Old-Time
Makers of Medicine

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

BY

James J. Walsh, K.C.St.G., M.D.
Ph.D., LL.D., Litt.D., Sc.D.

DEAN AND PROFESSOR OF NERVOUS DISEASES AND OF THE HISTORY OF MEDICINE AT
FORDHAM UNIVERSITY SCHOOL OF MEDICINE; PROFESSOR OF PHYSIOLOGICAL
PSYCHOLOGY AT THE CATHEDRAL COLLEGE, NEW YORK

NEW YORK

FORDHAM UNIVERSITY PRESS

1911

Copyright 1911

JAMES J. WALSH

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

TO

REVEREND DANIEL J. QUINN, S.J.

The historical material here presented was gathered for my classes at Fordham University School of Medicine during your term as president of the University. It seems only fitting then, that when put into more permanent form it should appear under the patronage of your name and tell of my cordial appreciation of more than a quarter of a century of valued friendship.

"When we have thoroughly mastered contemporary science it is time to turn to past science; nothing fortifies the judgment more than this comparative study; impartiality of mind is developed thereby, the uncertainties of any system become manifest. The authority of facts is there confirmed, and we discover in the whole picture a philosophic teaching which is in itself a lesson; in other words, we learn to know, to understand, and to judge."—Littré: Œuvres d'Hippocrate, T. I, p. 477.

"There is not a single development, even the most advanced of contemporary medicine, which is not to be found in embryo in the medicine of the olden time."—Littré: Introduction to the Works of Hippocrates.

"How true it is that in reading this history one finds modern discoveries that are anything but discoveries, unless one supposes that they have been made twice."—Dujardin: Histoire de la Chirurgie, Paris, 1774 (quoted by Gurlt on the post title-page of his Geschichte der Chirurgie, Berlin, 1898).

PREFACE

The material for this book was gathered partly for lectures on the history of medicine at Fordham University School of Medicine, and partly for articles on a number of subjects in the Catholic Encyclopedia. Some of it was developed for a series of addresses at commencements of medical schools and before medical societies, on the general topic how old the new is in surgery, medicine, dentistry, and pharmacy. The information thus presented aroused so much interest, the accomplishments of the physicians and surgeons of a period that is usually thought quite sterile in medical science proved, indeed, so astonishing, that I was tempted to connect the details for a volume in the Fordham University Press series. There is no pretence to any original investigation in the history of medicine, nor to any extended consultation of original documents. I have had most of the great books that are mentioned in the course of this volume in my hands, and have given as much time to the study of them as could be afforded in the midst of a rather busy life, but I owe my information mainly to the distinguished German and French scholars who have in recent years made deep and serious studies of these Old Makers of Medicine, and I have made my acknowledgments to them in the text as opportunity presented itself.

There is just one feature of the book that may commend it to present-day readers, and that is that our medieval medical colleagues, when medicine embraced most of science, faced the problems of medicine and surgery and the allied sciences that are now interesting us, in very much the same temper of mind as we do, and very often anticipated our solutions of them—much oftener, indeed, than most of us, unless we have paid special attention to history, have any idea of. The volume does not constitute, then, a contribution to that theme that has interested the last few generations so much,—the supposed continuous progress of the race and its marvellous advance,—but rather emphasizes that puzzling question, how is it that men make important discoveries and inventions, and then, after a time, forget about them so that they have to be made over again? This is as true in medical science and in medical practice as in every other department of human effort. It does not seem possible that mankind should ever lose sight of the progress in medicine and surgery that has been made in recent years, yet the history of the past would seem to indicate that, in spite of its unlikelihood, it might well come about. Whether this is the lesson of the book or not, I shall leave readers to judge, for it was not intentionally put into it.

OUR LADY'S DAY IN HARVEST, 1911.

CONTENTS

"Of making many books there is no end."—Eccles. xii, 12 (circa 1000 b.c.).

"The little by-play between Socrates and Euthydemus suggests an advanced condition of medical literature: 'Of course, you who have so many books are going in for being a doctor,' says Socrates, and then he adds, 'there are so many books on medicine, you know.' As Dyer remarks, whatever the quality of these books may have been, their number must have been great to give point to this chaff."—Aequanimitas, William Osler, M.D., F.R.S., Blakistons, Philadelphia, 1906.

"Augescunt aliae gentes, aliae minuuntur;
Inque brevi spatio mutantur saecla animantum,
Et, quasi cursores vitai lampada tradunt."

—OVID.

One nation rises to supreme power in the world, while another declines, and, in a brief space of time, the sovereign people change, transmitting, like racers, the lamp of life to some other that is to succeed them.

"There is one Science of Medicine which is concerned with the inspection of health equally in all times, present, past and future."

—PLATO.

I
INTRODUCTION

Under the term Old-Time Medicine most people probably think at once of Greek medicine, since that developed in what we have called ancient history, and is farthest away from us in date. As a matter of fact, however, much more is known about Greek medical writers than those of any other period except the last century or two. Our histories of medicine discuss Greek medicine at considerable length and practically all of the great makers of medicine in subsequent generations have been influenced by the Greeks. Greek physicians whose works have come down to us seem nearer to us than the medical writers of any but the last few centuries. As a consequence we know and appreciate very well as a rule how much Greek medicine accomplished, but in our admiration for the diligent observation and breadth of view of the Greeks, we are sometimes prone to think that most of the intervening generations down to comparatively recent times made very little progress and, indeed, scarcely retained what the Greeks had done. The Romans certainly justify this assumption of non-accomplishment in medicine, but then in everything intellectual Rome was never much better than a weak copy of Greek thought. In science the Romans did nothing at all worth while talking about. All their medicine they borrowed from the Greeks, adding nothing of their own. What food for thought there is in the fact, that in spite of all Rome's material greatness and wide empire, her world dominance and vaunted prosperity, we have not a single great original scientific thought from a Roman.

Though so much nearer in time medieval medicine seems much farther away from us than is Greek medicine. Most of us are quite sure that the impression of distance is due to its almost total lack of significance. It is with the idea of showing that the medieval generations, as far as was possible in their conditions, not only preserved the old Greek medicine for us in spite of the most untoward circumstances, but also tried to do whatever they could for its development, and actually did much more than is usually thought, that this story of "Old-Time Makers of Medicine" is written. It represents a period—that of the Middle Ages—that is, or was until recently, probably more misunderstood than any other in human history. The purpose of the book is to show at least the important headlands that lie along the stream of medical thought during the somewhat more than a thousand years from the fall of the Roman Empire under Augustulus (476) until the discovery of America. After that comes modern medicine, for with the sixteenth century the names and achievements of the workers in medicine are familiar—Paracelsus, Vesalius, Columbus, Servetus, Cæsalpinus, Eustachius, Varolius, Sylvius are men whose names are attached to great discoveries with which even those who are without any pretence to knowledge of medical history are not unacquainted. In spite of nearly four centuries of distance in time these men seem very close to us. Their lives will be reserved for a subsequent volume, "Our Forefathers in Medicine."

It is usually the custom to contemn the Middle Ages for their lack of interest in culture, in education, in literature, in a word, in intellectual accomplishment of any and every kind, but especially in science. There is no doubt about the occurrence of marked decadence in the intellectual life of the first half of this period. This has sometimes been attributed to what has been called the inhibitory effect of Christianity on worldly interests. Religion is said to have occupied people so much with thoughts of the other world that the beauties and wonders, as well as much of the significance, of the world around them were missed. Those who talk thus, however, forget entirely the circumstances which brought about the serious decadence of interest in culture and science at this time. The Roman Empire had been the guardian of letters and education and science. While the Romans were not original in themselves, at least they had shown intense interest in what was accomplished by the Greeks and their imitation had often risen to heights that made them worthy of consideration for themselves. They were liberal patrons of Greek art and of Greek literature, and did not neglect Greek science and Greek medicine. Galen's influence was due much more to the prominence secured by him as the result of his stay in Rome than would have been possible had he stayed in Asia. There are many other examples of Roman patronage of literature and science that might be mentioned. As we shall see, Rome drained Greece and Asia Minor of their best, and appropriated to herself the genius products of the Spanish Peninsula. Rome had a way of absorbing what was best in the provinces for herself.

Just as soon as Rome was cut off from intimate relations with the provinces by the inwandering of barbarians, intellectual decadence began. The imperial city itself had never been the source of great intellectual achievement, and the men whom we think of as important contributors to Rome's literature and philosophy were usually not born within the confines of the city. It is surprising to take a list of the names of the Latin writers whom we are accustomed to set down simply as Romans and note their birthplaces. Rome herself gave birth to but a very small percentage of them. Virgil was born at Mantua, Cicero at Arpinum, Horace out on the Sabine farm, the Plinys out of the city, Terence in Africa, Persius up in Central Italy somewhere, Livy at Padua, Martial, Quintilian, the Senecas, and Lucan in Spain. When the government of the city ceased to be such as assured opportunity for those from outside who wanted to make their way, decadence came to Roman literature. Large cities have never in history been the fruitful mothers of men who did great things. Genius, and even talent, has always been born out of the cities in which it did its work. It is easy to understand, then, the decadence of the intellectual life that took place as the Empire degenerated.

For the sake of all that it meant in the Roman Empire to look towards Rome at this time, however, it seemed better to the early Christians to establish the centre of their jurisdiction there. Necessarily, then, in all that related to the purely intellectual life, they came under the influences that were at work at Rome at this time. During the first centuries they suffered besides from the persecutions directed against them by the Emperors at various times, and these effectually prevented any external manifestations of the intellectual life on the part of Christians. It took much to overcome this serious handicap, but noteworthy progress was made in spite of obstacles, and by the time of Constantine many important officials of the Empire, the educated thinking classes of Rome, had become Christians. After the conversion of the Emperor opportunities began to be afforded, but political disturbances consequent upon barbarian influences still further weakened the old civilization until much of the intellectual life of it almost disappeared.

Gradually the barbarians, finding the Roman Empire decadent, crept in on it, and though much more of the invasion was peaceful than we have been accustomed to think, the Romans simply disappearing because family life had been destroyed, children had become infrequent, and divorce had become extremely common, it was not long before they replaced the Romans almost entirely. These new peoples had no heritage of culture, no interest in the intellectual life, no traditions of literature or science, and they had to be gradually lifted up out of their barbarism. This was the task that Christianity had to perform. That it succeeded in accomplishing it is one of the marvels of history.

The Church's first grave duty was the preservation of the old records of literature and of science. Fortunately the monasteries accomplished this task, which would have been extremely perilous for the precious treasures involved but for the favorable conditions thus afforded. Libraries up to this time were situated mainly in cities, and were subject to all the vicissitudes of fire and war and other modes of destruction that came to cities in this disturbed period. Monasteries, however, were usually situated in the country, were built very substantially and very simply, and the life in them formed the best possible safeguard against fire, which worked so much havoc in cities. As we shall see, however, not only were the old records preserved, but excerpts from them were collated and discussed and applied by means of direct observation. This led the generations to realize more and more the value of the old Greek medicine and made them take further precautions for its preservation.

The decadence of the early Middle Ages was due to the natural shifting of masses of population of this time, while the salvation of scientific and literary traditions was due to the one stable element in all these centuries—the Church. Far from Christianity inhibiting culture, it was the most important factor for its preservation, and it provided the best stimulus and incentive for its renewed development just as soon as the barbarous peoples were brought to a state of mind to appreciate it.

Bearing this in mind, it is easier to understand the course of medical traditions through the Middle Ages, and especially in the earlier period, with regard to which our documents are comparatively scanty, and during which the disturbed conditions made medical developments impossible, and anything more than the preservation of the old authors out of the question. The torch of medical illumination lighted at the great Greek fires passes from people to people, never quenched, though often burning low because of unfavorable conditions, but sometimes with new fuel added to its flame by the contributions of genius. The early Christians took it up and kept it lighted, and, with the Jewish physicians, carried it through the troublous times of the end of the old order, and then passed it on for a while to the Arabs. Then, when favorable conditions had developed again, Christian schools and scholars gave it the opportunity to burn brightly for several centuries at the end of the Middle Ages. This medieval age is probably the most difficult period of medical history to understand properly, but it is worth while taking the trouble to follow out the thread of medical tradition from the Greeks to the Renaissance medical writers, who practically begin modern medicine for us.

It is easy to understand that Christianity's influence on medicine, instead of hampering, was most favorable. The Founder of Christianity Himself had gone about healing the sick, and care for the ailing became a prominent feature of Christian work. One of the Evangelists, St. Luke, was a physician. It was the custom a generation ago, and even later, when the Higher Criticism became popular, to impugn the tradition as to St. Luke having been a physician, but this has all been undone, and Harnack's recent book, "Luke the Physician," makes it very clear that not only the Third Gospel, but also the Acts, could only have been written by a man thoroughly familiar with the Greek medical terms of his time, and who had surely had the advantage of a training in the medical sciences at Alexandria. This makes such an important link in medical traditions that a special chapter has been devoted to it in the Appendix.

Very early in Christianity care for the ailing poor was taken up, and hospitals in our modern sense of the term became common in Christian communities. There had been military hospitals before this, and places where those who could afford to pay for service were kept during illness. Our modern city hospital, however, is a Christian institution. Besides, deformed and ailing children were cared for and homes for foundlings were established. Before Christianity the power even of life and death of the parents over their children was recognized, and deformed or ailing children, or those that for some reason were not wanted, were exposed until they died. Christianity put an end to this, and in two classes of institutions, the hospitals and the asylums, abundant opportunity for observation of illness was afforded. Just as soon as Christianity came to be free to establish its institutions publicly, hospitals became very common. The Emperor Julian, usually known as the Apostate, who hoped to re-establish the old Roman Olympian religion, wrote to Oribasius, one of the great physicians of this time, who was also an important official of his household, that these Christians had established everywhere hospitals in which not only their own people, but also those who were not Christians, were received and cared for, and that it would be idle to hope to counteract the influence of Christianity until corresponding institutions could be erected by the government.

From the very beginning, or, at least, just as soon as reasonable freedom from persecution gave opportunity for study, Christian interest in the medical sciences began to manifest itself. Nemesius, for instance, a Bishop of Edessa in Syria, wrote toward the end of the fourth century a little work in Greek on the nature of man, which is a striking illustration of this. Nemesius was what in modern times would be called a philosopher, that is, a speculative thinker and writer, with regard to man's nature, rather than a physical scientist. He was convinced, however, that true philosophy ought to be based on a complete knowledge of man, body and soul, and that the anatomy of his body ought to be a fundamental principle. It is in this little volume that some enthusiastic students have found a description that is to them at least much more than a hint of knowledge of the circulation of the blood. Hyrtl doubts that the passage in question should be made to signify as much as has been suggested, but the occurrence of any even distant reference to such a subject at this time shows that, far from there being neglect of physical scientific questions, men were thinking seriously about them.

Just as soon as Christianity brought in a more peaceful state of affairs and had so influenced the mass of the people that its place in the intellectual life could be felt, there comes a period of cultural development represented in philosophy by the Fathers of the Church, and during which we have a series of important contributors to medical literature. The first of these was Aëtius, whose career and works are treated more fully in the chapter on "Great Physicians in Early Christian Times." He was followed by Alexander of Tralles, probably a Christian, for his brother was the architect of Santa Sophia, and by Paul of Ægina, with regard to whom we know only what is contained in his medical writings, but whose contemporaries were nearly all Christians. Their books are valuable to us, partly because they contain quotations from great Greek writers on medicine, not always otherwise available, but also because they were men who evidently knew the subject of medicine broadly and thoroughly, made observations for themselves, and controlled what they learned from the Greek forefathers in medicine by their own experience. Just at the beginning of the Middle Ages, then, under the fostering care of Christianity there is a period of considerable importance in the history of medical literature. It is one of the best proofs that we have not only that Christianity did not hamper medical development, but that, directly and indirectly, by the place that it gave to the care of the ailing in life as well as the encouragement afforded to the intellectual life, it favored medical study and writing.

A very interesting chapter in the story of the early Christian physician is to be found in what we know of the existence of women physicians in the fourth and fifth centuries. Theodosia, the mother of St. Procopius the martyr, was, according to Carptzovius, looked upon as an excellent physician in Rome in the early part of the fourth century. She suffered martyrdom under Diocletian. There was also a Nicerata who practised at Constantinople under the Emperor Arcadius. It is said that to her St. John Chrysostom owed the cure of a serious illness. From the very beginning Christian women acted as nurses, and deaconesses were put in charge of hospitals. Fabiola, at Rome, is the foundress of the first important hospital in that city. The story of these early Christian women physicians has been touched upon in the chapter on "Medieval Women Physicians," as an introduction to this interesting feature of Salernitan medical education.

