Medieval Medicine

One very interesting contribution to medical literature that comes to us from Salerno bears the title “The Coming of a Physician to His Patient, or an Instruction for the Physician Himself.” It illustrates very well the practical nature of the teaching of Salerno, and gives a rather vivid picture of the medical customs of the time. The instruction as to the conduct of the physician when he first comes into the house and is brought to the patient runs as follows:

“When the doctor enters the dwelling of his patient, he should not appear haughty, nor covetous, but should greet with kindly, modest demeanour those who are present, and then seating himself near the sick man accept the drink which is offered him [sic], and praise in a few words the beauty of the neighbourhood, the situation of the house, and the well-known generosity of the family—if it should seem to him suitable to do so. The patient should be put at his ease before the examination begins, and the pulse should be felt deliberately and carefully. The fingers should be kept on the pulse at least until the hundredth beat in order to judge of its kind and character; the friends standing round will be all the more impressed because of the delay, and the physician’s words will be received with just that much more attention.”

The rest of the advice smacks rather more of sophistication than we care to think of in a professional man, but its display of a profound knowledge of human nature makes it interesting.

“On the way to see the sick person he (the physician) should question the messenger who has summoned him upon the circumstances and the conditions of the illness of the patient; then, if not able to make any positive diagnosis after examining the pulse and the urine, he will at least excite the patient’s astonishment by his accurate knowledge of the symptoms of the disease, and thus win his confidence.”

Salerno taught as well as it could the science of medicine, and initiated great advances in surgery; but it also emphasized the art of medicine, and recognized very clearly that the personality of the physician counted for a great deal, and that his influence upon his patients must be fostered quite as sedulously as his knowledge of the resources of medicine for their ills.

CHAPTER IV

MONTPELLIER AND MEDICAL EDUCATION IN THE WEST

After Salerno the next great medical school was that of Montpellier in the South of France. The conditions which brought about its original establishment are very like those which occasioned the foundation of Salerno. Montpellier, situated not far from the Mediterranean, came to be a health resort. Patients flocked to it from many countries of the West of Europe; physicians settled there because patients were numerous, and medical instruction came to be offered to students. Fame came to the school. The fundamental reason for this striking development of the intellectual life seems to have been that Montpellier was not far from Marseilles, which had been a Greek colony originally and continued to be under Greek influence for many centuries. As a consequence of this the artistic and intellectual life of the southern part of France was higher during the earlier Middle Ages than that of any other part of Europe, except certain portions of South Italy. The remains of the magnificent architecture of the Roman period are well known, and Provence has always been famous for its intellectual and literary life. Among a people who were in this environment, we might well look for an early renaissance of education.

It is not surprising, then, that one of the earliest of the medical schools of modern history around which there gradually developed a university should have come into existence in this part of the world. What is even more interesting perhaps for us, is that this medical school has persisted down to our own day, and has always been, for nearly ten centuries now, a centre of excellent medical education.

There gathered around the story of its origin such legends as were noted with regard to the history of Salerno, and there is no doubt that Jewish and Moorish physicians who became professors there contributed not a little to the prestige of the school and the reputation that it acquired throughout Europe. The attempt to attribute all of the stimulus for the intellectual life at Montpellier to these foreign elements is, however, simply due to that paradoxical state of mind which has so often tried to minimize the value of Christian contributions to science and the intellectual life, even by the exaggeration of the significance of what came from foreign and un-Christian sources. Proper recognition must be accorded to both Jewish and Moorish factors at Montpellier, but the one important element is that these foreign professors brought with them, even though always in rather far-fetched translations, the ideas of the great Greek masters of medicine to which the region and the people around Montpellier were particularly sensitive, because of the Greek elements in the population, and hence the development of a significant centre of education here.

