 Preface and Chapter 1 of Old Time Makers of Medicine. This is a LibriVox recording. All LibriVox recordings are in the public domain. For more information or to volunteer, please visit LibriVox.org. Recording by Adam Marsatich, September 2009, Alexandria, Virginia. Old Time Makers of Medicine by James Joseph. 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 pretense 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 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, face 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 marvelous 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 Ladies' Day in Harvest, 1911 Chapter 1 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 accomplish, 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 Augustalis, 476, until the discovery of America. After that comes modern medicine, for with the 16th century, the names and achievements of the workers in medicine are familiar, Paracelsus, Vesalius, Columbus, Civetus, Eustaceus, Verolius, Silveus are men whose names are attached to great discoveries, with which even those who are without any pretense 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 condemn 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 the 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 a 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 not usually 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, Horus out of the Sabine farm, the Plaines out of the city, Terence in Africa, Perseus up in central Italy somewhere, Livy at Padua, Marchel Quintilian, the Seneca's, and Lucan in Spain. When the government of the city ceased to be such as a short opportunity for those from outside who wanted to make their way, decadence came to Roman literature. Most cities have never in history been the fruitful mothers of men who did great things. Genius, and even talent, had 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 to the Roman Empire to look towards Rome at this time, however, it seemed better to the early Christians to establish the center 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 the 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 had 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 troubulous 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 worthwhile 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 higher criticism became popular, to impugn the tradition as to St. Luke having been a physician. But this has all been undone, and Harnak'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 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 reestablish the old Roman-Olympian religion, wrote to Orbecius, 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. Nimesius, 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. Nimesius 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. Hurdle doubts that the passage in question should be made to signify as much as had 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 Aetius, whose career and works are treated more fully in the chapter on great physicians in early Christian times. He was followed by Alexander of Tralys, probably a Christian, for his brother was the architect of Santa Sophia, and by Paul of Aegina, 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 Saint Procopius the martyr, was, according to Carptovius, 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 nice Sirata, who practiced at Constantinople under Emperor Arcadius. It is said that, to her, Saint John Chrysostom owed the cure of a serious illness. From the very beginning, Christian women acted as nurses, and Deconesses were put in charge of hospitals. Fabiola, at Rome, is the founder 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 tranquility 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 conceited 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 Vusset, 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 Muhammad, 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 400 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 8th, 9th, and 10th 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 the 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 the 13th 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 10th 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 traveled 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 the 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 practice for oneself 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 practice 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 Grecia, 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 but a short time that of a series of schools in the north Italian universities, Padua, Pia Senza, 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. Juan Franck was the carrier of surgery, and many French students who went to Italy came back with Italian methods. In the 14th century, Guy de Choliac made the grand tour in Italy, and then came back to write a textbook of surgery that is one of the monuments in this department of medical science. Before his time, Montpelier had attracted attention, but now it came to be looked upon as a recognized center of great medical teaching. The absence of the popes from Italy and the influence of their present 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 marvelous development of surgery that took place in the 13th and 14th 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 anesthesia 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 anesthesia 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 setback 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 anesthesia, was marvelously 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 are called dentatories. Guy de Choliak'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 textbooks 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 toward 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 the 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 after the 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 worthwhile 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 fifteen hundred only seemed to them to prove the ignorance and the depth 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 now know 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 many 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. End of Chapter 1. Chapter 2 of Old Time Makers of Medicine. This is a LibriVox recording. All LibriVox recordings are in the public domain. For more information or to volunteer, please visit LibriVox.org. Recording by Adam Marsatich, September 2009, Alexandria, Virginia. Old Time Makers of Medicine by James Joseph. Chapter 2. Great Physicians in Early Christian Times. Part 1 of 3. 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 assistance 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 specially pointed out. Saint Basil, about the middle of the fourth century, erected what was spoken of as a city for the sick, before the gates of Caesarea. Gregory of Nazianon, his friend, says, quote, 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 entrusted to the care of doctors and nurses, end quote. 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 adopted 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 refer 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 Harnak has found among the text that illustrate the history of early Christian literature this one. Quote, 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. Harnak, 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. 