During the early Christian centuries much was owed to the genius and the devotion to medicine of distinguished Jewish physicians. Their sacred and rabbinical writers always concerned themselves closely with medicine, and both the Old Testament and the Talmud must be considered as containing chapters important for the medical history of the periods in which they were written. At all times the Jews have been distinguished for their knowledge of medicine, and all during the Middle Ages they are to be found prominent as physicians. They were among the teachers of the Arabs in the East and of the Moors in Spain. They were probably among the first professors at Salerno as well as at Montpellier. Many prominent rulers and ecclesiastics selected Jewish physicians. Some of these made distinct contributions to medicine, and a number of them deserve a place in any account of medicine in the making during the Middle Ages. One of them, Maimonides, to whom a special chapter is devoted, deserves a place among the great makers of medicine of all time, because of the influence that he exerted on his own and succeeding generations. Any story of the preservation and development of medical teaching and medical practice during the Middle Ages would be decidedly incomplete without due consideration of the work of Jewish physicians.

Western medical literature followed Roman literature in other departments, and had only the Greek traditions at second hand. During the disturbance occasioned by the invasion of the barbarians there was little opportunity for such leisure as would enable men to devote themselves with tranquillity to medical study and writing. Medical traditions were mainly preserved in the monasteries. Cassiodorus, who, after having been Imperial Prime Minister, became a monk, recommended particularly the study of medicine to the monastic brethren. With the foundation of the Benedictines, medicine became one of the favorite studies of the monks, partly for the sake of the health of the brethren themselves, and partly in order that they might be helpful to the villages that so often gathered round their monasteries. There is a well-grounded tradition that at Monte Cassino medical teaching was one of the features of the education provided there by the monks. It is generally conceded that the Benedictines had much to do with the foundation of Salerno. In the convents for women as well as the monasteries for men serious attention was given to medicine. Women studied medicine and were professors in the medical department of Salerno. Other Italian universities followed the example thus set, and so there is abundant material for the chapter on "Medieval Women Physicians."

The next phase of medical history in the medieval period brings us to the Arabs. Utterly uninterested in culture, education, or science before the time of Mohammed, with the growth of their political power and the foundation of their capitals, the Arab Caliphs took up the patronage of education. They were the rulers of the cities of Asia Minor in which Greek culture had taken so firm a hold, and captive Greece has always led its captors captive. With the leisure that came for study, Arabians took up the cultivation of the Greek philosophers, especially Aristotle, and soon turned their attention also to the Greek physicians Hippocrates and Galen. For some four hundred years then they were in the best position to carry on medical traditions. Their teachers were the Christian and Jewish physicians of the cities of Asia Minor, but soon they themselves became distinguished for their attainments, and for their medical writings. Interestingly enough, more of their distinguished men flourished in Spain than in Asia Minor. We have suggested an explanation for this in the fact that Spain had been one of the most cultured provinces of the Roman Empire, providing practically all the writers of the Silver Age of Latin literature, and evidently possessing a widely cultured people. It was into this province, not yet utterly decadent from the presence of the northern Goths, that the Moors came and readily built up a magnificent structure of culture and education on what had been the highest development of Roman civilization.

The influence of the Arabs on Western civilization, and especially on the development of science in Europe, has been much exaggerated by certain writers. Closely in touch with Greek thought and Greek literature during the eighth, ninth, and tenth centuries, it is easy to understand that the Arabian writers were far ahead of the Christian scholars of Europe of the same period, who were struggling up out of the practical chaos that had been created by the coming of the barbarians, and who, besides, had the chance for whatever Greek learning came to them only through the secondary channels of the Latin writers. Rome had been too occupied with politics and aggrandizement ever to become cultured. In spite of this heritage from the Greeks, decadence took place among the Arabs, and, as the centuries go on, what they do becomes more and more trivial, and their writing has less significance. Just the opposite happened in Europe. There, there was noteworthy progressive development until the magnificent climax of thirteenth century accomplishment was reached. It is often said that Europe owed much to the Arabs for this, but careful analysis of the factors in that progress shows that very little came from the Arabs that was good, while not a little that was unfortunate in its influence was borrowed from them with the translations of the Greek authors from that language, which constituted the main, indeed often the only, reason why Arabian writers were consulted.

With the foundation of the medical school of Salerno in the tenth century, the modern history of medical education may be said to begin, for it had many of the features that distinguish our modern university medical schools. Its professors often came from a distance and had travelled extensively for purposes of study; they attracted patients of high rank from nearly every part of Europe, and these were generous in their patronage of the school. Students came from all over, from Africa and Asia, as well as Europe, and when abuses of medical practice began to creep in, a series of laws were made creating a standard of medical education and regulating the practice of medicine, that are interesting anticipations of modern movements of the same kind. Finally a law was passed requiring three years of preliminary work in logic and philosophy before medicine might be taken up, and then four years at medicine, with a subsequent year of practice with a physician before a license to practise for one's self was issued. In addition to this there was a still more surprising feature in the handing over of the department of women's diseases to women professors, and the consequent opening up of licensure to practise medicine to a great many women in the southern part of Italy. The surprise that all this should have taken place in the south of Italy is lessened by recalling the fact that the lower end of the Italian peninsula had been early colonized by Greeks, that its name in later times was Magna Græcia, and that the stimulus of Greek tradition has always been especially favorable to the development of scientific medicine.

Salerno's influence on Bologna is not difficult to trace, and the precious tradition of surgery particularly, which was carried to the northern university, served to initiate a period of surgery lasting nearly two centuries, during which we have some of the greatest contributions to this branch of medical science that were ever made. The development of the medical school at Bologna anticipated by but a short time that of a series of schools in the north Italian universities. Padua, Piacenza, Pisa, and Vicenza had medical schools in the later Middle Ages, the works of some of whose professors have attracted attention. It was from these north Italian medical schools that the tradition of close observation in medicine and of thoroughly scientific surgery found its way to Paris. Lanfranc was the carrier of surgery, and many French students who went to Italy came back with Italian methods. In the fourteenth century Guy de Chauliac made the grand tour in Italy, and then came back to write a text-book of surgery that is one of the monuments in this department of medical science. Before his time, Montpellier had attracted attention, but now it came to be looked upon as a recognized centre of great medical teaching. The absence of the Popes from Italy and the influence of their presence at Avignon made itself felt. While culture and education declined in Italy in the midst of political disturbances, they advanced materially at the south of France.

For our generation undoubtedly the most interesting chapter in the history of medieval medicine is that which tells of the marvellous development of surgery that took place in the thirteenth and fourteenth centuries. Considerable space has been devoted to this, because it represents not only an important phase of the history of medicine, and recalls the names and careers of great makers of medicine, but also because it illustrates exquisitely the possibility of important discoveries in medicine being made, applied successfully for years, and then being lost or completely forgotten, though contained in important medical books that were always available for study. The more we know of this great period in the history of surgery, the more is the surprise at how much was accomplished, and how many details of our modern surgery were anticipated. Most of us have had some inkling of the fact that anæsthesia is not new, and that at various times in the world's history men have invented methods of producing states of sensibility in which more or less painless operations were possible. Very few of us have realized, however, the perfection to which anæsthesia was developed, and the possibility this provided for the great surgeons of the later medieval centuries to do operations in all the great cavities of the body, the skull, the thorax, and the abdomen, quite as they are done in our own time and apparently with no little degree of success.

Of course, any such extensive surgical intervention even for serious affections would have been worse than useless under the septic conditions that would surely have prevailed if certain principles of antisepsis were not applied. Until comparatively recent years we have been quite confident in our assurance that antisepsis and asepsis were entirely modern developments of surgery. More knowledge, however, of the history of surgery has given a serious set-back to this self-complacency, and now we know that the later medieval surgeons understood practical antisepsis very well, and applied it successfully. They used strong wine as a dressing for their wounds, insisted on keeping them clean, and not allowing any extraneous material of any kind, ointments or the like, to be used on them. As a consequence they were able to secure excellent results in the healing of wounds, and they were inclined to boast of the fact that their incisions healed by first intention and that, indeed, the scar left after them was scarcely noticeable. We know that wine would make a good antiseptic dressing, but until we actually read the reports of the results obtained by these old surgeons, we had no idea that it could be used to such excellent purpose. Antisepsis, like anæsthesia, was marvellously anticipated by the surgical forefathers of the medieval period.

It has always seemed to me that the story of Medieval Dentistry presented an even better illustration of a great anticipatory development of surgery. This department represents only a small surgical specialty, but one which even at that period was given over to specialists, who were called dentatores. Guy de Chauliac's review of the dentistry of his time and the state of the specialty, as pictured by John of Arcoli, is likely to be particularly interesting, because if there is any department of medical practice that we are sure is comparatively recent in origin, it is dentistry. Here, however, we find that practically all our dental manipulations, the filling of teeth, artificial dentures, even orthodontia, were anticipated by the dentists of the Middle Ages. We have only the compressed account of it which is to be found in text-books of general surgery, and while in this they give mainly a heritage from the past, yet even this suffices to give us a picture very surprising in its detailed anticipation of much that we have been inclined to think of as quite modern in invention and discovery.

Medicine developed much more slowly than surgery, or, rather, lagged behind it, as it seems nearly always prone to do. Surgical problems are simple, and their solution belongs to a great extent to a handicraft. That is, after all, what chirurgy, the old form of our word surgery, means. Medical problems are more complex and involve both art and science, so that solutions of them are often merely temporary and lack finality. During the Middle Ages, however, and especially towards the end of them, the most important branches of medicine, diagnosis and therapeutics, took definite shape on the foundations that lie at the basis of our modern medical science. We hear of percussion for abdominal conditions, and of the most careful study of the pulse and the respiration. There are charts for the varying color of the urine, and of the tints of the skin. With Nicholas of Cusa there came the definite suggestion of the need of exact methods of diagnosis. A mathematician himself, he wished to introduce mathematical methods into medical diagnosis, and suggested that the pulse should be counted in connection with the water clock, the water that passed being weighed, in order to get very definite comparative values for the pulse rate under varying conditions, and also that the specific gravity of fluids from the body should be ascertained in order to get another definite datum in the knowledge of disease. It was long before these suggestions were to bear much fruit, but it is interesting to find them so clearly expressed.

At the very end of the Middle Ages came the father of modern pharmaceutical chemistry, Basil Valentine. Already the spirit that was to mean so much for scientific investigation in the Renaissance period was abroad. Valentine, however, owes little to anything except his own investigations, and they were surprisingly successful, considering the circumstances of time and place. His practical suggestions so far as drugs were concerned did not prove to have enduring value, but then this has been a fate shared by many of the masters of medicine. There were many phases of medical practice, however, that he insisted on in his works. He believed that the best agent for the cure of the disease was nature, and that the physician's main business must be to find out how nature worked, and then foster her efforts or endeavor to imitate them. He insisted, also that personal observation, both of patients and drugs, was more important than book knowledge. Indeed, he has some rather strong expressions with regard to the utter valuelessness of book information in subjects where actual experience and observation are necessary. It gives a conceit of knowledge quite unjustified by what is really known.

What is interesting about all these men is that they faced the same problems in medicine that we have to, in much the same temper of mind that we do ourselves, and that, indeed, they succeeded in solving them almost as well as we have done, in spite of all that might be looked for from the accumulation of knowledge ever since.

It was very fortunate for the after time that in the period now known as the Renaissance, after the invention of printing, there were a number of serious, unselfish scholars who devoted themselves to the publication in fine printed editions of the works of these old-time makers of medicine. If the neglect of them that characterized the eighteenth and early nineteenth centuries had been the rule at the end of the fifteenth and during the sixteenth century, we would almost surely have been without the possibility of ever knowing that so many serious physicians lived and studied and wrote large important tomes during the Middle Ages. For our forefathers of a few generations ago had very little knowledge, and almost less interest, as to the Middle Ages, which they dismissed simply as the Dark Ages, quite sure that nothing worth while could possibly have come out of the Nazareth of that time. What they knew about the people who had lived during the thousand years before 1500 only seemed to them to prove the ignorance and the depths of superstition in which they were sunk. That medieval scholars should have written books not only well worth preservation, but containing anticipations of modern knowledge, and, though of course they could not have known that, even significant advances over their own scientific conditions, would have seemed to them quite absurd.

Fortunately for us, then, the editions of the early printed books, so many of them monuments of learning and masterpieces of editorial work with regard to medieval masters of medicine, were lying in libraries waiting to be unearthed and restudied during the nineteenth century. German and French scholars, especially during the last generation, have recovered the knowledge of this thousand years of human activity, and we know now and can sympathetically study how the men of these times faced their problems, which were very much those of our own time, in almost precisely the same spirit as we do ours at the present time, and that their solutions of them are always interesting, often thorough and practical, and more frequently than we would like to think possible, resemble our own in many ways. For the possibility of this we are largely indebted originally to the scholars of the Renaissance. Without their work that of our investigators would have been quite unavailing. It is to be hoped, however, that our recovery of this period will not be followed by any further eclipse, though that seems to be almost the rule of human history, but that we shall continue to broaden our sympathetic knowledge of this wonderful medieval period, the study of which has had so many surprises in store for us.

II
GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES

What we know of the life of the Founder of Christianity and how much He did for the ailing poor would make us expect that the religion that He established would foster the care and the cure of suffering humanity. As we have outlined in the Introduction, the first of the works of Christian service that was organized was the care of the sick. At first a portion of the bishop's house was given over to the shelter of the ailing, and a special order of assistants to the clergy, the deaconesses, took care of them. As Christians became more numerous, special hospitals were founded, and these became public institutions just as soon as freedom from persecution allowed the Christians the liberty to give overt expression to their feelings for the poor. While hospitals of limited capacity for such special purposes as the sheltering of slaves or of soldiers and health establishments of various kinds for the wealthy had been erected before Christianity, this was the first time that anyone who was ill, no matter what the state of his pecuniary resources, could be sure to find shelter and care. The expression of the Emperor Julian the Apostate, that admission to these hospitals was not limited to Christians, is the best possible evidence of the liberal charity that inspired them.

The ordinary passing student of the history of medicine or of hospital foundation and organization, can have no idea of the magnitude of some of these institutions, and their importance in the life of the time, unless it is especially pointed out. St. Basil, about the middle of the fourth century, erected what was spoken of as "a city for the sick," before the gates of Cæsarea. Gregory of Nazianzen, his friend, says "that well built and furnished houses stood on both sides of streets symmetrically laid out about the church, and contained rooms for the sick, and the infirm of every variety were intrusted to the care of doctors and nurses." There were separate buildings for strangers, for the poor, and for the ailing, and comfortable dwellings for the physicians and nurses. An important portion of the institution was set apart for the care of lepers, which constituted a prominent feature in Basil's work in which he himself took a special interest. Earlier in the same century Helena, the mother of the Emperor Constantine, had built similar institutions around Jerusalem, and during this same century nearly everywhere we have evidence of organization of hospitals and of care for the ailing poor.

Not only were hospitals erected, but arrangements were made for the care of the ailing poor in their own homes and for the visitation of them, and for the bringing to places adapted for their care and treatment of such as were found on the street, or neglected in their homes. The Church evidently considered itself bound to care for men's bodies as well as their souls, and many of the expressions in common use among Christians referred to this fact. Religion itself was spoken of as a medicine of the soul and the body. Christianity was defined as the religion of healing. The word salvation had a reference to both body and soul. Baptism was spoken of as the bath of the soul, the holy Eucharist as the elixir of immortal life, and penance as the medicine of the soul. It is not surprising to find, then, that Harnack has found among the texts that illustrate the history of early Christian literature this one: "In every community there shall be at least one widow appointed to assist women who are stricken with illness, and this widow shall be trained in her duties, neat and careful in her ways, shall not be self-seeking, must not indulge too freely in wine in order that she may be able to take up her duties at night as well as by day, and shall consider it her duty to keep the Church officials informed of all that seems necessary."

The saving of deformed and ailing infants or children whose parents did not care to have the trouble of rearing them, required the establishment by the Christians of another set of institutions, Foundling Asylums and Hospitals for Children. Until the coming of Christianity parents were supposed to have the right of life and death over their children, and no one questioned it. In every country in the world until the coming of Christianity this had always been the case. Besides, there were institutions for the care of the old. These are the classes of mankind who are especially liable to suffer from disease, and the opportunity to study human ailments in such institutions could scarcely help but provide facilities for clinical observation such as had not existed before. Unfortunately the work of Christianity was hampered, first by the Roman persecutions, and then later by the invasion of the barbarians, who had to be educated and lifted up to a higher plane of civilization before they could be brought to appreciate the value of medical science, much less contribute to its development.