The date of the rise of the medical school at Montpellier is, as suggested by Puschmann, veiled in the obscurity of tradition. There seems to be no doubt that it goes back to as early as the tenth century, it was already famous in the eleventh, and it attracted students from all over Europe during the twelfth century. When Bishop Adalbert of Mainz came thither in 1137, the school possessed buildings of its own, as we learn from the words of a contemporary, Bishop Anselm of Havelberg. St. Bernard in a letter written in 1153 tells that the Archbishop of Lyons, being ill, repaired to Montpellier to be under the treatment of the physicians there. Perhaps the most interesting feature of this letter is the fact that the good Archbishop not only spent what money he had with him on physicians, but ran into debt.

The two schools, Salerno and Montpellier, came to be mentioned by writers of the period as representing the twins of medical learning of the time. John of Salisbury, a writer of the early thirteenth century, declares that those who wished to devote themselves to medicine at this time went either to Salerno or Montpellier. Ægidius or Gilles de Corbeil, the well-known physician, and Hartmann von der Aue, the Meistersinger, both mention Salerno and Montpellier, usually in association, in their writings, and make it very clear that in the West at least the two names had come to be almost invariably connected as representing rival medical schools of about equal prominence.

The reputation of Montpellier spread in Italy also, however, and we have the best evidence for this from an incident that took place in Rome at the beginning of the thirteenth century, which is more fully dwelt on in the chapter on Medieval Hospitals. Pope Innocent III. wanted to create a model hospital at Rome, and made inquiries as to who would be best fitted to organize such an institution. He was told of the work of Guy or Guido of Montpellier, who was a member of the Order of the Holy Ghost and had made a great hospital at Montpellier. Accordingly Guy was summoned to Rome, and the establishment of the Santo Spirito Hospital was entrusted to him. It was on the model of this that a great many hospitals were founded throughout the world, for Pope Innocent insisted that every diocese in Christianity should have a hospital, and Bishops who came on formal visits to the Holy See were asked to inspect the Santo Spirito for guidance in their own diocesan hospital establishments. Many of the hospitals throughout the world came as a result to be hospitals of the Holy Ghost and this contribution alone of Montpellier to the medical world of the time was of great significance and must have added much to her prestige.

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HOLY GHOST HOSPITAL (LÜBECK)

From “The Thirteenth: Greatest of Centuries,” by J. J. Walsh

Montpellier, like Salerno, seems to have attracted students to its medical school from all over the world. There were undoubtedly many English there, and probably also Irish and Scotch, though the journey must have been much longer and more difficult to make than is that from America to Europe at the present time. Of course there came many from Spain and from North France and the Netherlands. The fact that a number of Italians went there before the close of the Middle Ages shows how deeply interested were the men of this time in knowledge for its own sake, and indicates that something of that internationality of culture which we are priding ourselves on at the present time, because our students from all countries go far afield for postgraduate work and there is an interchange of professors, existed at this period. In spite of the fact that books were only written by hand, the teaching of distinguished professors had a wide diffusion, and students were quite ready to go through the drudgery of making these handwritten copies of a favourite master’s work. They had plenty of common sense as well as powers of observation, and some of their writing is still of great practical value.

A number of men who are famous in the history of medicine made their medical studies at Montpellier in the twelfth and thirteenth centuries. Among them are Mondeville, who afterwards taught surgery at Paris; and Guy de Chauliac, who was a Papal Physician at Avignon and at the same time a professor at Montpellier, probably spending a certain number of weeks, or perhaps months, each year in the university town. Sketches of these men, and of other students and teachers at Montpellier who reached distinction in surgery, will be found in the chapter on Surgeons of the West of Europe. Some other distinguished Montpellierians deserve brief mention.

One of the distinguished professors at Montpellier was the well-known Arnold de Villanova, of whose name there are a number of variants, including even Rainaldus and Reginaldus. In 1285 he was already a famous physician, and was sent for to treat Peter III., King of Aragon, who was severely ill. In 1299 he was summoned on a consultation to the bedside of King Philip the Handsome (le Bel) at Paris. After this we hear of him in many places, as at the Court of Pope Benedict XI. at Rome, and in 1308 as the physician and friend of Pope Clement V. at Avignon. His writings were printed in a number of editions in the Renaissance time, Venice 1505, Lyons 1509, 1520, 1532, Basel 1585, and his medical and astronomical and chemical works in separate volumes at Lyons in 1586.

