons, for he is the first representative, in modern times, that is, who, after the incentive of antiquity had passed, devoted himself to creating a medical literature by translations, by editions, and by the collation of his own and others' observations on medical subjects. He is the connecting link between Arabian medicine and Western medical studies. The fact that he was first a traveller over most of the educational world of his time, then a professor at the University of Salerno who attracted many students, and finally a Benedictine monk in the great abbey at Monte Cassino, shows how his life ran the gamut of the various phases of interest in the intellectual world of his time. It was his retirement to the famous monastery that gave him the opportunity, the leisure, the reference library for consultation that a writer feels he must have near him, and probably also the means necessary for the publication of his works. Not only did the monks of Monte Cassino itself devote themselves to the copying of his many books, but other Benedictine monasteries in various parts of the world made it a point to give wide diffusion to his writings.

As a study in successful publication, that is, in the securing of wide attention to writings within a short time, the career of Constantine and the story of his books would be extremely interesting. Medieval distribution of books is usually thought to have been rather halting, but here was an exception. It was largely because Benedictines all over the world were deeply interested in what this brother Benedictine was writing that wide distribution was secured for his work within a very short time. His superiors among the Benedictines had a profound interest in what he was doing. The great Benedictine Abbot Desiderius of Monte Cassino, who afterwards became Pope, used all of his extensive influence in both positions to secure an audience for the books—hence the many manuscript copies of his writings that we have. It is probable that Constantine established a school of writers at Monte Cassino, for he could scarcely have accomplished so much by himself as has been attributed to him. Besides, his works attracted so much attention that writers of immediately succeeding generations who wanted to secure attention for their works sometimes attributed them to him in order to take advantage of his popularity. It is rather difficult, then, to determine with absolute assurance which are Constantine's genuine works. Some of those attributed to him are undoubtedly spurious. What we know with certainty, however, is that his authentic works meant much for his own and after generations.

Constantine was born in the early part of the eleventh century, and died near its close, having lived probably well beyond eighty years of age, his years running nearly parallel with his century. His surname, Africanus, is derived from his having been born in Africa, his birthplace being Carthage. Early in life he seems to have taken up with ardor the study of medicine in his native town, devoting himself, however, at the same time to whatever of physical science was available. Like many another young man since his time, not satisfied with the knowledge he could secure at home, he made distant journeys, gathering medical and scientific information of all kinds wherever he went. According to a tradition that seems to be well grounded, some of these journeys took him even into the far East. During his travels he became familiar with a number of Oriental languages, and especially studied the Arabian literature of science very diligently.

At this time the Arabs, having the advantage of more intimate contact with the Greek medical traditions in Asia Minor, were farther advanced in their knowledge of the medical sciences than the scholars in the West. They had better facilities for obtaining the books that were the classics of medicine, and, with any desire for knowledge, could scarcely fail to secure it.

What was best in Arabian medicine was brought to Salerno by Constantine and, above all, his translation of many well-known Arabian medical authors proved eminently suggestive to seriously investigating physicians all over the world in his time. Before he was to be allowed to settle down to his literary work, however, Constantine was to have a very varied experience. Some of this doubtless was to be valuable in enabling him to set the old Arabian teachers of medicine properly before his generation. After his Oriental travels he returned to his native Carthage in order to practise medicine. It was not long, however, before his superior medical knowledge, or, at least, the many novelties of medical practice that he had derived from his contact with the East, drew upon him the professional jealousy of his colleagues. It is very probable that the reputation of his extensive travels and wide knowledge soon attracted a large clientele. This was followed quite naturally by the envy at least of his professional brethren. Feeling became so bitter, that even the possibility of serious personal consequences for him because of false accusations was not out of the question. Whenever novelties are introduced into medical science or medical practice, their authors are likely to meet with this opposition on the part of colleagues, and history is full of examples of it. Galvani was laughed at and called the frogs' dancing-master; Auenbrugger was made fun of for drumming on people; Harvey is said to have lost half of his consulting practice;—all because they were advancing ideas that their contemporaries were not ready to accept. We are rather likely to think that this intolerant attitude of mind belongs to the older times, but it is rather easy to trace it in our own.

In Constantine's day men had ready to hand a very serious weapon that might be used against innovators. By craftily circulated rumors the populace was brought to accuse him of magical practices, that is, of producing his cures by association with the devil. We are rather prone to think little of a generation that could take such nonsense seriously, but it would not be hard to find analogous false notions prevalent at the present time, which sometimes make life difficult, if not dangerous, for well-meaning individuals.[10] Life seems to have been made very uncomfortable for Constantine in Carthage. Just the extent to which persecution went, however, we do not know. About this time Constantine's work attracted the attention of Duke Robert of Salerno. He invited him to become his physician. After he had filled the position for a time a personal friendship developed, and, as has often happened to the physicians of kings, he became a royal counsellor and private secretary. When the post of professor of medicine at Salerno fell vacant, it is not surprising, then, that Constantine should have been made professor, and from here his teaching soon attracted the attention of all the men of his time.