Harnack, whose writings in the higher criticism of Scripture have attracted so much attention in recent years, began his career in the study of Christian antiquities with a monograph on Medical Features of Early Christianity.[1] He mentions altogether some sixteen physicians who reached distinction in the earliest days of Christianity. Some of these were priests, some of them bishops, as Theodotos of Laodicea; Eusebius, Bishop of Rome; Basilios, Bishop of Ancyra, and at least one, Hierakas, was the founder of a religious order. The first Christian physicians came mainly from Syria, as might be expected, for here the old Greek medical traditions were active. Among them must be enumerated Cosmas and Damian, physicians who were martyred in the persecution of Diocletian, and who have been chosen as the patrons of the medical profession. Justinian erected a famous church to them. It became the scene of pilgrimages. Organizations of various kinds since, as the College of St. Come, and medical societies, have been named after them.

Some idea of the interest of ecclesiastics in medical affairs may be gathered from a letter of Bishop Theodoret of Cyrus, directed to the prefect of the city, when he was about to leave the place. He wrote (see Puschmann, Vol. I., p. 494): "When I took up the Bishopric of Cyrus I made every effort to bring in from all sides the arts that would be useful to the people. I succeeded in persuading skilled physicians to take up their residence here. Among these is a very pious priest, Peter, who practises medicine with great skill, and is well known for his care for the people. Now that I am about to leave the city, some of those who came at my invitation are preparing also to go. Peter seems resolved to do this. I appeal to your highness, therefore, in order to commend him to your special care. He handles patients with great skill and brings about many cures."

Distinguished Christian writers and scholars, and the Fathers of the Church in the early centuries, evidently paid much attention to medicine. Tertullian speaks of medical science as the sister of philosophy, and has many references to the medical doctrines discussed in his time. Lactantius, in his work, "De Opificio Dei," has much to say with regard to the human body as representing the necessity for design in creation. His teleological arguments have much more force now than they would have had for people generally twenty years ago. We have come back to recognize the place of teleology. Clement of Alexandria was an early Christian temperance advocate, who argued that the use of wine was only justified when it did good as a medicine. The problems of embryology and of diseases of childhood interested him as they did many other of the early Christian writers.

AËTIUS

The first great Christian physician whose works meant much for his own time, and whose writings have become a classic in medicine, was Aëtius Amidenus, that is, Aëtius of Amida, who was born in the town of that name in Mesopotamia, on the upper Tigris (now Diarbekir), and who flourished about the middle of the sixth century. His medical studies, as he has told us himself, were made at Alexandria. After having attracted attention by his medical learning and skill, he became physician to one of the emperors at Byzantium, very probably Justinian, (527-565). He seems to have been succeeded in the special post that was created for him at court by Alexander of Tralles, the second of the great Christian physicians. There is no doubt that Aëtius was a Christian, for he mentions Christian mysteries, and appeals to the name of the Saviour and the martyrs. He was evidently a man of wide reading, for he quotes from practically every important medical writer before his time. Indeed, he is most valuable for the history of medicine, because he gives us some idea of the mode of treatment of various subjects by predecessors whose fame we know, but none of whose works have come to us. His official career and the patronage of the Emperor, the breadth of his scholarship, and the thoroughly practical character of his teaching, show how medical science and medical art were being developed and encouraged at this time.

Aëtius' work that is preserved for us is known in medical literature as his sixteen books on medical practice. In most of the manuscript it is divided into four Tetrabibloi, or four book parts, each of which consists of four sections called Logoi in Greek, Sermones in Latin. This work embraces all the departments of medicine, and has a considerable portion devoted to surgery, but most of the important operations and the chapters on fractures and dislocations are lacking. Aëtius himself announces that he had prepared a special work on surgery, but this is lost. Doubtless the important chapters that we have noted as lacking in his work would be found in this. He is much richer in pathology than most of the older writers, at least of the Christian era; for instance, Gurlt says that he treats this feature of the subject much more extensively even than Paulus Æginetus, but most of his work is devoted to therapeutics.

At times those who read these old books from certain modern standpoints are surprised to find such noteworthy differences between writers on medicine, who are separated sometimes only by a generation, and sometimes by not more than a century, in what regards the comparative amount of space given to pathology, etiology, and therapeutics. Just exactly the same differences exist in our own day, however. We all know that for those who want pathology and etiology the work of one of our great teachers is to be consulted, while for therapeutics it is better to go to someone else. When we find such differences among the men of the olden time we are not so apt to look at them with sympathetic discrimination, as we do with regard to our contemporaries. We may even set them down to ignorance rather than specialization of interest. These differences depend on the attitude of mind of the physician, and are largely the result of his own personal equation. They do not reflect in any way either on his judgment or on the special knowledge of his time, but are the index of his special receptivity and teaching habit.

Aëtius' first and second books are taken up entirely with drugs. The first book contains a list of drugs arranged according to the Greek alphabet. In the third book other remedial measures, dietetic, manipulative, and even operative, are suggested. In these are included venesection, the opening of an artery, cupping, leeches, and the like. The fourth and fifth books take up hygiene, special dietetics, and general pathology. In the sixth book what the Germans call special pathology and therapy begins with the diseases of the head. The first chapter treats of hydrocephalus. In this same book rabies is treated. What Aëtius has consists mainly of quotations from previous authors, many of whom he had evidently read with great care.

Concerning those "bitten by a rabid dog or those who fear water," Gurlt has quoted the following expression, with regard to which most people will be quite ready to agree with him when he says that it contains a great deal of truth, usually thought to be of much later origin: "When, therefore, any one has been bitten by a rabid dog the treatment of the wound must be undertaken just as soon as possible, even though the bite should be small and only superficial. One thing is certain, that none of those who are not rightly treated escape the fatal effect. The first thing to do is to make the wound larger, the mouth of it being divided and dilated by the scalpel. Then every portion of it and the surrounding tissues must be firmly pressed upon with the definite purpose of causing a large efflux of blood from the part. Then the wound should be deeply cauterized, etc."

There are special chapters devoted to eye and ear diseases, and to various affections of the face. Under this the question of tattooing and its removal comes in. It is surprising how much Aëtius has with regard to such nasal affections as polyps and ulcers and bleedings from the nose. In this book, however, he treats only of their medicinal treatment. What he has to say about affections of the teeth is so interesting that it deserves a paragraph or two by itself.

He had much to say with regard to the nervous supply of the mucous membranes of the gums, tongue, and mouth, and taught that the teeth received nerves through the small hole existing at the end of every root. For children cutting teeth he advised the chewing of hard objects, and thought that the chewing of rather hard materials was good also for the teeth of adults. For fistulas leading to the roots of teeth he suggests various irritant treatments, and, if they do not succeed, recommends the removal of the teeth. He seems to have known much about affections of the gums and recognizes a benignant and malignant epulis. He thought that one form of epulis was due to inflammation of a chronic character, and suggests that if remedies do not succeed it should be removed. His work is of interest mainly as showing that even at this time, when the desire for information of this kind is usually supposed to have been in abeyance, physicians were gathering information about all sorts even of the minor ailments of mankind, gathering what had been written about them, commenting on it, adding their own observations, and in general trying to solve the problems as well as they could.

Aëtius seems to have had a pretty good idea of diphtheria. He speaks of it in connection with other throat manifestations under the heading of "crusty and pestilent ulcers of the tonsils." He divides the anginas generally into four kinds. The first consists of inflammation of the fauces with the classic symptoms, the second presents no inflammation of the mouth nor of the fauces, but is complicated by a sense of suffocation—apparently our croup. The third consists of external and internal inflammation of the mouth and throat, extending towards the chin. The fourth is an affection rather of the neck, due to an inflammation of the vertebræ—retropharyngeal abscess—that may be followed by luxation and is complicated by great difficulty of respiration. All of these have as a common symptom difficulty of swallowing. This is greater in one variety than in another at different times. In certain affections even "drinks when taken are returned through the nose."

Hypertrophy of the tonsils—Aëtius speaks of them as glands—is to be treated by various astringent remedies, but if these fail the structures should be excised. His description of the excision is rather clear and detailed. The patient should be put in a good full light, and the mouth should be held open and each gland pulled forward by a hook and excised. The operator should be careful, however, only to excise those portions that are beyond the natural size, for if any of the natural substance of the gland is cut into, or if the incision is made beyond the projecting portion of the tonsil, there is grave danger of serious hemorrhage. After excision a mixture of water and vinegar should be kept in the mouth for some time. This should be administered cold in order to prevent the flow of blood. After this very cold water should be taken.

In this same book, Chapter L, he treats of foreign bodies in the respiratory and upper digestive tracts. If there is anything in the larynx or the bronchial tubes the attempt must be made to secure its ejection by the production of coughing or sneezing. If the foreign body can be seen it should be grasped with a pincers and removed. If it is in the esophagus, Aëtius suggests that the patient should be made to swallow a sponge dipped in grease, or a piece of fat meat, to either of which a string has been attached, in order that the foreign body may be caught and drawn out. If it seems preferable to carry the body on into the stomach, the swallowing of large mouthfuls of fresh bread or other such material is recommended.

With regard to goitre, Aëtius has some interesting details. He says that "all tumors occurring in the throat region are called bronchoceles, for every tumor among the ancients was called a cele, and, though the name is common to them, they differ very much from one another." Some of them are fatty, some of them are pultaceous, some of them are cancerous, and some of them he calls honey tumors, because of a honey-like humor they contain. "Sometimes they are due to a local dilatation of the blood vessels, and this is most frequently connected with parturition, apparently being due to the drawing of the breath being prevented or repressed during the most violent pains of the patient. Such local dilatation at this point of the veins is incurable, but there are also hard tumors like scirrhus and malignant tumors, and those of great size. With the exception of these last, all the tumors of this region are easily cured, yielding either to surgery or to remedies. Surgery must be adapted to the special tumor, whether it be honey-like or fatty, or pultaceous." The prognosis of goitrous tumors is much better than might be expected, but evidently Aëtius saw a number of the functional disturbances and enlargements of the thyroid gland, which are so variable in character as apparently to be quite amenable to treatment.

Aëtius' treatment of the subject of varicosities is quite complete in its suggestions. "The term varices," he says, "is applied to dilated veins, which occur sometimes in connection with the testes and sometimes in the limbs. Operations on testicular varices patients do not readily consent to; those on the limbs may be cured in several ways. First, simple section of the skin lying above the dilated vessel is made, and with the hook it is separated from the neighboring tissues and tied. After this the dilated portion is removed and pressure applied by means of a bandage. The patient is ordered to remain quiet, but with the legs higher than the head. Some people prefer treatment by means of the cautery." Gurlt, in his "History of Surgery," calls attention to the fact that two of our modern methods of treating varicose veins are thus discussed in Aëtius, that by ligation and that by the cautery. The cautery was applied over a space the breadth of a finger at several points along the dilated veins.

Aëtius' chapters on obstetrics and gynæcology are of special interest, because, while we are prone to think that gynæcology particularly is a comparatively modern development of surgery, this surgical authority of the early Middle Ages treats it rather exhaustively. His sixteenth book is for the most part (one hundred and eleven chapters of it) devoted to these two subjects. He has a number of interesting details in the first thirty-six chapters with regard to conception, pregnancy, labor, and lactation, which show how practical were the views of the physicians of the time. Gurlt has given us some details of his chapters on diseases of the breast. Aëtius differentiates phagedenic and rodent ulcers and cancer. All the ordinary forms of phagedenic ulcer yield to treatment, while malignant growths are rendered worse by them. Where ulcers are old, he suggests the removal of their thickened edges by the cautery, for this hastens cure and prevents hemorrhage. With regard to cancer, he quotes from Archigenes and Leonides. He says that these tumors are very frequent in women, and quite rare in men. Even at this time cancer had been observed and recognized in the male breast. He emphasizes the fact that cancerous nodules become prominent and become attached to surrounding tissues. There are two forms, those with ulcer, and those without. He describes the enlargement of the veins that follows, the actual varicosities, and the dusky or livid redness of the parts which seem to be soft, but are really very hard. He says that they are often complicated by very painful conditions, and that they cause enlargement of the glands and of the arms. The pain may spread to the clavicle and the scapula, and he seems to think that it is the pain that causes the enlargement of the glands at a distance.

His description of ulcerative cancer of the breast is very striking. He says that it erodes without cause, penetrating ever deeper and deeper, and cannot be stopped until it emits a secretion worse than the poison of wild beasts, copious and abominable to the smell. With these other symptoms pains are present. This form of cancer is especially made worse by drugs and by all manner of manipulation. The paragraph from Leonides quoted by Aëtius gives a description of operation for cancer of the breast, in which he insists particularly on the extensive removal of tissue and the free use of the cautery. "The cautery is used at first in order to prevent bleeding, but also because it helps to destroy the remains of diseased tissues. When the burning is deep, prognosis is much better. Even in cases where indurated tumors of the breast occur that might be removed without danger of bleeding, it is better to use the cautery freely, though the amputation of such a portion down to the healthy parts may suffice." Aëtius quotes this with approval.

Others before Aëtius had suggested the connection between hypertrophy of the clitoris and certain exaggerated manifestations of the sexual instinct, and the development of vicious sexual habits. As might be expected from this first great Christian physician and surgeon, he emphasizes this etiology for certain cases, and outlines an operation for it. This operation had been suggested before, but Aëtius goes into it in detail and describes just how the operation should be done, so as to secure complete amputation of the enlarged organ, yet without injury. He warns of the danger of removing more than just the structure itself, because this may give rise to ugly and bothersome scars. After the operation a sponge wet with astringent wine should be applied, or cold water, especially if there is much tendency to bleeding, and afterwards a sponge with manna or frankincense scattered over it should be bound on. He treats of other pathological conditions of the female genitalia, varicose veins, growths of various kinds, hypertrophy of the portio vaginalis uteri, an operation for which is described, and of various tumors. He describes epithelioma very clearly, enumerates its most frequent locations in their order, lays down its bad prognosis, and hence the necessity for early operation with entire removal of the new growth whenever possible. He feared hemorrhage very much, however, and warns with regard to it, and evidently had had some very unfortunate experiences in the treatment of these conditions.

Aëtius seems to have had as thoroughly scientific an interest in certain phases of chemistry apart from medicine as any educated physician of the modern time might have. Mr. A. P. Laurie, in his "Materials of the Printer's Craft,"[2] calls attention to the fact that the earliest reference to the use of drying oil for varnish is made by the physician Aëtius.

Aëtius, or Aëtios, to use for the nonce the Greek spelling of his name, which sometimes occurs in medical literature, and should be known, has been the subject of very varied estimation at different times. About the time of the Renaissance he was one of the first of the early writers on medicine accorded the honor of printing, and then was reprinted many times, so that his estimation was very high. With the reawakening of clinical medicine in the seventeenth century his reputation waxed again, and Boerhaave declared that the works of Aëtius had as much importance for physicians as had the Pandects of Justinian for lawyers. This high estimation had survived almost from the time of the Renaissance, when Cornelius went so far as to say: "Believe me, that whoever is deeply desirous of studying things medical, if he would have the whole of Galen abbreviated and the whole of Oribasius extended, and the whole of Paulus (of Ægina) amplified, if he would have all the special remedies of the old physicians as well in pharmacy as in surgery boiled down to a summa for all affections, he will find it in Aëtius." Naturally enough, this exaggerated estimation was followed by a reaction, in which Aëtius came to be valued at much less than he deserved. After all is taken into account in the vicissitudes of his fame, it is clear, however, that he is one of the most important links in the chain of medical tradition, and himself worthy to be classed among makers of medicine for his personal observations and efforts to pass on the teachings of the old to succeeding generations.

ALEXANDER OF TRALLES

An even more striking example than the life and work of Aëtius as evidence for the encouragement and patronage of medicine in early Christian times, is to be found in the career of Alexander of Tralles, whose writings have been the subject of most careful attention in the Renaissance period and in our own, and who must be considered one of the great independent thinkers in medicine. While it is usually assumed that whatever there was of medical writing during the Middle Ages was mere copying and compilation, here at least is a man who could not only judiciously select, but who could critically estimate the value of medical opinions and procedure, and weighing them by his own experience and observation, turn out work that was valuable for all succeeding generations. The modern German school of medical historians have agreed in declaring him an independent thinker and physician, who represents a distinct link in medical tradition.

He came of a distinguished family, in which the following of medicine as a profession might be looked upon as hereditary. His father was a physician, and it is probable that there were physicians in preceding generations, and one of his brothers, Dioscoros, was also a successful physician. Altogether four of his brothers reached such distinction in their life work that their names have come down to us through nearly fifteen hundred years. The eldest of them was Anthemios, the builder of the great church of Santa Sophia in Constantinople. As this is one of the world's great churches, and still stands for the admiration of men a millennium and a half after its completion, it is easy to understand that Anthemios' reputation is well founded. A second brother was Metrodoros, a distinguished grammarian and teacher, especially of the youthful nobility of Byzantium, as it was then called, or Constantinople, as we have come to call it. A third brother was a prominent jurist, also in Constantinople. The fourth brother, Dioscoros, like Alexander, a physician, remained in his birthplace, Tralles, and acquired there a great practice.