His aphorisms are well known, and used to be frequently quoted during the Middle Ages and afterwards, and some of them deserve to be remembered even at the present time. For instance, he said: “Where the veins and arteries are notably large, incision and deep cauterization should be avoided.” “When cauterization is to be done the direct cautery should be used; caustic applications are only suitable for very timid patients.” “The lips of a wound will glue together of themselves if there is no foreign substance between them, and in this way the natural appearance of the part will be preserved.” “In large wounds sutures should be used, and silk thread tied at short distances makes the best sutures.” “The infection of the dura mater is followed in most cases by death.” “A collection of pus is best dissolved by incision and cleaning out of the purulent material.” “To put off the opening of an abscess brings many dangers with it.” “In most cases of scrofula external applications are better than the use of the knife. Scrofulous patients always have other sources of infection within them, and so it does them no good to operate externally.” “Tranquil and pure air is the best friend for convalescents.”

Villanova advised that the bite of a mad dog should not be permitted to heal at once, but the wound should be enlarged and allowed to bleed freely, leeches and cups being used to encourage bleeding, and healing should not be permitted for forty days. He believed very thoroughly in drainage, and in the dilation of narrow fistulous openings. He describes anthrax or carbuncle, and has chapters on various painful conditions for which he employs the terms arthritis, sciatica, chiragra, podagra, and gonagra.

Villanova’s treatment of the subject of hernia shows how thoroughly conservative he was, and how careful were his observations. In young persons in recent hernias he advised immediate complete reposition of the contents of the sac, the bringing together of the hernial opening by means of adhesive plaster, above which a bandage was placed, and the patient should be put to bed with the feet and legs elevated and the head depressed for ten to fifteen days or more if necessary. He says that “there are some—especially surgeons—who claim that they can cure hernia by incision, and some others by means of a purse-string ligature, and still others by the cautery or by some cauterizing material [they manifestly had our complete catalogue of ‘fakes’ in the matter]; but I prefer not to mention these procedures, since I have seen many patients perish under them, and others brought into serious danger of death, and I do not think that the surgeon will acquire glory or an increase of his friends from such perilous procedures, and I do not approve their use.”

One of the important writers of Montpellier was Gilbertus Anglicus (Gilbert the Englishman), who is called in one of the old translations of Mesue Doctor Desideratissimus, which I suppose might be Anglicized “loveliest of doctors.” After his studies in England he went for graduate work to some of the famous foreign universities, and is named as a chancellor of Montpellier. His best-known work is his “Compendium Medicinæ,” which bore as its full title “The Compendium of Medicine of Gilbert the Englishman; useful not only to physicians, but to clergymen for the treatment of all and every disease.” Gurlt says that it contains little that is original, being a copy of Roger of Parma and Theodoric of Lucca, with a number of quotations from the Arabs, nearly all of whom Gilbert seems to have read with considerable attention. It is interesting to find that Gilbert was definitely of the opinion that cancer is incurable except by incision or cauterization. He declares that it yields to no medicine except surgery.

Another of the men whose names are connected with Montpellier was John of Gaddesden, often called Joannes Anglicus. He was a student of Merton College, and received his degree of doctor of medicine at Oxford. He studied afterwards at Montpellier and also at Paris, and settled down to practise in London. He treated the son of King Edward II. for smallpox, and having wrapped him in red cloth and made all the hangings of his bed red, so that the patient was completely surrounded by this colour, he declared that he made “a good cure, and I cured him without any vestiges of the pocks.” The treatment is interesting, as an anticipation in a certain way of Finsen’s red light treatment for smallpox in our own time. Hanging the room, and especially the doors and the windows, with red when smallpox was to be treated was a favourite treatment down at Montpellier. Gaddesden’s book is called by the somewhat fanciful name “Rosa Anglica.” Bernard Gordon of Montpellier had written a “Lilium Medicinæ,” and we have a “Flos Medicinæ” from Salerno, so that flower names for medical textbooks were evidently the fashion of the time.