Constantine seems to have greatly enhanced the reputation of the medical school, and added to the medical prestige of Salerno. After teaching for some ten years there, however, he gave up his professorship—the highest position in the medical world of the time—apparently with certain plans in mind. He wanted leisure for writing the many things in medicine that he had learned in his travels in the East, so as to pass his precious treasure of knowledge on to succeeding generations; and then, too, he seems to have longed for that peace that would enable him not only to do his writing undisturbed, but to live his life quietly far away from the strife of men and the strenuous existence of a court and of a great school.

There was probably another and more intimate personal reason for his retirement. Abbot Desiderius of the Benedictine Abbey of Monte Cassino, not far away, had become a close and valued friend. Before having been made abbot, Desiderius and Constantine probably were fellow professors at Salerno, for we know that Desiderius himself and many of his fellow Benedictines taught in the undergraduate department there. Desiderius enjoyed the reputation of being one of the most learned men of the time when his election to the abbacy at Monte Cassino took him away from Salerno. His departure was a blow to Constantine, who had learned by years of friendship that to be near his intimate friend, the pious scholarly Benedictine, was a solace in life and a never failing incentive to his own intellectual work. Desiderius seems, indeed, to have been a large factor in influencing the great physician to write his books rather than devote himself to oral teaching, since the circulation of his writing would confer so much more of benefit on a greater number of people. Perhaps another element in the situation was that Desiderius was desirous of having the learned physician, the travelled scholar, at Monte Cassino, for the sake of his influence on the scholarship of the abbey, and for the incentive that he would be to the younger monks to apply themselves to the varied field of knowledge which the Benedictines had chosen for themselves at this time.

Whatever hopes of mutual solace and helpfulness and of the joys of intimate close friendship may have been in the minds of these two most learned men of their time, they were destined to be grievously disappointed. Only a few years after Constantine's entrance into the monastery at Monte Cassino Desiderius was elected Pope. The humble Benedictine did not want to take the exalted position, but it was plainly shown to him that it was his duty, and that he must not shirk it. Accordingly, under the name of Pope Victor III, he became one of the great Popes of the eleventh century. One might think that he could have summoned Constantine to Rome, but perhaps he knew that his friend would prefer the quietude of the cloister, and then, too, probably he wanted to allow him the opportunity to accomplish that writing for which Constantine and himself had planned when the great physician entered the monastery.

All that we know for sure is that some twenty years of Constantine's life were spent as a monk in Monte Cassino, where he devoted his time mainly to the writing of his books. One bond of union there was. Each of the works, as soon as completed, was sent off to the Pope as long as he lived. On the other hand, though busy with his Papal duties, Pope Victor constantly stimulated Constantine, even from distant Rome, to go on with his work. There were messages of brotherly interest and solicitude just as in the old days. The great African physician's best known work, the so-called "Liber Pantegni," which is really a translation of the "Khitaab el Maleki" of Ali Ben el-Abbas, is dedicated to Desiderius. Constantine wrote a number of other books, most of them original, but it is difficult now to decide just which of those that pass under his name are genuine. Many were subsequently attributed to him that are surely not his.

These translators of the Middle Ages proved to be not only the channels through which information came to their generations, but they were also incentives to study and investigation. It is when men can get a certain amount of information rather easily that they are tempted to seek further in order to solve the problems that present themselves. There are three great translators whose work meant much for the Middle Ages at this time. They were, besides Constantine in the eleventh century, Gerard of Cremona, in the twelfth, and the Jewish Faradj Ben Salim, at Naples, in the thirteenth. Gerard did in Spain for the greater Arabian writers what Constantine had accomplished for those of lesser import. Under the patronage of the Emperor Frederick Barbarossa, he published translations of Rhazes, Isaac Judaeus, Serapion, Abulcasis, and Avicenna. His work was done in Toledo, the city in which, during the twelfth and thirteenth centuries, so many translators were at work making books for the Western world.

Constantine did much more than merely bring out his translations of Arabian works. He gave a zest to the study of the old masters, issued editions of certain, at least, of the works of Hippocrates ("Aphorisms") and Galen ("Microtechnics"), and, in general, called attention to the precious treasure of medical lore that must be used to advantage if men were to teach the rising generation out of the accumulated knowledge of the past. Pagel, in Puschmann's "Handbook," does not hesitate to say that "a farther merit of Constantine must be recognized, inasmuch as that not long after his career the second epoch of the school of Salerno begins, marked not only by a wealth of writers and writings on medicine, but, above all, because from this time on the study of Greek medicine received renewed encouragement through the Latin versions of the Arabian literature. We may think as we will of the worth of these works, but this much is sure, that in many ways they brought about a broadening and an improvement of Greek knowledge, especially from the pharmacopeia standpoint."