It was with his father at Tralles that Alexander received his early medical training. The father of a friend and colleague, Cosmas, who later dedicated a book to Alexander, was also his teacher, while he was in his native city. As a young man, Alexander undertook extensive travels, which led him into Italy, Gaul, Spain, and Africa, everywhere gathering medical knowledge and medical experience. Then he settled down at Rome, probably in an official position, and practised medicine successfully until a very old age. He was probably eighty years of age when, some time during the first decade of the seventh century, he died.

Puschmann, who has made a special study of Alexander's life and work, suggests that since some of his books have the form of academic lectures he was probably a teacher of medicine at Rome. As might be expected from what we know of the relations of the rest of the family to the nobility of the time, it is easy to understand, especially in connection with hints in Alexander's favorite modes of therapeutics, that costliness of remedies made no difference to his patients, that he must have had the treatment of some of the wealthiest families in Rome.

His principal work is a Treatise on the Pathology and Therapeutics of Internal Diseases, in twelve books. The first eleven books were evidently material gathered for lectures or teaching of some kind. The twelfth book, in which considerable use of Aëtius' writings is made, was written, according to Puschmann, toward the end of Alexander's life, and was meant to contain supplementary matter, comprising especially his views gathered from observation as to the pathology of internal diseases. A shorter treatise of Alexander is with regard to intestinal parasites. There are many printed editions of these books, and many manuscript copies are in existence. Alexander was often quoted during the Middle Ages, and in recent years, with the growth of our knowledge of medical history, he has come to be a favorite subject of study.

Alexander's first book of pathology and therapeutics treats of head and brain diseases. For baldness, the first symptom of which is falling out of the hair, he counsels cutting the hair short, washing the scalp vigorously, and the rubbing in of sulphur ointments. For grey hair he suggests certain hair dyes, as nutgalls, red wine, and so forth. For dandruff, which he described as the excessive formation of small flake-like scales, he recommends rubbing with wine, with certain salves, and washing with salt water.

He gives a good deal of attention to diseases of the nervous system. He has a rather interesting chapter on headache. The affection occurs in connection with fevers, after excess in drinking, and as a consequence of injury to the skull. Besides, it develops as a result of disturbances of the natural processes in the head, the stomach, the liver, and the spleen. Headache, as the first symptom of inflammation of the brain, is often the forerunner of convulsions, delirium, and sudden death. Chronic or recurrent headache occurs in connection with plethora, diseases of the brain, biliousness, digestive disturbances, insomnia, and continued worry. Hemicrania has its origin in the brain, because of the presence of toxic materials, and specially their transformation into gaseous substances. It also occurs in connection with abdominal affections. This latter remark particularly is directed to the cases which occur in women.

For apoplexy and the consequent paralysis, Alexander considered venesection the best remedy. Massage, rubbings, baths, and warm applications are recommended for the paralytic conditions. He had evidently had considerable experience with epilepsy. It develops either from injuries of the head or from disturbances of the stomach, or occasionally other parts of the body. When it occurs in nursing infants, nourishment is the best remedy, and he gives detailed directions for the selection of a wet nurse, and very careful directions as to her mode of life. He emphasizes very much the necessity for careful attention to the gastro-intestinal tract in many cases of epilepsy. Planned diet and regular bowels are very helpful. He rejects treatment of the condition by surgery of the head, either by trephining or by incisions, or cauterization. Regular exercise, baths, sexual abstinence are the foundation of any successful treatment. It is probable that we have returned to Alexander's treatment of epilepsy much more nearly than is generally thought. There are those who still think that remedies of various kinds do good, but in the large epileptic colonies regular exercise, bland diet, regulation of the bowels, and avoidance of excesses of all kinds, with occupation of mind, constitute the mainstay of their treatment.

Alexander has much to say with regard to phrenitis, a febrile condition complicated by delirium, which, following Galen, he considers an affection of the brain. It is evidently the brain fever of the generations preceding the last, an important element of which was made up of the infectious meningitises. Alexander suggests its treatment by opiates after preliminary venesection, rubbings, lukewarm baths, and stimulating drinks. Every disturbance of the patient must be avoided, and visitors must be forbidden. The patient's room should rather be light than dark. His teaching crops up constantly in the centuries after his time, until the end of the nineteenth century, and while we now understand the causes of the condition better, we can do little more for it than he did.

Alexander divided mental diseases into two, the maniacal and melancholic. Mania was, however, really a further development of melancholia, and represented a high grade of insanity. Under melancholy he groups not only what we denominate by that term, but also all depressed conditions, and the paranoias, as also many cases of imbecility. The cause of mental diseases was to be found in the blood. He counselled the use of venesection, of laxatives and purgatives, of baths and stimulant remedies. He insisted very much, however, on mental influence in the disease, on change of place and air, visits to the theatre, and every possible form of mental diversion, as among the best remedial measures.

After his book on diseases of the head, his most important section is on diseases of the respiratory system. In this he treats first of angina, and recommends as gargles at the beginning light astringents; later stronger astringents, as alum and soda dissolved in warm water, should be employed. Warm compresses, venesection from the sublingual veins, and from the jugular, and purgatives in severe cases, are the further remedies. He treats of cough as a symptom due to hot or cold, dry or wet dyscrasias. Opium preparations carefully used are the best remedies. The breathing in of steam impregnated with various ethereal resins, was also recommended.

He gives a rather interestingly modern treatment of consumption. He recommends an abundance of milk with a strong nutritious diet, as digestible as possible. A good auxiliary to this treatment was change of air, a sea voyage, and a stay at a watering-place. Asses' and mares' milk are much better for these patients than cows' and goats' milk. There is not enough difference in the composition of these various milks to make their special consumption of import, but it is probable that the suggestive influence of the taking of an unusual milk had a very favorable effect upon patients, and this effect was renewed frequently, so that much good was ultimately accomplished. For hemoptysis, especially when it was acute and due as Alexander thought to the rupture of a blood vessel in the lungs, he recommended the opening of a vein at the elbow or the ankle—in order to divert the blood from the place of rupture to the healthy parts of the circulation. He insisted that the patients must rest, that they should take acid and astringent drinks, that cold compresses should be placed upon the chest (our ice bags), and that they should take only a liquid diet at most lukewarm, or, better, if agreeable to them, cold. When the bleeding stopped, a milk cure was very useful for the restoration of these patients to strength.

It is not surprising, then, to find that Alexander suggests a thoroughly rational treatment for pleurisy. He recognizes this as an inflammation of the membrane covering the ribs, and its symptoms are severe pain, disturbance of breathing, and coughing. In certain cases there is severe fever, and Alexander knows of purulent pleurisy, and the fact that when pus is present the side on which it is is warmer than the other. Pleurisy can be, he says, rather easily confounded with certain liver affections, but there is a peculiar hardness of the pulse characteristic of pleurisy, and there is no expectoration in liver cases, though it also may be absent in many cases of pleurisy. Sufferers from liver disease usually have a paler color than pleuritics. His treatment consists in venesection, purgatives, and, when pus is formed, local incision. He recommends the laying on of sponges dipped in warm water, and the internal use of honey lemonade. Opium should not be used unless the patient suffers from sleeplessness.

Some of the general principles of therapeutics that Alexander lays down are very interesting, even from our modern standpoint. Trust should not be placed in any single method of treatment. Every available means of bringing relief to the patient should be tried. "The duty of the physician is to cool what is hot, to warm what is cold, to dry what is moist, and to moisten what is dry. He should look upon the patient as a besieged city, and try to rescue him with every means that art and science places at his command. The physician should be an inventor, and think out new ways and means by which the cure of the patient's affection and the relief of his symptoms may be brought about." The most important factor in his therapeutics is diet. Watering-places and various forms of mineral waters, as well as warm baths and sea baths, are constantly recommended by him. He took strong ground against the use of many drugs, and the rage for operating. The prophylaxis of disease is in Alexander's opinion the important part of the physician's duty. His treatment of fever shows the application of his principle: cold baths, cold compresses, and a cooling diet, were his favorite remedies. He encouraged diaphoresis nearly always, and gave wine and stimulating drugs only when the patient was very weak. He differentiates two kinds of quartan fever. One of these he attributes to an affection of the spleen, because he had noticed that the spleen was enlarged during it, and that, after purgation, the enlarged spleen decreased in size.

Alexander was a strong opponent of drastic remedies of all kinds. He did not believe in strong purgatives, nor in profuse and sudden blood-lettings. He opposed arteriotomy for this reason, and refused to employ extensive cauterization. His diagnosis is thorough and careful. He insisted particularly on inspection and palpation of the whole body; on careful examination of the urine, of the feces, and the sputum; on study of the pulse and the breathing. He thought that a great deal might be learned from the patient's history. The general constitution is also of importance. His therapeutics is, above all, individual. Remedies must be administered with careful reference to the constitution, the age, the sex, and the condition of the patient's strength. Special attention must always be paid to nature's efforts to cure, and these must be encouraged as far as possible. Alexander had no sympathy at all with the idea that remedies must work against nature. His position in this matter places him among the dozen men whose name and writings have given them an enduring place in the favor of the profession at all times, when we were not being carried away by some therapeutic fad or imagining that some new theory solved the whole problem of the causation and cure of disease.

Gurlt, in his "History of Surgery," has abstracted from Alexander particularly certain phases of what the Germans call external pathology and therapeutics. For instance, Alexander's treatment of troubles connected with the ear is very interesting. Gurlt declares that this chapter alone provides striking evidence for Alexander's practical experience and power of observation, as well as for his knowledge of the literature of medicine. He considers that only a short abstract is needed to show that.

For water that has found its way into the external ear, Alexander suggests a mode of treatment that is still popularly used. The patient should stand upon the leg corresponding to the side on which there is water in his ear, and then, with head leaning to that side, should hop or kick out with the other leg. The water may be drawn out by means of suction through a reed. In order to get foreign bodies out of the external auditory canal, an ear spoon or other small instrument should be wrapped in wool and dipped in turpentine, or some other sticky material. Occasionally he has seen sneezing, especially if the mouth and nose are covered with a cloth, and the head leant toward the affected side, bring about a dislodgment of the foreign body. If these means do not succeed, gentle injections of warm oil or washing out of the canal with honey water should be tried. Foreign bodies may also be removed by means of suction. Insects or worms that find their way into the ear may be killed by injections of acid and oil, or other substances.

Gurlt also calls attention to Alexander's careful differentiation of certain very dangerous forms of inflammation of the throat from others which are rather readily treated. He says, "Inflammation of the throat may, under certain circumstances, belong to the severest diseases. The patients succumb to it as a consequence of suffocation, just as if they were choked or hanged. For this reason, perhaps, the affection bears the name synanche, which means constriction." He then points out various other forms of inflammation of the throat, acute and chronic, suggesting various names and the differential diagnostic signs.

One of the most surprising chapters of Alexander's knowledge of pathology and therapeutics is to be found in his treatment of the subject of intestinal worms, which is contained in a letter sent by him to his friend, Theodore, whose child was suffering from them. He describes the oxyuris vermicularis with knowledge manifestly derived from personal observation. He dwells on the itching in the region of the anus, caused by the oxyuris, and the fact that they probably find their way into the upper part of the digestive tract because of the soiling of the hands. He knew that the tapeworms often reached great length,—he has seen one over sixteen feet long,—and also that they had a life cycle, so that they existed in two different forms. He describes the roundworms as existing in the intestines, but occasionally wandering into the stomach to be vomited. His vermifuges were the flowers and the seeds of the pomegranate, the seeds of the heliotrope, castor-oil, and certain herbs that are still used, by country people, at least, as worm medicines. For roundworms he recommended especially a decoction of artemisia maritima, coriander seeds, and decoctions of thyme. Our return to thymol for intestinal parasites is interesting. For the oxyuris he prescribed clysters of ethereal oils. We have not advanced much in our treatment of intestinal worms in the fifteen hundred years since Alexander's time.

PAUL OF ÆGINA

Another extremely important writer in these early medieval times, whose opportunities for study in medicine and for the practice of it, were afforded him by Christian schools and Christian hospitals, was Paul of Ægina. He was born on the island of Ægina, hence the name Æginetus, by which he is commonly known. There used to be considerable doubt as to just when Paul lived, and dates for his career were placed as widely apart as the fifth and the seventh centuries. We know that he was educated at the University of Alexandria. As that institution was broken up at the time of the capture of the city by the Arabs, he cannot have been there later than during the first half of the seventh century. An Arabian writer, Abul Farag, in "The Story of the Reign of the Emperor Heraclius," who died 641, says that "among the celebrated physicians who flourished at this time was Paulus Æginetus." In his works Paul quotes from Alexander of Tralles, so that there seems to be no doubt now that his life must be placed in the seventh century.

The most important portion of Paul's work for the modern time is contained in his sixth book on surgery. In this his personal observations are especially accumulated. Gurlt has reviewed it at considerable length, devoting altogether nearly thirty pages to it, and it well deserves this lengthy abstract. Paul quotes a great many of the writers on surgery before his time, and then adds the results of his own observation and experience. In it one finds careful detailed descriptions of many operations that are usually supposed to be modern. Very probably the description quoted by Gurlt of the method of treating fishbones that have become caught in the throat will give the best idea of how thoroughly practical Paul is in his directions. He says: "It will often happen in eating that fishbones or other objects may be swallowed and get caught in some part of the throat. If they can be seen they should be removed with the forceps designed for that purpose. Where they are deeper, some recommend that the patient should swallow large mouthfuls of bread or other such food. Others recommend that a clean soft sponge of small circumference to which a string is attached be swallowed, and then drawn out by means of the string. This should be repeated until the bone or other object gets caught in the sponge and is drawn out. If the patient is seen immediately after eating, and the swallowed object is not visible, vomiting should be brought on by means of a finger in the throat or irritation with the feather, and then not infrequently the swallowed object will be brought up with the vomit."

In the chapter immediately following this, XXXIII, there is a description of the method of opening the larynx or the trachea, with the indications for this operation. The surgeon will know that he has opened the trachea when the air streams out of the wound with some force, and the voice is lost. As soon as the danger of suffocation is over, the edges of the wound should be freshened and the skin surfaces brought together with sutures. Only the skin without the cartilage should be sutured, and general treatment for encouraging union should be employed. If the wound fails to heal immediately, a treatment calculated to encourage granulations should be undertaken. This same method of treatment will be of service whenever we happen to have a patient who, in order to commit suicide, has cut his throat. Paul's exact term is, perhaps, best translated by the expression, slashed his larynx.

One of the features of Paul's "Treatise on Surgery" is his description of a radical operation for hernia. He describes scrotal hernia under the name enterocele, and says that it is due either to a tearing or a stretching of the peritoneum. It may be the consequence either of injury or of violent efforts made during crying. When the scrotum contains only omentum, he calls the condition epiplocele; when it also contains intestine, an epiplo-enterocele. Hernia that does not descend into the scrotum he calls bubonocele. For operation the patient should be placed on the back, and, the skin of the inguinal region being stretched by an assistant, an oblique incision in the direction in which the blood vessels run should be made. The incision should then be stretched by means of retractors, until the contents of the sac can be lifted out. All adhesions should be broken up and the fat be removed, and the hernia replaced within the abdomen. Care should be taken that no loop of intestine is allowed to remain. Then a large needle with double thread made of ten strands should be run through the middle of the incision in the end of the peritoneum, and tied firmly in cross sutures. The outer structures should be brought together with a second ligature, and the lower end of the incision should have a wick placed in it for drainage, and the site of operation should be covered with an oil bandage.

The Arab writer, Abul Farag, to whose references we owe the definite placing of the time when Paul lived, said that "he had special experience in women's diseases, and had devoted himself to them with great industry and success. The midwives of the time were accustomed to go to him and ask his counsel with regard to accidents that happen during and after parturition. He willingly imparted his information, and told them what they should do. For this reason he came to be known as the Obstetrician." Perhaps the term should be translated the man-midwife, for it was rather unusual for men to have much knowledge of this subject. His knowledge of the phenomena of menstruation was as wide and definite. He knew a great deal of how to treat its disturbances. He seems to have been the first one to suggest that in metrorrhagia, with severe hemorrhage from the uterus, the bleeding might be stopped by putting ligatures around the limbs. This same method has been suggested for severe hemorrhage from the lungs as well as from the uterus in our own time. In hysteria he also suggested ligature of the limbs, and it is easy to understand that this might be a very strongly suggestive treatment for the severer forms of hysteria. It is possible, too, that the modification of the circulation to the nervous system induced by the shutting off of the circulation in large areas of the body might very well have a favorable physical effect in this affection. Paul's description of the use of the speculum is as complete as that in any modern text-book of gynæcology.