Gaddesden’s book is almost entirely a compilation, and except in the relation of his surgical experience, contains little that is new. Guy de Chauliac was quite impatient with it, and declared that “lately there had arisen a foolish Anglican rose which was sent to me and I looked it over. I expected to find the odour of sweetness in it, but I found only some old fables.” The criticism is, however, as Gurlt remarks, too severe and not quite justified, representing rather Guy’s high ideal of the originality that a new textbook should possess, than a legitimate critical opinion. If our own textbooks were to be judged by any such lofty standard, most of them would suffer rather severely.

Another of the well-known teachers at Montpellier was Valesco de Taranta. There are the usual variants of his name, his first name being written also Balesco, and his last name sometimes Tharanta. He was a Portuguese who studied in Lisbon, and later in Montpellier, where he taught afterwards and was considered one of the distinguished professors of his day, being for a time chancellor. He became so well known that he was summoned in consultation to the French King Charles VI., and there is some doubt as to whether he did not become his regular physician. One of his works, the “Philonium Pharmaceuticum et Chirurgicum de medendis omnibus, cum internis tum externis, humani corporis affectionibus,” had the honour of being printed at Lyons in two editions in 1490, and one at Venice the same year, at Lyons 1500, Venice 1502, Lyons 1516, 1521, 1532, 1535, Venice 1589, and Lyons 1599. It has also been reprinted subsequently in a number of editions, so that it must have been a much-read book. Valesco had two favourite authors, Galen and Guy de Chauliac. The fact that he should have appreciated two such great men so thoroughly is of itself the best evidence of his own ability and critical judgment. His book, from the number of printed editions, must have been in the hands of practically all the progressive physicians of the southern part of France, at least during the fifteenth, sixteenth, and part of the seventeenth centuries.

A very well-known teacher of Montpellier, who has had a reputation in English-speaking countries because his name was supposed to indicate that he was a Scotchman, was Bernard Gordon or de Gordon, whose name is, however, also written Gourdon. He was a teacher at Montpellier at the end of the thirteenth and the beginning of the fourteenth century. His textbook of medicine, in accordance with the custom of the time, is called by the flowery title “Lilium Medicinæ,” the Lily of Medicine. While much of his information was derived from the Arabs, some of his teaching was an advance on theirs, and he described the acute fevers, leprosy, scabies, anthrax, as well as erysipelas, and still more strangely phthisis, as contagious. Dr. Garrison has called attention in his “History of Medicine” to the fact that the book is notable as containing the first description of a modern truss, and a very early mention of spectacles under the Latin name oculus berellinus. In recent years it has come to be the custom to think of Gordon or Gourdon as probably not of Scotch but of French origin—that is, born somewhere in the confines of what we now call France. There are a number of French places of the name of Gourdon from any of which he might have come.

Montpellier represented for the West of Europe then very nearly what Salerno did for Italy and Eastern Europe. It very probably attracted many of the English and Scotch students of medicine, though not all the names supposed to be of British origin have proved to be so with the development of our knowledge. Montpellier has survived, however, while Salerno disappeared as a force in medical education. Its story would well deserve telling in detail, and doubtless the new national spirit of the French after the war will prove an incentive to the writing of it.

CHAPTER V

LATER MEDIEVAL MEDICINE

Medicine in the later Middle Ages, that is, from the tenth to the middle of the fifteenth centuries, was greatly influenced by the medical schools which arose in Italy and the West of Europe during this period. These were organized mainly in connection with universities, Salerno, Montpellier, Bologna, Paris, Padua, in the order of their foundations, so far as they can be ascertained. These university medical schools represented serious scientific teaching in medicine, and certainly were not more prone to accept absurdities of therapeutics and other phases of supposed medical knowledge than have been the universities of any other corresponding period of time. Five centuries represent a very long interval in the history of humanity, and provide opportunities for a great many curious developments and ups and downs of interest, all of which must not be considered as representing any particular generation or even century in the history of that time. The absurdities came and went quite as in more modern times; but all the while there was an undercurrent of solid medical knowledge, founded on observation and definite clinical research, superadded to the information obtained from the classics of medicine.