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 Theodotus of Laudicia, Eusebius, Bishop of Rome, Basilios, Bishop of Ancyra, and at least one, Herakus, 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, Cosmus and Damien, 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. Combe 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 Pushman Volume 1, page 494, quote, when I took up the bishopress 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 practices 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, end quote. Distinguished Christian writers and scholars, and the fathers of the church in the early centuries, evidently paid much attention to medicine. Turtulian 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 de, has much to say with regard to the human body, as representing the necessity for design and creation. His teleological arguments have much more force now than they would have had for people generally 20 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. Asius, the first great Christian physician whose works meant much for his own time and whose writings have become a classic in medicine, was Asius Amidenus, that is, Asius of Amida, who was born in the town of that name in Mesopotamia, on the upper Tigris, now Deir Bekir, 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 a special post that was created for him at court by Alexander of Trolles, the second of the great Christian physicians. There is no doubt that Asius was a Christian, for he mentions Christian mysteries and appeals to the name of the Savior 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. Asius's work, that is preserved for us, is known in medical literature as his 16 books on medical practice. In most of the manuscript, it is divided into four tetrabibloids, or four book parts, each of which consists of four sections called logoi, in Greek, ceremonies 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. Asius 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, Grolf says that he treats this feature of the subject much more extensively, even than Paulus Agenetes, 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. Asias's 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 venisection, 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 Asias 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, girl has quoted the following expression, with regard to which most people will be quite readily to agree with him when he says that it contains a great deal of truth, usually thought to be of, much later origin. Quote, When, therefore, anyone 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 definite purpose of causing a large efflux of blood from the part. Then the wound should be deeply cauterized, etc. End quote. There are special chapters devoted to eye and ear diseases, and to various effectations of the face. Under this, the question of tattooing and its removal comes in. It is surprising how much Asias has with regard to such nasal effectations as polyps and ulcers and bleeding from the nose. In this book, however, he treats only of their medical treatment. What he has to say about effectations 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 mucus membranes of the gums, tongue, and mouth, and taught that the teeth receive 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 effections of the gums, and recognizes a benignant and malignant epulus. He thought that one form of epulus 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 they 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. Asius 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 fossils with the classic symptoms. The second presents no inflammation of the mouth nor of the fossils, 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 vertebrae, retro-pharyngeal abscesses 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, quote, drinks when taken are returned through the nose, end quote. Hypertrophy of the tonsils, Asias 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. End of Part 1 of 3 Chapter 2 of Old Time Makers of Medicine This is a LibriVox recording. All LibriVox recordings are in the public domain. For more information, or to volunteer, please visit LibriVox.org. Recording by Adam Marsatich, September 2009, Alexandria, Virginia, Old Time Makers of Medicine by James Joseph. Chapter 2, Part 2 of 3 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 pinchers and removed. If it is in the esophagus, Asius 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, Asius 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 seal, and though the name is common to them, they differ very much from one another. Some of them are fatty, some of them are pultatious, some of them are cancerous, and some of them he calls honey tumors, because of a honey-like humor that they contain. Quote, sometimes they are due to a local dilation 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 dilation at this point of the veins is incurable, but there are also hard tumors like cyrus 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 pultatious. The prognosis of goiterous tumors is much better than might be expected, but evidently Aecius 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. Aecius' treatment of the subject of varicositis is quite complete in its suggestions. Quote, the term varices, end quote, he says, quote, is applied to dilated veins, which occurs 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 coterie, end quote. Girl, in his history of surgery, calls attention to the fact that two of our modern methods of treating varicose veins are thus discussed in Aecius, that by ligation and that by the coterie. The coterie was applied over a space the breath of a finger at several points along the dilated veins. Aecius's chapters on obstetrics and gynecology are of special interest, because, while we are prone to think that gynecology particularly is a comparatively modern development of surgery, this surgical authority of the Middle Ages treats it rather exhaustively. His 16th book is for the most part, 111 chapters of it, devoted to these two subjects. He has a number of interesting details in the first 36 chapters with regard to conception, pregnancy, labor and lactation, which show how practical were the views of the physicians at the time. Girl has given us some details of his chapters on diseases of the breast. Aecius differentiates phageadenic and rodent ulcers in cancer. All of the ordinary forms of phageadenic 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 coterie, 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 varicocities, 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 be 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 Asius, gives a description of operation for the cancer of the breast, in which he insists particularly on the extensive removal of tissue and the free use of the coterie. Quote, the coterie 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 coterie freely, though the amputation of such a portion down to the healthy parts may suffice. End quote. Asius quotes this with approval. Others before Asius 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 Asius 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 mana 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 uterae, an operation for which is described, and of various tumors. He describes epithelemia 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. Asius 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. AP Lorry, in his Materials on the Printer's Craft, calls attention to the fact that the earliest reference to the use of drying oil for varnish is made by the physician Asius. Asius, or asios, 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 rewakening of clinical medicine in the 17th century, his reputation waxed again, and Bohorov declared that the works of Asius had as much importance for physicians as had the pandex of Justinian for lawyers. This high estimation had survived almost from the time of the Renaissance when Cornelius went so far as to say, quote, Believe me, that whoever is deeply desirous of studying things medical, if he would have the whole of Galen abbreviated, and the whole of Orabaceus extended, and the whole of Paulus, of Aegina, amplified, if he would have all the special remedies of the old physicians, as well in pharmacy, as in surgery, boiled down to a summer for all affections, he will find it in Asius, end quote. Naturally enough, this exaggerated estimation was followed by a reaction in which Asius 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 Trales An even more striking example than the life and work of Asius, as evidence for the encouragement and patronage of medicine in early Christian times, is to be found in the career of Alexander of Trales, 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 last 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, Dio Scoros, was also a successful physician. All together, four of his brothers reached such distinction in their life work, that their names have come down to us through nearly 1500 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 Metrodorus, 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, Dio Scoros, like Alexander, a physician, remained in his birthplace, Trellis, and acquired there a great practice. It was with his father at Trellis 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 practiced medicine successfully until a very old age. He was probably eighty years of age, when, sometime during the first decade of the seventh century, he died. Pushman, 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 Asias's writings is made, was written, according to Pushman, 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. End of Part Two of Three