FURTHER CHRISTIAN PHYSICIANS

Another distinguished Christian medical scientist was Theophilus Protosbatharius, who belonged to the court of the Greek Emperor Heraclius, in the seventh century. He seems to have had a life very full of interest and surprisingly varied duties. He was a bishop, and, at the same time, commander of the imperial bodyguard, and the author of a little work on the fabric of the human body. The most surprising chapter in the history of the book is that for some two centuries, in quite modern times, it was used as a text-book of anatomy at the University of Paris. It was printed in a number of editions early in the history of printing, at least one very probably before 1500, and several later.

There are very interesting phases of medicine delightfully surprising in their modernity to be found here and there in many of these early Christian writers on medicine. For instance, in a compend of medicine written by one Leo, who, under the Emperor Theophilus, seems to have been a prominent physician of Byzantium (the compend was written for a young physician just beginning practice), we find the following classification of hydrops or abdominal dilatation: "There are three kinds; the first is ascites, due to the presence of watery fluid, for which we do paracentesis; second, tympany, when the abdomen is swollen from the presence of air or gas. This may be differentiated by percussion of the belly. When air is present the sound given forth is like that of a drum, while in the first form ascites the sound is like that from a sack [the word used is the same as for a wine sack]; the third form is called anasarca, when the whole body swells."

It has often been the subject of misunderstanding as to why medicine should have developed among the Latin Christian nations so much more slowly than among the Arabs during the early Middle Ages. Anyone who knows the conditions in which Christianity came into existence in Italy will not be surprised at that. The Arabs in the East were in contact with Greek thought, and that is eminently prolific and inspiring. At the most, the Christians in Italy got their inspiration at second hand through the Romans. The Romans themselves, in spite of intimate contact with Greek physicians, never made any important contributions to medical science, nor to science of any kind. Their successors, the Christians of Rome and Italy, then could scarcely be expected to do better, hampered especially, as they were, by the trying social conditions created by the invasion of the barbarians from the North. Whenever the Christians were in contact with Greek thought and Greek medicine, above all, as at Alexandria, or in certain of the cities of the near East, we have distinguished contributions from them.

ARABIAN CHRISTIAN PHYSICIANS

That this is not a partial view suggested by the desire to make out a better case for Christianity in its relation to science will be very well understood, besides, from the fact that a number of the original physicians of Arab stock who attracted attention during the first period of Arabian medicine, that is, during the eighth and ninth centuries, were Christians. There are a series of physicians belonging to the Christian family Bachtischua, a name which is derived from Bocht Jesu, that is, servant of Jesus, who, from the middle of the eighth to the middle of the eleventh century, acquired great fame. The first of them, George (Dschordschis), after acquiring fame elsewhere, was called to Bagdad by the Caliph El-Mansur, where, because of his medical skill, he reached the highest honors. His son became the body-physician of Harun al-Raschid. In the third generation Gabriel (Dschibril) acquired fame and did much, as had his father and grandfather, for the medicine of the time, by translations of the Greek physicians into Arabian.

These men may well be said to have introduced Greek medicine to the Mohammedans. It was their teaching that aroused Moslem scholars from the apathy that had characterized the attitude of the Arabian people toward science at the beginning of Mohammedanism. As time went on, other great Christian medical teachers distinguished themselves among the Arabs. Of these the most prominent was Messui the elder, who is also known as Janus Damascenus. Both he and his father practised medicine with great success in Bagdad, and his son became the body-physician to Harun al-Raschid either after or in conjunction with Gabriel Bachtischua. Like his colleague or predecessor in official position, he, too, made translations from the Greek into Arabic. Another distinguished Arabian Christian physician was Serapion the elder. He was born in Damascus, and flourished about the middle of the ninth century. He wrote a book on medicine called the "Aggregator," or "Breviarium," or "Practica Medicinæ," which appeared in many printed editions within the century after the invention of printing. During the ninth century, also, we have an account of Honein Ben Ischak, who is known in the West as Johannitius. After travelling much, especially in Greece and Persia, he settled in Bagdad, and, under the patronage of the Caliph Mamum, made many translations. He translated most of the old Greek medical writers, and also certain of the Greek philosophic and mathematical works. The accuracy of his translations became a proverb. His compendium of Galen was the text-book of medicine in the West for many centuries. It was known as the "Isagoge in Artem Parvam Galeni." His son, Ishac Ben Honein, and his nephew, Hobeisch, were also famous as medical practitioners and translators.

Still another of these Arabian Christians, who acquired a reputation as writers in medicine, was Alkindus. He wrote with regard to nearly everything, however, and so came to be called the philosopher. He is said altogether to have written and translated about two hundred works, of which twenty-two treat of medicine. He was a contemporary of Honein Ben Ischak in the ninth century. Another of the great ninth-century Christian physicians and translators from the Greek was Kostaben Luka. He was of Greek origin, but lived in Armenia and made translations from Greek into Arabic. Nearly all of these men took not alone medical science, but the whole round of physical science, for their special subject. A typical example in the ninth century was Abuhassan Ben Korra, many of whose family during succeeding generations attracted attention as scholars. He became the astronomer and physician of the Caliph Motadhid. His translations in medical literature were mainly excerpts from Hippocrates and Galen meant for popular use. These Christian translators, thoroughly scientific as far as their times permitted them to be, were wonderfully industrious in their work as translators, great teachers in every sense of the word, and they are the men who formed the traditions on which the greater Arabian physicians from Rhazes onward were educated.

It would be easy to think that these men, occupied so much with translations, and intent on the re-introduction of Greek medicine, might have depended very little on their own observations, and been very impractical. All that is needed to counteract any such false impression, however, is to know something definite about their books. Gurlt, in his "History of Surgery," has some quotations from Serapion the elder, who is often quoted by Rhazes. In the treatment of hemorrhoids Serapion advises ligature and insists that they must be tied with a silk thread or with some other strong thread, and then relief will come. He says some people burn them medicinis acutis (touching with acids, as some do even yet), and some incise them with a knife. He prefers the ligature, however. He calmly discusses the removal of stones from the kidney by incision of the pelvis of the kidney through an opening in the loin. He considers the operation very dangerous, however, but seems to think the removal of a stone from the bladder a rather simple procedure. His description of the technique of the use of a catheter and of a stylet with it, and apparently also of a guide for it in difficult cases, is extremely interesting. He suggests the opening of the bladder in the median line, midway between the scrotum and the anus, and the placing of a canula therein, so as to permit drainage until healing occurs.

Even this brief review of the careers and the writings of the physicians of early Christian times shows how well the tradition of old Greek medicine was being carried on. There was much to hamper the cultivation of science in the disturbances of the time, the gradual breaking up of the Roman Empire, and the replacement of the peoples of southern Europe by the northern nations, who had come in, yet in spite of all this, medical tradition was well preserved. The most prominent of the conservators were themselves men whose opinions on problems of practical medicine were often of value, and whose powers of observation frequently cannot but be admired. There is absolutely no trace of anything like opposition to the development of medical science or medical practice, but, on the contrary, everywhere among political and ecclesiastical authorities, we find encouragement and patronage. The very fact that, in the storm and stress of the succeeding centuries, manuscript copies of the writings of the physicians of this time were preserved for us in spite of the many vicissitudes to which they were subjected from fire, and war, and accidents of various kinds for hundreds of years, until the coming of printing, shows in what estimation they were held. During this time they owed their preservation to churchmen, for the libraries and the copying-rooms were all under ecclesiastical control.

III
GREAT JEWISH PHYSICIANS[3]

Any account of Old-Time Makers of Medicine without a chapter on the Jewish Physicians would indeed be incomplete. They are among the most important factors in medieval medicine, representing one of the most significant elements of medical progress. In spite of the disadvantages under which their race labored because of the popular feeling against them on the part of the Christians in the earlier centuries and of the Mohammedans later, men of genius from the race succeeded in making their influence felt not only on their own times, but accomplished so much in making and writing medicine as to influence many subsequent generations. Living the segregated life that as a rule they had to, from the earliest times (the Ghettos have only disappeared in the nineteenth century), it would seem almost impossible for them to have done great intellectual work. It is one of the very common illusions, however, that great intellectual work is accomplished mainly in the midst of comfortable circumstances and as the result of encouraging conditions. Most of our great makers of medicine at all times, and never more so than during the past century, have been the sons of the poor, who have had to earn their own living, as a rule, before they reached manhood, and who have always had the spur of that necessity which has been so well called the mother of invention. Their hard living conditions probably rather favored than hampered their intellectual accomplishments.

It is not unlikely that the difficult personal circumstances in which the Jews were placed had a good deal to do at all times with stimulating their ambitions and making them accomplish all that was in them. Certain it is that at all times we find a wonderful power in the people to rise above their conditions. With them, however, as with other peoples, luxury, riches, comfort, bring a surfeit to initiative and the race does not accomplish so much. At various times in the early Middle Ages, particularly, we find Jewish physicians doing great work and obtaining precious acknowledgment for it in spite of the most discouraging conditions. Later it is not unusual to find that there has been a degeneration into mere money-making as the result of opportunity and consequent ease and luxury. At a number of times, however, both in Christian and in Mohammedan countries, great Jewish physicians arose whose names have come to us and with whom every student of medicine who wants to know something about the details of the course of medical history must be familiar. There are men among them who must be considered among the great lights of medicine, significant makers always of the art and also in nearly all cases of the science of medicine.

A little consideration of the history of the Jewish people and their great documents eliminates any surprise there may be with regard to their interest in medicine and successful pursuit of it during the Middle Ages. The two great collections of Hebrew documents, the Old Testament and the Talmud, contain an immense amount of material with reference to medical problems of many kinds. Both of these works are especially interesting because of what they have to say of preventive medicine and with regard to the recognition of disease. Our prophylaxis and diagnosis are important scientific departments of medicine dependent on observation rather than on theory. While therapeutics has wandered into all sorts of absurdities, the advances made in prophylaxis and in diagnosis have always remained valuable, and though at times they have been forgotten, re-discovery only emphasizes the value of preceding work. It is because of what they contain with regard to these two important medical subjects that the Old Testament and the Talmud are landmarks in the history of medicine as well as of religion.

Baas, in his "Outlines of the History of Medicine," says: "It corresponds to the reality in both the actual and chronological point of view to consider the books of Moses as the foundation of sanitary science. The more we have learned about sanitation in the prophylaxis of disease and in the prevention of contagion in the modern time, the more have we come to appreciate highly the teachings of these old times on such subjects. Moses made a masterly exposition of the knowledge necessary to prevent contagious disease when he laid down the rules with regard to leprosy, first as to careful differentiation, then as to isolation, and finally as to disinfection after it had come to be sure that cure had taken place. The great lawgiver could insist emphatically that the keeping of the laws of God not only was good for a man's soul but also for his body."

With this tradition familiarly known and deeply studied by the mass of the Hebrew people, it is no surprise to find that when the next great Hebrew development of religious writing came in the Talmud during the earlier Middle Ages, that also contains much with regard to medicine, not a little of which is so close to absolute truth as never to be out of date. Friedenwald, in his "Jewish Physicians and the Contributions of the Jews to the Science of Medicine," a lecture delivered before the Gratz College of Philadelphia fifteen years ago, summed up from Baas' "History of Medicine" the instructions in the Talmud with regard to health and disease. The summary represents so much more of genuine knowledge of medicine and surgery than might be expected at the early period at which it was written, during the first and second century of our era, that it seems well to quote it at some length.

"Fever was regarded as nature's effort to expel morbific matter and restore health; which is a much safer interpretation of fever, from a practical point of view, than most of the theories bearing on this point that have been taught up to a very recent period. They attributed the halting in the hind legs of a lamb to a callosity formed around the spinal cord. This was a great advance in the knowledge of the physiology of the nervous system. An emetic was recommended as the best remedy for nausea. In many cases no better remedy is known to-day. They taught that a sudden change in diet was injurious, even if the quality brought by the change was better. That milk fresh from the udder was the best. The Talmud describes jaundice and correctly ascribes it to the retention of bile, and speaks of dropsy as due to the retention of urine. It teaches that atrophy or rupture of the kidneys is fatal. Induration of the lungs (tuberculosis) was regarded as incurable. Suppuration of the spinal cord had an early, grave meaning. Rabies was known. The following is a description given of the dog's condition: 'His mouth is open, the saliva issues from his mouth; his ears drop; his tail hangs between his legs; he runs sideways, and the dogs bark at him; others say that he barks himself, and that his voice is very weak. No man has appeared who could say that he has seen a man live who was bitten by a mad dog.' The description is good, and this prognosis as to hydrophobia in man has remained unaltered till in our day when Pasteur published his startling revelation. The anatomical knowledge of the Talmudists was derived chiefly from dissection of the animals. As a very remarkable piece of practical anatomy for its very early date is the procuring of the skeleton from the body of a prostitute by the process of boiling, by Rabbi Ishmael, a physician, at the close of the first century. He gives the number of bones as 252 instead of 232. The Talmudists knew the origin of the spinal cord at the foramen magnum and its form of termination; they described the œsophagus as being composed of two coats; they speak of the pleura as the double covering of the lungs; and mention the special coat of fat about the kidneys. They had made progress in obstetrics; described monstrosities and congenital deformities; practised version, evisceration, and Cæsarian section upon the dead and upon the living mother. A. H. Israels has clearly shown in his 'Dissertatio Historico-Medica Inauguralis' that Cæsarian section, according to the Talmud, was performed among the Jews with safety to mother and child. The surgery of the Talmud includes a knowledge of dislocation of the thigh bone, contusions of the skull, perforation of the lungs, œsophagus, stomach, small intestines, and gall bladder; wounds of the spinal cord, windpipe, of fractures of the ribs, etc. They described imperforate anus and how it was to be relieved by operation. Chanina Ben Chania inserted natural and wooden teeth as early as the second century, C. E."

There is a famous summing up of the possibilities of life and happiness in the Talmud that has been often quoted—its possible wanting in gallantry being set down to the times in which it was written. "Life is compatible with any disease, provided the bowels remain open; any kind of pain, provided the heart remain unaffected; any kind of uneasiness, provided the head is not attacked; all manner of evils, except it be a bad woman."

There are many other interesting suggestions in the Talmud. Sometimes they have come to be generally accepted in the modern time, sometimes they are only curious notions that have not, however, lost all their interest. The crucial incision for carbuncle is a typical example of the first class and the suggestion of the removal of superfluous fat from within the abdomen or in the abdominal wall itself by operation is another. That they had some idea of the danger of sepsis may be gathered from the fact that they suspected iron surgical instruments and advised the use of others of less enduring character.

The Talmud itself was indeed a sort of encyclopedia in which was gathered knowledge of all kinds from many sources. It was not particularly a book of medicine, though it contains so many medical ideas. In many parts of it the authors' regard for science is emphatically expressed. Landau, in his "History of Jewish Physicians," closes his account of the Talmud with this paragraph:

"I conclude this brief review of Talmudic medicine with some reference to how high the worth of science was valued in this much misunderstood work. In one place we have the expression 'occupation with science means more than sacrifice.' In another 'science is more than priesthood and kingly dignity.'"[4]

After all this of national tradition in medicine before and after Christ, it is only what we might quite naturally expect to find, that there is scarcely a century of the Middle Ages which does not contain at least one great Jewish physician and sometimes there are more. Many of these men made distinct contributions to medical science and their names have been held in high estimation ever since. Perhaps I should say that they were held in high estimation until that neglect of historical studies which characterized the eighteenth century developed, and that there has been a reawakening of interest in our time. We forget this curious decadence of the later seventeenth and eighteenth centuries which did so much to obscure history and especially the history of the sciences. Fortunately the scholars of the sixteenth and early seventeenth centuries accomplished successfully the task of printing many of the books of these old-time physicians and secured their publication in magnificent editions. These were bought eagerly by scholars and libraries all over Europe in spite of the high price they commanded in that era of slow, laborious printing. The Renaissance exhibits some of its most admirable qualities in its reverence for these old workers in science and above all for the careful preparation by its scholars of the text of these first editions of old-time physicians. The works have often been thus literally preserved for us, for some of them at least would have disappeared among the vicissitudes of the intervening time, most of which was anything but favorable to the preservation of old-time works, no matter what their content or value.