Even as early as the tenth century the thoroughly conservative teaching of Salerno in medicine made itself felt, and above all counteracted the Oriental tendencies to over-refinement of drugging, which had led to the so-called calendar prescription. This was the most noteworthy element in the medical practice of the later Middle Ages, but its significance has been dwelt on in the chapter on Salerno and the Beginnings of Medical History. While Arabic polypharmacy is the most striking feature of Mohammedan influence on medicine at this time, there were a number of Arabian and Jewish physicians who made a deep impression on the medicine of the later Middle Ages—that is, subsequent to the tenth century. Their work was felt not only in their own time, but for many subsequent centuries even down to and beyond the Renaissance, and they therefore must find a place in medieval medical history. This influence was exerted ever so much more outside of Italy than in the Italian peninsula, where the tradition of their contact with the original Greek authors still remained, and where they were making medicine and surgery for themselves quite apart from Arabian influence.

The more one knows about the conditions in Italian medicine the less question is there of Arabian contributions to it. De Renzi in his History of Italian Medicine makes it very clear that the Arabs exercised no significant influence either at Salerno or elsewhere. The Benedictines and Cassiodorus afford evidence of the study of the Greek medical classics in Latin translations. Muratori cites a manuscript which he had consulted in the Medicean Library at Florence, and which, though written between the eighth and ninth centuries, says not a word of the Arabs and bears the title of “Abstracts from Hippocrates, Galen, Oribasius, Heliodorus, Asclepiades, Archigenes, Dioclis, Amyntas, Apollonius, Nymphiodorus, Ruffius, Ephesinus, Soranus, Ægineta, and Palladius.” These and not the Arabs were the masters of the Italians, and it was fortunate, for the world was thus saved many Arabian mistakes and their tendency to neglect surgery. Before Salerno began to exert its real influence, some of the Arabian physicians came to occupy places of prominence in the medicine of the time.

The most important of these was Avicenna, born toward the end of the tenth century in the Persian province of Chorasan, at the height of Arabian influence. He is sometimes spoken of as the Arabian Galen. His famous book, “The Canon,” was the most consulted medical book throughout Europe for centuries. There are very few subjects in medicine that did not receive suggestive treatment at his hands. He has definite information with regard to Bubonic plague and the filaria medinensis. He has special chapters with regard to obesity, emaciation, and general constitutional conditions. He has chapters on cosmetics and on affections of the hair and nails that are interesting reading. The Renaissance scholars wrote many commentaries on his work, and for long after the introduction of printing his influence was felt widely.

His Arabic colleague in the West was Avenzoar, to call him by the transformation of his Arabic family name, Ibn-Zohr. He was born near Seville, and probably died there, in 1162, well past ninety years of age. He was the teacher of Averröes, who always speaks of him with great respect. He is interesting as probably the first to suggest nutrition per rectum. His apparatus for the purpose consisted of the bladder of a goat with a silver cannula fastened into its neck. Having first carefully washed out the rectum with cleansing and purifying clysters, he injected the nutriment—eggs, milk, and gruel—into the gut. His idea was that the intestine would take this and, as he said, suck it up, carrying it back to the stomach, where it would be digested.

The bladders of animals were very commonly used by these Moorish physicians and by their disciples, and the profession generally, for generations, for a great many purposes for which we now use rubber bags. Abulcasis, for instance, used a sheep’s bladder introduced into the vagina and filled with air as a colpeurynter for supporting the organs in the neighbourhood, and also in fractures of the pubic arch.