During the second and third centuries of our era, while the Talmudic writings were taking shape, three great Jewish physicians came into prominence. The first of them, Chanina, was a contemporary of Galen. According to tradition, as we have said, he inserted both natural and artificial teeth before the close of the second century. The two others were Rab or Raw and Samuel. Rab has the distinction of having studied his anatomy from the human body. According to tradition he did not hesitate to spend large sums of money in order to procure subjects for dissection. At this time it is very doubtful whether Galen, though only of the preceding generation, ever had the opportunity to study more than animals or, at most, a few human bodies. Samuel, the third of the group, was an intimate friend of Rab's, perhaps a disciple, and his fame depends rather on his practice of medicine than of research in medical science. He was noted for his practical development of two specialties that cannot but seem to us rather distant from each other. His reputation as a skilful obstetrician was only surpassed by the estimation in which he was held as an oculist. He seems to have turned to astronomy as a hobby, and was highly honored for his knowledge of this science. Probably there is nothing commoner in the story of great Jewish physicians than their successful pursuit of some scientific subject as a hobby and reaching distinction in it. Their surplus intellectual energy needed an outlet besides their vocation, and they got a rest by turning to some other interest, often accomplishing excellent results in it. Like most great students with a hobby, the majority of them were long-lived. Their lives are a lesson to a generation that fears intellectual overwork.

During the fourth century we have a number of very interesting traditions with regard to a great Jewish physician, Abba Oumna, to whom patients flocked from all over the world. He seems particularly to have been anxious to make his services available to the scholars of his time. He looked upon them as brothers in spirit, fellow-laborers whose investigations were as important as his own and whose labors for mankind he hoped to extend by the helpfulness of his profession. In order that it might be easy for them to come to him without feeling abashed by their poverty, and yet so that they might pay him anything that they thought they were able to, he hung up a box in his anteroom in which each patient might deposit whatever he felt able to give. His kindliness towards men became the foundation for many legends. Needless to say he was often imposed upon, but that seems to have made no difference to him, and he went on straightforwardly doing what he thought he ought to do, regardless of the devious ways of men, even those whom he was generously assisting. While we do not know much of his scientific medicine, we do know that he was a fine example of a practitioner of medicine on the highest professional lines.

With the foundation of the school at Djondisabour in Arabistan or Khusistan by the Persian monarch Chosroes, some Jewish physicians come into prominence as teachers, and this is one of the first important occasions in history when they teach side by side with Christian colleagues. Djondisabour seems distant from us now, lying as it does in the province just above the head of the Persian Gulf, and it is a little hard to understand its becoming a centre of culture and education, yet according to well-grounded historical traditions students flocked here from all parts of the world, and its medical instruction particularly became famous. According to the documents and traditions that we possess, clinical teaching was the most significant feature of the school work and made it famous. As a consequence graduates from here were deemed fully qualified to become professors in other institutions and were eagerly sought by various medical schools in the East.

With the rise of the strong political power of the Mohammedans enough of peace came to the East at least to permit the cultivation of arts and sciences to some extent again, and then at once the eminence of Jewish physicians, both as teachers and practitioners of medicine, once more becomes manifest. The first of the race who comes into prominence is Maser Djawah Ebn Djeldjal, of Basra. To him we owe probably more than to anyone else the preservation of old scientific writings and the cultivation of arts and sciences by the Mohammedans. He prevailed on Caliph Moawia I, whose physician he had become, to cause many foreign works, and especially those written in Greek, to be translated into Arabic. He seems to have taken a large share of the labor of the translation on himself and prevailed upon his pupil, the son of Moawia, to translate some works on chemistry. The translation for which Maser Djawah is best known is that of the Pandects of Haroun, a physician of Alexandria. The translation of this work was made toward the end of the seventh century. Unfortunately the "Pandects" has not come down to us, either in original or translation, but we have fragments of the translation preserved by Rhazes, the distinguished Arabian medical writer and physician of the ninth century, and there seems no doubt that it contained the first good description of smallpox, a chapter in medicine that is often—though incorrectly—attributed to Rhazes himself. Rhazes quoted Maser Djawah freely and evidently trusted his declarations implicitly.

The succeeding Caliphs of the first Arabian dynasty did not exhibit the same interest in education, and above all in science, that characterized Moawia. Political ambition and the desire for military glory seem to have filled up their thoughts and perhaps they had not the good fortune to fall under the influence of physicians so wise and learned as Maser Djawah. More probably, however, they themselves lacked interest. Toward the end of the seventh century they were succeeded by the Abbassides. Almansor, the second Caliph of this dynasty, was attacked by a dangerous disease and sent for a physician of the Nestorian school. After his restoration to health he became a liberal patron of science and especially medical science. The new city of Bagdad, which had become the capital of the realm of the Abbassides, was enriched by him with a large number of works on medicine, which he caused to be translated from the Greek. He did not confine himself to medicine, however, but also brought about translations of works with regard to other sciences. One of these, astronomy, was a favorite. He made it a particular point to search out and encourage the translation of such books as had not previously been translated from Greek into Arabic. While he provided a translation of Ptolemy he also had translations made of Aristotle and Galen.

It is not surprising, then, that the school of Bagdad became celebrated. Jewish physicians seem to have been most prominent in its foundation, and the most distinguished product of it is Isaac Ben Emran, almost as celebrated as a philosopher as he is as a physician. One of his expressions with regard to the danger of a patient having two physicians whose opinions disagree with regard to his illness has been deservedly preserved for us. Zeid, an Emir of one of the chief cities of the Arabs in Barbary, fell ill of a tertian fever and called Isaac and another physician in consultation. Their opinions were so widely in disaccord that Isaac refused to prescribe anything, and when the Emir, who had great confidence in him, demanded the reason, he replied, "disagreement of two physicians is more deadly than a tertian fever." This Isaac, who is said to have died in 799, is the great Jewish physician, one of the most important members of the profession in the eighth century. His principal work was with regard to poisons and the symptoms caused by them. This is often quoted by medical writers in the after time.

The prominent Jewish physician of the ninth century was Joshua Ben Nun. Haroun al-Raschid, whose attempts to secure justice for his people are the subject of so much legendary lore, and whose place in history may be best recalled by the fact that he is a contemporary of Charlemagne, was particularly interested in medicine. He founded the city of Tauris as a memorial of the cure of his wife. He was a generous patron of the school of Djondisabour and established a medical school also at Bagdad. He provided good salaries for the professors, insisted on careful examinations, and raised the standard of medical education for a time to a noteworthy degree. The greatest teacher of this school at Bagdad was Joshua Ben Nun, sometimes known as the Rabbi of Seleucia. His teaching attracted many students to Bagdad and his fame as one of the great practitioners of medicine of this time brought many patients. Among his disciples was John Masuée, whose Arabian name is so different, Yahia Ben Masoviah, that in order to avoid confusion in reading it is important to know both. Almost better known, perhaps, at this time was Abu Joseph Jacob Ben Isaac Kendi. Fortunately for the after time, these men devoted themselves not only to their own observations and writings but made a series of valuable translations. Joshua Ben Nun seems to have been particularly zealous in this matter, following the example of Maser Djawah of Basra.

Bagdad then became a centre for Arabian culture. Mahmoud, one of Haroun's successors, provided in Bagdad a refuge for the learned men of the East who were disturbed by the wars and troubles of the time. He became a liberal patron of literature and education. When the Emperor Michael III of Constantinople was conquered in battle, one of the obligations imposed upon him was to send many camel loads of books to Bagdad, and Aristotle and Plato were studied devotedly and translated into Arabic. The era of culture affected not only the capital but all the cities, and everywhere throughout the Arabian empire schools and academies sprang up. We have records of them at Basra, Samarcand, Ispahan. From here the thirst for education spread to the other cities ruled by the Mohammedans, and each town became affected by it. Alexandria, the cities of the Barbary States, those of Sicily and Provence, where Moorish influences were prominent, and of distant Spain, Cordova, Seville, Toledo, Granada, Saragossa, all took up the rivalry for culture which made this a glorious period in the history of the intellectual life.

Already, in the chapter on "Great Physicians in Early Christian Times," I have pointed out that many of the teachers of the Arabs were Christian physicians. Here it is proper to emphasize the other important factor in Arabian medicine, the Jewish physicians, who influenced the great Arabian rulers, and were the teachers of the Arabs in medicine and science generally. These Christian and Jewish physicians particularly encouraged the translation of the works of the great Greek physicians and thus kept the Greek medical tradition from dying out. It is not until the end of the ninth, or even the beginning of the tenth, century that we begin to have important contributors to medicine from among the Arabs themselves. Even at this time they have distinguished rivals among Jewish physicians. Indeed these acquired such a reputation that they became the physicians to monarchs and even high ecclesiastics, and we find them nearly everywhere throughout Europe. Their success was so great that it is not surprising that after a time the vogue of the Jewish physicians should have led to jealousy of them and to the passage of laws and decrees limiting their sphere of activity.

The great Jewish physician of the ninth century was Isaac Ben Soliman, better known as Isaac el Israili, and who is sometimes spoken of as d'Israeli. He was a pupil of Isaac Ben Amram the younger, probably a grandson of another Isaac Ben Amram, who, after having become famous in Bagdad, went to Cairo and became the physician of the Emir Zijadeth III. The younger Isaac established a school, and it was with him that Israeli obtained his introduction to medicine. He practised first as an oculist and then became body-physician to the Sultan of Morocco. Because of the sympathy of his character and his unselfishness he acquired great popularity. Hyrtl refers to him respectfully as "that scholarly son of Israel." Curiously enough, considering racial feeling in the matter, he never married, and when asked why he had not, and whether he did not think that he might regret it, he replied, "I have written four books through which my memory will be better preserved than it would be by descendants." The four books are his "Treatise on Fevers," his "Treatise on Simple Medicines and Ailments," a treatise on the "Elements," and a treatise "On the Urine." Besides these, we have from him shorter works, "On the Pulse," "On Melancholy," and "On Dropsy." His hope with regard to his fame from these works was fulfilled, for they were printed as late as 1515 at Leyden, and Sprengel declared them the best compendium of simple remedies and diet that we have from the Arabian times. One of his translators into Latin has called him the monarch of physicians.

Some of his maxims are extremely interesting in the light of modern notions on the same subjects. He declared emphatically that "the most important duty of the physician is to prevent illness." "Most patients get better without much help from the physician by the power of nature." He emphasized his distrust of using many medicines at the same time in the hope that some of them would do good. He laid it down as a rule: "Employ only one medicine at a time in all your cases and note its effects carefully." He was as wise with regard to medical ethics as therapeutics. He advised a young physician, "Never speak unfavorably of other physicians. Every one of us has his lucky and unlucky hours." It is pleasant to learn that the old gentleman lived to fill out a full hundred years of life, and that in his declining years he was surrounded by the good will and the affection of many who had learned to know his precious qualities of heart and mind. More than of any other class of physicians do we find the large human sympathies of the Jewish physicians of the Middle Ages praised by their contemporaries and succeeding generations.

During the next centuries a number of Jewish physicians became prominent, though none of them until Maimonides impressed themselves deeply upon the medical life of their own and succeeding centuries. Very frequently they were the physicians to royal personages. Zedkias, for instance, was the physician to Louis the Pious and later to his son Charles the Bald. His reputation as a physician was great enough to give him the popular estimation of a magician, but it did not save him from the accusation of having poisoned Charles when that monarch died suddenly. There seem to be no good grounds, however, for the accusation. There were a number of schools of medicine, in Sicily and the southern part of Italy, in which Jewish, Arabian, and Christian physicians taught side by side. One of these teachers was Jude Sabatai Ben Abraham, usually known by the name of Donolo, who was famous both as a writer on medicine and on astronomy. Donolo studied and probably taught at Tarentum, and there were similar schools at Palermo, at Bari, and then later on the mainland at Salerno. The foundation of Salerno, in which Jewish physicians also took part, we shall discuss later in the special chapter devoted to that subject.

One of the great translators whose work meant very much for the medical science of his own and succeeding generations was the distinguished Jewish physician, Faradj Ben Salim, sometimes spoken of as Farachi Faragut or Ferrarius, who was born at Girgenti in Sicily. He made his medical studies in Salerno and did his work under the patronage of Charles of Anjou towards the end of the thirteenth century. His greatest work is the translation of the whole of the "Continens" of Rhazes. The translation is praised as probably the best of its time made in the Middle Ages. Faradj came at the end of a great century, when the intellectual life of Europe had reached a high power of expression, and it is not surprising that he should have proved equal to his environment. This translation has also some additions made by Faradj himself, notably a glossary of Arabian names.

In Spain also Jewish physicians rose to distinction. The most distinguished in the tenth century was Chasdai Ben Schaprut. Like many other of the great physicians of this time, he had studied astronomy as well as the medical sciences. He became the physician of the Caliph Abd-er-Rahman III of Cordova. He seems also to have exercised some of the functions of Prime Minister to the Caliph, and took advantage of diplomatic relations between his sovereign and the Byzantine Emperor to obtain some works of Dioscorides. These he translated into Arabian with the help of a Greek monk, whom he seems also to have secured through the diplomatic relations. Undoubtedly he did much to usher in that enthusiasm for education and study which characterized the next centuries, the eleventh and twelfth, at Cordova in Spain, when such men as Avenzoar, Avicenna, and Averroës attracted the attention of the educational world of the time. Jewish writers have sometimes claimed one of the most distinguished of these, Avenzoar himself, as a Jew, but Hyrtl and other good authorities consider him of Arabic extraction and point to the fact that his ancestors bore the name of Mohammed. This is not absolutely conclusive evidence, but because of it I have preferred to class Avenzoar among the Arabian physicians.

The one historical fact of importance for us is that everywhere in Europe at that time Jews were being accorded opportunities for the study and practice of medicine. There are local incidents of persecution, but we are not so far away from the feelings that brought these about as to misunderstand them or to think that they were anything more than local, popular manifestations. The more we know about the details of the medical history of these times the deeper is the impression of academic freedom and of opportunities for liberal education.

Much has been said about the intolerance of ecclesiastical authorities toward the Jews, and of Church decrees that either absolutely forbade their practice of the medical profession and their devotion to scientific study, or at least made these pursuits much more difficult for them than for others. Of course it has to be conceded, even by those who most insistently urge the existence of formal legislation in the matter, that in spite of these decrees and intolerance and opposition, Jews continued to practise medicine and to be the chosen physicians of kings and even of high ecclesiastical dignitaries, as well indeed of the Popes themselves. This, it is usually declared, must be attributed to the surpassing skill of the Jewish physicians, causing men to overcome their prejudices and override even their own legal regulations. There is no doubt at all about the skill of Jewish physicians at many times during the Middle Ages. There is no doubt also of the sentiment of opposition that often developed between the Christian peoples and the Jews. Any excuse is good enough to justify men, to themselves at least, in putting obstacles in the paths of those who are more successful than they are themselves. Religion often became a cloak for ill-will and persecution.

The state of affairs that has been presumed however, according to which laws and decrees were being constantly issued forbidding the practice of medicine to Jews by the ecclesiastical authorities, while at the same time they themselves and those who were nearest to them were employing Jewish physicians, is an absurdity that on the face of it calls for investigation of the conditions and from its very appearance would indicate that the ordinary historical assumption in the matter must be wrong.

I have been at some pains, then, to try to find out just what were the conditions in Europe with regard to the practice of medicine by the Jews. There is no doubt that at Salerno, where the influence of the Benedictines was very strong and where the influence of the Popes and the ecclesiastical authorities was always dominant, full liberty of studying and teaching was from the earliest days allowed to the Jews. Down at Montpellier it seems clear that Jewish physicians had a large part in the foundation of the medical school, and continued for several centuries to be most important factors in the maintenance of its reputation and the upbuilding of that fame which draw students from even distant parts of Europe to this medical school of the south of France. During the ninth, tenth, eleventh, and twelfth centuries Jewish physicians were frequently in attendance on kings and the higher nobility, on bishops and archbishops, cardinals, and even Popes. Every now and then the spirit of intolerance among the populace was aroused, and occasionally the death of some distinguished patient while in a Jewish physician's hands was made the occasion for persecution. We must not forget, after all, that even as late as Elizabeth's time, when Shakespeare wrote "The Merchant of Venice," he was taking advantage of the popular sentiment aroused by the execution of Lopez, the Queen's physician, for a real or supposed participation in a plot against her Majesty's life. Shylock was presented the next season for the sake of adventitious popularity that would thus accrue to the piece. The character was played so as to depict all the worst traits of the Jew, and was scornfully laughed at at every representation. This is an index of the popular feeling of the time. Bitter intolerance of the Jew has continued. Down almost to our own time the Ghettos have existed in Europe, and popular tumults against them continue to occur. Quite needless to say, these do not depend on Christianity, but on defective human nature.

During the Middle Ages the best possible criterion of the attitude of the Church authorities towards the Jews is to be found in the legislation of Pope Innocent III. He is the greatest of the Popes of the Middle Ages; he shaped the policy of the Church more than any other; his influence was felt for many generations after his own time. His famous edict with regard to them was well known: "Let no Christian by violence compel them to come dissenting or unwilling to Baptism. Further, let no Christian venture maliciously to harm their persons without a judgment of the civil power or to carry off their property or change their good customs which they have hitherto in that district which they inhabit." Innocent himself and several of his predecessors and successors are known to have had Jewish physicians. Example speaks even louder than precept, and the example of such men must have been a wonderful advertisement for the Jewish physicians of the time.

Besides Innocent III, many of the Popes of the twelfth and thirteenth centuries issued similar decrees as to the Jews. It may be recalled that this was the time when the Papacy was most powerful in Europe and when its decrees had most weight in all countries. Alexander II, Gregory IX, and Innocent IV all issued formal documents demanding the protection of the Jews, and especially insisting that they must not be forced to receive Baptism nor disturbed in the celebration of their festivals. Clement VI did the same thing in the next century, and even offered them a refuge from persecution throughout the rest of France at Avignon. Distinguished Jewish scholars, who know the whole story from careful study, have given due credit to the Popes for all that they did for their people. They have even declared that if the Jews were not exterminated in many of the European countries it was because of the protection afforded by the Church. We have come to realize in recent years that persecution of the Jews is not at all a religious matter, but is due to racial prejudice and jealousy of their success by the peoples among whom they settle. All sorts of pretexts are given for this persecution at all times. Formal Church documents and the personal activities of the responsible Church officials show that during the Middle Ages the Church was a protector and not a persecutor of the Jews.

There is abundant historical authority for the statement that the Popes were uniformly beneficent in their treatment of the Jews. In order to demonstrate this there is no need to quote Catholic historians, for non-Catholics have been rather emphatic in bringing it out. Neander, the German Protestant historian, for instance, said:

"It was a ruling principle with the Popes after the example of their great predecessor, Gregory the Great, to protect the Jews in the rights which had been conceded to them. When the banished Popes of the twelfth century returned to Rome, the Jews went forth in their holiday garments to meet them, bearing before them the 'thora,' and Innocent II, on an occasion of this sort, blessed them."

English non-Catholic historians can be quoted to the same effect. The Anglican Dean Milman, for instance, said: "Of all European sovereigns, the Popes, with some exceptions, have pursued the most humane policy towards the Jews. In Italy, and even in Rome, they have been more rarely molested than in the other countries."

Hallam has expressed himself to the same effect, especially as regards the protection afforded to the Jew by the laws of the Church from the injustice of those around him. Laws sometimes fail of their purpose and the persecuting spirit of the populace is often hard to control, but everything that the central authority could do to afford protection was done and essential justice was enshrined in the Church laws.

Prominent ecclesiastics would naturally follow the lines laid down by their Papal superiors. The attitude of those whose lives mark epochs in the history of Christianity and who had more to do almost with the shaping of the policy of the Church at many times than the Popes themselves, can be quoted readily to this same effect. Neander has called particular attention to St. Bernard's declarations with regard to the evils that would follow any tolerance of such an abuse as the persecution of the Jews.

"The most influential men of the Church protested against such un-Christian fanaticism. When the Abbot Bernard of Clairvaux was rousing up the spirit of the nations to embark in the second crusade, and issued for this purpose, in the year 1146, his letters to the Germans (East Franks), he at the same time warned them against the influence of those enthusiasts who strove to inflame the fanaticism of the people. He declaimed against the false zeal, without knowledge, which impelled them to murder the Jews, a people who ought to be allowed to live in peace in the country."

But it has been said that there are decrees against Jewish physicians, issued especially in the south of France, by various councils and synods of the Church. Attention needs to be called at once to the fact that these are entirely local regulations and have nothing to do with the attitude of the Church as a whole, but represent what the ecclesiastical authorities of a particular part of the country deem necessary for some special reason in order to meet local conditions. Indeed at the end of the thirteenth and the early fourteenth century, when these decrees were being issued in France, full liberty was allowed in Italy, and there were no restrictions either as to medical practice or education founded on adhesion to Judaism.

What need to be realized in order to understand the issuance of certain local ecclesiastical regulations forbidding Jews to practise medicine are the special conditions which developed in France at this time. Many Jews had emigrated from Spain to France, and the reputation acquired by Jewish physicians at Montpellier led to a number of the race taking up the practice of medicine without any further qualification than the fact that they were Jews. That gave them a reputation for curative powers of itself because of the fame of some Jewish doctors and their employment by the nobility and the highest ecclesiastics. It was hard to regulate these wandering physicians. As a consequence of this, the faculty at Paris, always jealous of its own rights and those of its students, at the beginning of the fourteenth century absolutely forbade Jews from practising on Christian patients within its jurisdiction. Of course the faculty of the University of Paris was dominated by ecclesiastical authorities. The medical school was, however, almost entirely independent of ecclesiastical influence, and was besides largely responsible for this decree. It was felt that something had to be done to stop the evil that had arisen and the charlatanry and quackery which was being practised. This was, however, rather an attempt to regulate the practice of medicine and keep it in the hands of medical school graduates than an example of intolerance towards the Jews. Practically no Jews had graduated at its university, Montpellier being their favorite school, and Paris was not a little jealous of its rights to provide for physicians from the northern part of France. We have not got away from manifestations of that spirit even yet, as our non-reciprocating state medical laws show.

During the next quarter of a century decrees not unlike those of the University of Paris were issued in the south of France, especially in Provence and Avignon. Anyone who knows the conditions which existed in the south of France at this time with regard to medical practice will be aware that a number of attempts were made by the ecclesiastical authorities just at this time to regulate the practice of medicine. Great abuses had crept in. Almost anyone who wished could set up as a physician, and those who were least fitted were often best able to secure a large number of patients by their cleverness, their knowledge of men, and their smooth tongues. The bishops of various dioceses met, and issued decrees forbidding anyone from practising medicine unless he was a graduate of the medical school of the neighboring University of Montpellier. After a time it was found that the greatest number of violators of these decrees were Jews. Accordingly special regulations were made against them. They happen to be ecclesiastical regulations, because no other authority at that time claimed the right to regulate medical education and the practice of medicine.

What is sure is that many Jewish physicians reached distinction under Christian as well as Arabian rulers at all times during the Middle Ages. It would be quite impossible in the limited space at command here to give any adequate mention of what was accomplished by these Jewish physicians, whose names we have scarcely been able to more than catalogue, nor of the place they hold in their times. As the physicians of rulers, their influence for culture and the cultivation of science was extensive, and as a rule they stood for what was best and highest in education. The story of one of them, who is generally known in the Christian world at least, Maimonides, given in some detail, may serve as a type of these Jewish physicians of the Middle Ages. He lived just before the flourishing period of university life in the thirteenth century brought about that wonderful development of medicine and surgery in the west of Europe that meant so much for the final centuries of the Middle Ages. His works influenced not a little the great thinkers and teachers whose own writings were to be the foundations of education for several centuries after their time. Maimonides was well known in the Western universities. Though his life had been mainly spent in the East, and he died there, there was scarcely a distinguished scholar of Europe who was not acquainted directly or indirectly with his works, and the greater the reputation of the scholar, as a rule, the more he knew of Maimonides, Moses Ægyptæus, as he was called, and the more frequently he referred to his writings.

IV
MAIMONIDES

The life of one of the great Jewish physicians, who has come to be known in history as Maimonides, is of such significance in medical biography that he deserves to have a separate sketch. Born in Spain, his life was lived in the East, where his connection as royal physician with the great Sultan Saladin of Crusades fame made his influence widely felt. He is a type of the broadly educated man, conversant with the culture of his time and of the past, knowing much besides medicine, who has so often impressed himself deeply on medical practice. While the narrow specialists in each generation, the men who are quite sure that they are curing the special ills of men to which they devote themselves, have always felt that whatever of progress there was in any given time was due to them, they occupy but little space as a rule in the history of medicine. The men who loom large were the broad-minded, humanely sympathetic, deeply educated physicians, who treated men and their ills rather than their ills without due consideration of the individual, and who not only relieved the discomfort of their patients and greatly lessened human suffering, and added to the sum of human happiness in their time, but also left precious deeply significant lessons for succeeding generations of their profession. Hippocrates, Galen, Sydenham, Auenbrugger, Morgagni, these are representatives of this great class, and Maimonides must be considered one of them.

Moses Ben Maimum, whose Arabic name was Abu Amran Musa Ben Maimum Obaid Alla el-Cordovi, who was called by his Jewish compatriots Ramban or Rambam, was born at Cordova in Spain, on the 30th of March in 1135 or 1139, the year is in doubt. It might not seem of much import now after nearly eight centuries, but not a little ink is spilt over it yet by devoted biographers.

We are rather prone to think in our time that the conditions in which men were born and reared before what we are pleased to call modern times, and, above all, in the Middle Ages, must have made a distinct handicap for their intellectual development. Most of us are quite sure that the conditions in medieval cities were eminently unsuited for the stimulation of the intellect, for incentive to art impulse, for uplift in the intellectual life, or for any such broad interest in what has been so well called the humanities—the humanizing things that lift us above animal necessities—as would make for genuinely liberal education. We are likely to be set in the opinion that the environment of the growing youth of an old-time city, especially so early as the middle of the twelfth century, was poor and sordid. The cares of the citizens are presumed to have been mainly for material concerns, and, indeed, mostly for the wants of the body. They were only making a start on the way from barbarism to something like our glorious culmination of civilization. As "the heirs to all the ages in the foremost files of time" we are necessarily far in advance of them, and we are only sorry that they did not have the opportunity to live to see our day and enjoy the benefits of the evolution of humanity that is taking place during the eight centuries that have elapsed.

As a matter of fact, there was much more of abiding profound interest in real civilization in many a medieval city, much more general appreciation of art, much more breadth of intelligence and sympathy with what we call the humanities, than in most of our large cities. The large city, as we know it, is eminently a discourager of breadth of intelligence. Specialism in the various phases of money-making obscures culture. Maimonides, born in Cordova, was brought up amid surroundings that teemed with incentives of every kind to the development of intelligence, of artistic taste, and everything that makes for cultivation of intellect rather than of interest in merely material things.

It is well said that it is hard to judge the Cordova of old by its tawdry ruins of to-day. The educated visitor still stands in awe and admiration of the great mosque which expressed the high cultivation of the Moors of this time. It is a never-ending source of wonder to Americans. The city itself has many reminders of that fine era of Moorish culture and refinement of taste and of art expression, which made it in the best sense of the word a city beautiful. The Arab invaders had found a great prosperous country which had been the most cultured province of the Roman Empire, and on this foundation they made a marvellous development. "The banks of the Guadalquivir," says Mr. S. Lane-Poole in "The Moors in Spain" (London, 1887), "were bright with marble houses, mosques, and gardens, in which the rarest flowers and trees of other countries were carefully cultivated, and the Arabs introduced their system of irrigation which the Spaniards both before and since have never equalled." The greatest beauty of the city, of course, had come, and some of it had gone, before Maimonides' time. So much remains in spite of time and war, and many unfortunate influences, that we can have some idea how beautiful it must have been in his youth seven centuries ago, and how even more beautiful in the foretime. Of the great mosque writers of travel can scarcely say enough. Mr. Lane-Poole says: "Travellers stand amazed among the forest of columns which open out apparently endless vistas on all sides. The porphyry, jasper, and marbles are still in their places; the splendid glass mosaics, which artists from Byzantium came to make, still sparkle like jewels in the walls; the daring architecture of the sanctuary, with its fantastic crossed arches, is still as imposing as ever; the courtyard is still leafy with the orange trees that prolong the vistas of columns. As one stands before the loveliness of the great mosque, the thought goes back to the days of the glories of Cordova, the palmy days of the Great Khalif, which will never return."

Of all the countries in which the Jews all down the centuries have lived there is probably none of which they have been more loud in praise than Spain. Their poets sang of it as if it were their own country; for centuries the people were happier here than probably they have been anywhere else for so long a period. Elsewhere in this book I have called attention to all that Spain meant in Europe during all the centuries from the beginning of the Roman Empire down to the end of the Middle Ages. Maimonides was fortunate in his birthplace, then, and while circumstances compelled the family to move away, this change did not come until a good effect had been produced on the mind of the growing youth. Even when persecution came, Maimonides clung to Spain with a tenacity born of deep affection and emphasized by admiration for all that she was and had been. Cordova was the jewel of the Spain of this time, and though much less than she had been in the long preceding time, when she was the birthplace of Lucan and the two Senecas, or even than what she had been in Abd-er-Rahman's days, or when she was the birthplace of Averroës, still she remained wonderfully beautiful and attractive, winning and holding the affections of men.

Maimonides' father, Maimum Ben Joseph, was a member of the Rabbinical College of Cordova, and famous for his knowledge of the Talmud. There are some writings of his on mathematics and astronomy extant. He directed the education of his son, who, like many another distinguished scholar in later life, seems to have exhibited very little talent in his early years. There is no rule in the matter. Precocity often disappoints. Genius is often dull in childhood, but there are exceptions that prove both rules. The basis of education in Spain at that time among the Jews was the Bible, the Talmud, mathematics, and astronomy, a good rounded education in literature, the basis of law, and some exact physical science. After his preliminary education at home Maimonides studied the natural sciences and medicine with Moorish teachers. Nature-study, in spite of frequent expressions that declare it new in modern times, is as old as man. He also received a grounding in philosophy as a preparation for his scientific studies. At the age of twenty-three he began the composition of a commentary on the Talmud, which he continued to work at on his journeys in Spain and in Egypt. This is considered to be one of the most important of this class of works extant, though, almost needless to say, similar writings are very numerous.

In the light of wanderings in philosophy during the centuries since, it is rather interesting to quote from that work the end of man as this Jewish philosopher of the middle of the twelfth century saw it. Recent teleological tendencies in biology add to the interest of his views. According to Maimonides, "Man is the end of the whole creation, and we have only to look to him for the reason for its existence. Every object shows the end for which it was created. The palm-trees are there to provide dates; the spider to spin her webs. All the properties of an animal or a plant are directed so as to enable it to reach its purpose in life. What is the purpose of man? It cannot lie alone in eating and drinking or yielding to passion, nor in the building of cities and the ruling of others, since these objects lie outside of him, and do not touch his essential being. Such material striving he has in common with the animal. A man is lifted from a lower to a higher condition by his reason. Only through his reason is he placed above the animals. He is the only reasonable animal. His reason enables him to understand all things, especially the Unity of God, and all knowledge and science serve only to direct man to the knowledge of God. Passions are to be subdued, since the man who yields to passion subjects his spirit to his body, and does not reveal in himself the divine power which in him lies in his reason, but is swallowed up in the ocean of matter."

Not long after Maimonides passed his twentieth year the family, consisting of the father and his two sons, Moses and David, and a daughter, moved from Cordova to Fez, compelled by Jewish persecutions. Here it is said that they had to submit to wearing the mask of Islam in order to lead a peaceful existence. This has been doubted, however, and his whole life is in flagrant contradiction with any such even apparent apostasy from the faith of his fathers. Father and son took advantage of the opportunity of intercourse with Moorish physicians and philosophers to increase their store of knowledge, but could not be content in the political and religious conditions in which they were compelled to live. About 1155, then, they went to Jerusalem, but found conditions even more intolerable there, and turned back to Egypt, where they settled down in Old Cairo. In 1166 the father died, and after this we learn that the sons made a livelihood, and even laid the foundation of a fortune, by carrying on a jewelry trade. Moses still devoted most of his time to study, while his brother did most of the business, but the brother was lost in the Indian Ocean, and with him went not only a large sum of his own money, but also much that had been entrusted to him by others. Maimonides undertook to pay off these debts and at the same time had to meet the necessities not only of himself and sister, but also of the family of his dead brother. It was then that he took up the practice of medicine and succeeded in making a great name and reputation for himself. He continued to write, however, and completed his commentary on the Talmud.

About the age of fifty Maimonides, as seems to be true of a good many men who live to old age, became rather discouraged and despondent about himself. He refers to himself in his letters and writings rather frequently as an old and ailing man. He had nearly twenty years of active life ahead of him, but he had the persuasion that comes to many that he was probably destined to an early death. His son was born shortly after this time, and that seems to have had not a little to do with brightening his life. While in Egypt Maimonides married the sister of one of the royal secretaries, who, in turn, wedded Maimonides' sister. Maimonides took on himself the education of his son, who also became a physician, though his father was not to have the satisfaction of watching his success in the practice of his chosen profession. This son, Abraham, became the physician of Malie Alkamen, the brother of Saladin, and, besides, was a physician to the hospital at Cairo. His son, David, the grandson of Maimonides, practised medicine also at Cairo till 1300. He in turn left two sons, Abraham and Solomon, who achieved reputation in the chosen profession of their great-grandfather.

Maimonides, after the birth of his son, became one of the busiest of practising physicians. Indeed, it is hard to understand how he had the time to do any writing in his busy life. Still less can we understand his time for teaching. He was the physician to Saladin, whose relations with Richard Cœur de Lion have made him known to English-speaking people. Every morning, as the Court physician, Maimonides went to the palace, situated half a mile away from his dwelling, and if any of the many officials and dependents that then, as now, were at Oriental courts, were ill, he stayed there for some time. As a rule he could only get back to his own home in the afternoon, and then he was, as he says himself, "almost dying with hunger." Knowing the scantiness of the Oriental breakfast, we are not surprised. There he found his waiting-room full of patients, "Jews and Mohammedans, prominent and unimportant, friends and enemies," he says himself, "a varied crowd, who are looking for my medical advice. There is scarcely time for me to get down from my carriage and wash myself and eat a little, and then until night I am constantly occupied, so that, from sheer exhaustion, I must lie down. Only on the Sabbath day have I the time to occupy myself with my own people and my studies, and so the day is away from me." What a picture it is of the busy medical teacher at all times in the world's history, yet it must not be forgotten that it is from these busy men that we have derived our most precious lessons in caring for patients rather than disease, in the art of medicine rather than medical science—and their practical lessons have been valuable long after the fine-spun theories of the scientist that took so long to elaborate have been placed definitely in the lumber room.

His reputation as a writer on medical topics is not as great as that which has been accorded him for his writings on philosophy and in Talmudic literature, but he well deserves a place among the great practical masters of medicine, as well as high rank among the physicians of his time. There is little that is original in his writing, but his thoroughgoing common sense, his wide knowledge, and his discriminating, eclectic faculty make his writings of special value. As might have been expected, the Aphorisms of Hippocrates attracted his attention, and, besides, he wrote a series of aphorisms of his own. The most interesting of his writings, however, is a series of letters on dietetics written for the son of his patron Saladin. The young prince seems to have suffered from one of the neurotic conditions that so often develop in those who have their lives all planned for them, and little incentive to do things for themselves. The main portion of his complaints centred, as in the case of many another individual of leisure, in disturbances of digestion. Besides, he suffered from constipation and feelings of depression. Doubtless, like many a young person of the modern time, he was quite sure that these symptoms portended some insidious organic ailment that would surely bring an early death. When fathers, having done all that there is to do, just expect their sons to enjoy the fruits of the paternal accomplishments, conditions of this kind very often develop, unless the young man proceeds to occupy himself with even more dangerous distractions than he finds in unending thought about his own feelings.

The rules of life and health that Maimonides laid down in these letters have become part of our popular medical tradition. Probably more of the ordinarily current maxims as to health have been derived from them than would possibly be suspected by anyone not familiar with them. In various forms his rules have been published a number of times. A good idea of them can be obtained from the following compendium of them, which I abbreviate from a biographical sketch of Maimonides by Dr. Oppler, which appeared in the "Deutsches Archiv für Geschichte der Medizin und Medicinische Geographie" (Bd. 2, Leipzig, 1879).

1. Man is bound to lead a life pleasing to God if he wants to have a healthy body, and he must hold himself far from everything that can hurt his health and accustom himself to whatever renews his strength. He should eat and drink only when hungry and thirsty and should be particularly careful of the regular evacuation of his bowels and of his bladder. He must not delay either of these operations, but as far as possible satisfy the inclination at once.

2. A man must not overload his stomach but be content always with something less than is necessary to make him feel quite satisfied. He should not drink much during the meal and only of water and wine mixed, taking somewhat more after digestion has begun and after digestion is completed, in moderation according to his needs. Before a man sits down to table he should note whether he has any tendency to evacuation and should make the body warm by movement and activity. After this exercise he should rest a little before taking food. It is very beneficial after work to take a bath and then the meal.

3. Food should be taken always in the sitting position. There should be no riding nor walking, nor movements of the body until digestion is finished. The man who takes a walk or any strenuous occupation immediately after eating subjects himself to serious dangers of disease.

4. Day and night should be divided into twenty-four hours. Men should sleep for eight hours, and so arrange their sleep that the end of it comes with the dawn, so that from the beginning of sleep until sunrise there should be an eight-hour interval. We should all leave our beds about the time that the sun rises.

5. During sleep a man should lie neither on his face nor on his back but on his side, the beginning of the night on his left and at the end on his right. He should not go to sleep for three or four hours after eating and should not sleep during the day.

6. Fruits that are laxative, as grapes, figs, melons, gourds, should be taken only before meal time and not mixed with other food. It would be better to let these get into the abdominal organs and then take other food.

7. Eat what is easily digestible before what is difficult of digestion. The flesh of birds before beef and the flesh of calves before that of cows and steers. (Birds were then thought more digestible than other flesh; we have reversed the ruling. The note shows how light and digestible their flesh was considered and the reason therefor.)

8. In summer eat cooling food, acids, and no spices. In winter, on the contrary, eat warming foods, rich in spices, mustard, and other heating substances. In cold and warm climates one should eat according to the climatic conditions.

9. There are certain harmful foods that should be avoided. Large salt fish, old cheese, old pickled meat, young new wine, evil-smelling and bitter foods are often poisonous. There are also some which are less harmful, but are not to be recommended as ordinary nutritive materials. Large fish, cheese, milk more than twenty-four hours after milking, the flesh of old oxen, beans, peas, unleavened bread, sauerkraut, onions, radishes and the like. These are to be taken only in small quantities and only in the winter time and they should be avoided in the summer. Beans and lentils are to be recommended neither in winter nor summer.

10. As a rule one should avoid the eating of tree fruits, or not eat much of them, especially when they are dry and even less when they are green. If they are unripe they may cause serious damage. Johannesbrod is very harmful at all times, as are also all the sour fruits, and only small amounts of them should be eaten in summer or in warm countries.

11. The fruits that are to be recommended dry as well as fresh, are figs, grapes, and almonds. These may be eaten as one has the appetite for them, but one should not accustom himself to eat them much, though they are healthier than all other fruits.

12. Honey and wine are not good for children, though they are beneficial for older people, especially in winter. In summer one-third less of them should be eaten than in winter.

13. Special care should be taken to have regular movements of the bowels that carry off the impurities of the body. It is an axiom in medicine, that so long as evacuations are absent, or difficult, or require strong efforts, the individual is liable to serious disease. Every medical means should be taken to overcome constipation in order to escape its dangers. For this purpose young people should be given salty food, materials that have been soaked in olive oil, salt itself, or certain vegetable soups with olive oil and salt. Older people should take honey mixed with warm water early in the morning and four hours later should take their breakfast. This proceeding should be followed up from one to four days until the constipation is overcome.

14. Another axiom of medicine is that so long as a man is able to be active and vigorous, does not eat until he is over-full, and does not suffer from constipation, he is not liable to disease. Even such men, however, are much safer if they do not take food that may disagree with them.

15. Whoever gives himself up to inactivity, or puts off evacuations of the bowels, or suffers from constipation, will be sure to suffer from many diseases and will see his strength disappear even should he eat the best food in the world and make use of all the remedies that physicians have. Immoderate eating is a poison for men and the cause of many diseases which attack them. Most diseases come from either eating too much or partaking of unsuitable food. That was what Solomon meant with his proverb: "He who puts a guard over his mouth and his tongue protects himself from many evils," that is to say, whoever protects his mouth from the overindulgence in food and his tongue from unsuitable speech protects himself from many evils.

16. Every week at least a man should take a warm bath. One should not bathe when hungry, nor after eating until the food is digested, and bathe the whole body in warm but not too hot water and the head in hot water. Afterwards the body should be washed in lukewarm and cool water until finally cold water is used. One should pour neither cold nor even lukewarm water on the head, nor bathe in cold water in the winter time, nor when the body is tired and in perspiration. At such times the bath should be put off for a while.

17. As soon as one leaves the bath one should cover oneself, and especially cover the head, so that no draught may strike it. Even in summer, care must be taken to observe this rule. After this one should rest for a while until the heat of the body passes off and then should go to table. If one could sleep a little just before a meal it is often very beneficial. Neither during the bath nor immediately after it should cold water be drunk, and if there is an inappeasable thirst a little wine and water or water and honey should be taken. In winter it is beneficial to rub the body with oil after the bath.

18. Venesection should not be practised frequently, for it is only meant for serious illness. It should not be permitted in winter or summer, nor during the months of April or September (the "r" months). After passing his fiftieth year an individual should abstain from venesection. Venesection should not be practised on the day when one takes a bath or goes on a journey or returns from it. On the day when it is practised less than usual should be eaten and drunk, and the patient should give himself to rest, undertake no work nor bothersome occupation, and take no walk.

19. Whoever observes these rules of life faithfully I guarantee him a long life without disease. He shall reach a good old age, and when he comes to die will not need a physician. His body will remain always strong and healthy, unless of course he has been born with a weak nature, or has had an unfortunate bringing up, or should be attacked by epidemic disease or by famine.

20. Only the healthy should keep these rules. Whoever is ill or a sufferer from any injuries, or has lost his health through bad habits, for him there are special rules for each disease, only to be found in the medical books. Let it be remembered that every change in a life habit is the beginning of an ailment.

21. If no physician can be secured, then ailing people may use these rules as well as the healthy.

These rules are, of course, full of the common sense of medicine that endures at all times. For the tropical climate of the Eastern countries they probably represent as good advice as could be given even at the present time. With them before us it is not surprising to find that on other subjects Maimonides was just as sensible. Perhaps in nothing is this more striking than in his complete rejection of astrology. Considering how long astrology, in the sense of the doctrine of the stars influencing human health and destinies, had dominated men's minds, and how universal was the acceptance of it, Maimonides' strong expressions show how much genius lifts itself above the popular persuasions of its time, even among the educated, and how much it anticipates subsequent knowledge.

It is well to remind ourselves that as late as the middle of the eighteenth century Mesmer's thesis on "The Influence of the Stars on Human Constitutions" was accepted by the faculty of the University of Vienna as a satisfactory evidence not only of his knowledge of medicine, but of his power to reason about it. At the end of the twelfth century Maimonides was trying to argue it out of existence on the best possible grounds. "Know, my masters," he writes, "that no man should believe anything that is not attested by one of these three sanctions:—rational proof as in mathematical science, the perception of the senses, or traditions from the prophets and learned men." His biographer in the monograph "Maimonides," published by the Jewish Publication Society of America[5], expresses his further views on the subject in compendious form, and then gives his final conclusion as follows:

"'Works on astrology are the product of fools, who mistook vanity for wisdom. Men are inclined to believe whatever is written in a book, especially if the book be ancient; and in olden times disaster befell Israel because men devoted themselves to such idolatry instead of practising the arts of martial defence and government.' He says, that he had himself studied every extant astrological treatise, and had convinced himself that none deserved to be called scientific. Maimonides then proceeds to distinguish between astrology and astronomy, in the latter of which lies true and necessary wisdom. He ridicules the supposition that the fate of man could be dependent on the constellations, and urges that such a theory robs life of purpose, and makes man a slave of destiny. 'It is true,' he concludes, 'that you may find strange utterances in the Rabbinical literature which imply a belief in the potency of the stars at a man's nativity, but no one is justified in surrendering his own rational opinions because this or that sage erred, or because an allegorical remark is expressed literally. A man must never cast his own judgment behind him; the eyes are set in front, not in the back.'"

While Maimonides could be so positive in his opinions with regard to a subject on which he felt competent to say something, he was extremely modest with regard to many of the great problems of medicine. He often uses the expression in his writings, "I do not see how to explain this matter." He quotes with approval from a Rabbi of old who had counselled his students, "teach thy tongue to say, I do not know." In this, of course, he has given the best possible evidence of his largeness of mind and his capacity for making advance in knowledge. It is when men are ready to say, "I do not know," that progress becomes possible. It is very easy to rest in a conscious or unconscious pretence of knowledge that obscures the real question at issue. A great thinker, who lived in the century in which Maimonides died, Roger Bacon, set down as one of the four principal obstacles to advance in knowledge indeed, as the one of the four that hampered intellectual progress the most, the fact that men feared to say, "I do not know."

One of the most interesting features of Maimonides' career for the modern time is the influence that his writings exerted over the rising intellectual life of Europe within a half century after his death. Most people would be rather inclined to think that this Jewish author of the East would have very little influence over the thinkers and teachers of Europe within a generation after his death. He died in 1204, just at the beginning of one of the great productive centuries of humanity, perhaps one of the greatest of them all. In literature, in art, in architecture, in philosophy, and in education, this century made wonderful strides. Two of its greatest teachers, Albertus Magnus and his pupil, Thomas Aquinas, quote from Moses Ægyptæus, the European name for Maimonides at that time, and evidently knew his writings very well. Maimonides was for them an important connecting link with the world of old Greek thought. Others of the writers and teachers of this time, as William of Auvergne, and the two great Franciscans, Alexander of Hales and Duns Scotus, were also influenced by Maimonides. In a word, the educational world of that time was much more closely united than we might think, and it did not take long for a great writer's thoughts to make themselves felt several thousand miles away. Maimonides was, then, in his own time one of the world teachers, and, in a certain sense, he must always remain that, as representing a special development of what is best in human nature.

V
GREAT ARABIAN PHYSICIANS

In order to understand the place of the Arabs in medicine and in science, a few words as to the rise of this people to political power, and then to the cultivation of literature and of science, are necessary. We hear of the Arabs as hireling soldiers fighting for others during the centuries just after Christ, and especially in connection with the story of the famous Queen Zenobia at Palmyra. After the destruction of this city we hear nothing more of them until the time of Mohammed. During these six and a half centuries there is little question of education of any kind among them except that at the end of the sixth century, the Persian King Chosroes I, who was much interested in medicine, encouraged the medical school in Djondisabour, in Arabistan, founded at the end of the fifth century by the Nestorian Christians, who continued as the teachers there until it became one of the most important schools of the East. It was here that the first Arab physicians were trained, and here that the Christian physicians who practised medicine among the Arabs were educated.

Among the Arabs themselves, before the time of Mohammed, there had been very little interest in medicine. Gurlt notes that even the physician of the Prophet himself was, according to tradition, a Christian. Mohammed's immediate successors were not interested in education, and their people mainly turned to Christian and Jewish physicians for whatever medical treatment they needed. When the Caliphs came to be rulers of the Mohammedan Empire, they took special pains to encourage the study of philosophy and medicine; though dissection was forbidden by the Koran, most of the other medical sciences, and especially botany and all the therapeutic arts, were seriously cultivated.

Until the coming of Mohammed, the Arabs had been wandering tribes, getting some fame as hireling soldiers, but now, under the influence of a feeling of community in religion, and led by the military genius of some of Mohammed's successors, whose soldiers were inspired by the religious feelings of the sect, they made great conquests. The Mohammedan Empire extended from India to Spain within a century after Mohammed's death. Carthage was taken and destroyed, Constantinople was threatened. In 661, scarcely forty years after the hegira or flight of Mohammed, from which good Mohammedans date their era, the capital was transferred from Medina to Damascus, to be transferred from here to Bagdad just about a century later, where it remained until the Mongols made an end of the Abbasside rulers about the middle of the thirteenth century. At the beginning the followers of Mohammed were opposed to knowledge and education of all kinds. Mohammed himself had but little. According to tradition, he could not read or write. The story told with regard to the Caliph Omar and the great library of Alexandria, seems to have a foundation in reality, though such legends usually are not to be taken literally. Certainly it represents the traditional view as to the attitude of the earlier Moslem rulers to education. Omar was asked what should be done with the more than two million volumes. He said that the books in it either agreed with the Koran, or they did not. If they agreed with it they were quite useless. If they did not, they were pernicious. In either case, they should be done away with, because there was an element of danger in them. Accordingly, the precious volumes that had been accumulating for nearly ten centuries, served, it is said, to heat the baths of Alexandria for some six months—probably the most precious fuel ever used. Fortunately for posterity, the edict was not quite as universal in its application as the story would indicate, and exceptions were made for books of science.

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

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

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

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

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

RHAZES

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

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

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

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

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

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

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

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

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

ALI ABBAS

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

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

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

MOORISH PHYSICIANS

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

ABULCASIS

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

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

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

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

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

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

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

AVICENNA

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

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

AVENZOAR

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

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

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

AVERROËS

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

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

ARABIAN INFLUENCE

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

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

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

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

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

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

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

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

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

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

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

VI
THE MEDICAL SCHOOL AT SALERNO

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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