that Rhazes' most important work for pure medicine is his monograph on
smallpox. Its principal value is due to the fact that, though he has
consulted old authorities carefully, his discussion of the disease is
founded almost entirely on his own experience. His description of the
various stages of the disease, of the forms of the eruption, and of the
differential diagnosis, is very accurate. He compares the course of the
fever with that of other fevers, and brings out exactly what constitutes
the disease. His suggestions as to prognosis are excellent. Those cases,
he declares, are particularly serious in which the eruption takes on a
dark, or greenish, or violet color. The prognosis is also unfavorable
for those cases which, having considerable fever, have only a slight
amount of rash. His treatment of the disease in young persons was by
venesection and cool douches. Cold water and acid drinks should be
administered freely, so that sweat and other excretions may carry off
poisonous materials. Care must be taken to watch the pulse, the
breathing, the appearance of the feet, the evacuations from the bowels,
and to modify therapy in accordance with these indications. The eruption
is to be encouraged by external warmth and special care must be taken
with regard to complications in the eyes, the ears, the nose, the mouth,
and the pharynx.
A fact that will, perhaps, give the best idea to modern readers of the
place of Rhazes in the history of medicine is that Vesalius considered
it worth his while to make a translation of his principal work.
Unfortunately that translation has not come down to us. When Vesalius,
pestered by the controversies that had come upon him because of his
venturing to make his observations for himself, accepted the post of
physician to the Emperor Charles V, he burnt a number of his
manuscripts. Among these were his translation of Rhazes and some
annotations on Galen, which, as he says himself, had grown into a huge
volume. The Galenists were bitterly decrying his refusal to accept Galen
on many points, and both of these works would have added fuel to the
flame of controversy. He deemed it wiser, then, not to give any further
opportunities for rancorous criticism, and, feeling presumably that in
his new and important post it was not worth while to bother further over
the matter, he burnt them. He tells the reason in his letters to Joachin
Roelant: "When I was about to leave Italy to go to Court, since a number
of the physicians whom you know had made the worst kind of censure of
my books, both to the Emperor himself, and to other rulers, I burned
all the manuscripts that were left, although I had never suffered a
moment under the displeasure of the Emperor because of these complaints,
and in spite of the fact that a number of friends who were present urged
me not to destroy them."
Vesalius' translation of Rhazes was probably undertaken because he
recognized in him a kindred spirit of original investigation and
inquiry, whose work, because it was many centuries old, would command
the weight of an authority and at the same time help in the controversy
over Galenic questions. This, of itself, would be quite enough to make
the reputation of Rhazes, even if we did not know from the writings
themselves and from the admiration of many distinguished men as well as
the incentive that his works have so often proved to original
observation, that he is an important link in the chain of observers in
medicine, who, though we would naturally expect them to be so frequent,
are really so rare.
ALI ABBAS
Rhazes lived well on into the tenth century. His successor in prestige,
though not his serious rival, was Ali Ben el-Abbas, usually spoken of in
medical literature as Ali Abbas, a distinguished Arabian physician who
died near the end of the tenth century. He wrote a book on medicine
which, because of its dedication to the Sultan, to whom he was
body-physician, is known as the "Liber Regius," or "Royal Book of
Medicine." This became the leading text-book of medicine for the Arabs
until replaced by the "Canon of Avicenna" some two centuries later. The
"Liber Regius" was an extremely practical work and, like most of the
Arabian books of the early times, is simple and direct, quite without
many of the objectionable features that developed later in Arabian
medicine. It is valuable mainly for its contributions to diet and the
fact that Ali Abbas tested many of his medicines on ailing animals
before applying them to men. Of course, it owes much to earlier writers
on medicine, and especially to Paul of AEgina.
An example of its practical value is to be found in his description of
the treatment of a wound of the brachial artery, when, as happened often
in venesection from the median basilic vein, it was injured through
carelessness or inadvertence. If astringent or cauterizing methods do
not stop the bleeding, the artery should be exposed, carefully isolated,
tied in two places above and below the wound, and then cut across
between them. He has many similar practical bits of technique. For
instance, in pulling a back tooth he recommends that the gums be incised
so as to loosen them around the roots, and then the tooth itself may be
drawn with a special forceps which he calls a molar forceps. In ascites
he recommends that when other means fail an opening should be made three
finger-breadths below the navel with a pointed phlebotomy knife, and a
portion of the fluid allowed to evacuate itself. A tube should then be
inserted, but closed. The next day more of the fluid should be allowed
to come away, and then the tube removed and the abdomen wrapped with a
firm bandage.
It is easy to understand that Ali Abbas' book should have been popular,
and the more we know of it the easier it is to explain why Constantine
Africanus should have selected it for translation. It contains ten
theoretic and ten practical books, and gives an excellent idea of the
medical knowledge and medical practice of the time. Probably the fact
that Constantine had translated it led to its early printing, so that we
have an edition of it published at Venice in 1492, and another at Lyons
in 1523. During the Middle Ages the book was often spoken of as "Regalis
Dispositio," the "Royal Disposition of Medicine."
MOORISH PHYSICIANS
After Rhazes, the most important contributors to medical literature from
among the Arabs, with the single exception of Avicenna, were born in
Spain. They are Albucasis or Abulcasis, the surgeon; Avenzoar, the
physician, and Averroes, the philosophic theorist in medicine. Besides,
it may be recalled here that Maimonides, the great Jewish physician, was
born and educated at Cordova, in Spain. It might very well be a surprise
that these distinguished men among the Arabs should have flourished in
Spain, so far from the original seat of Arabian and Mohammedan dominion
in the East, where, owing to conditions in the modern time, the
English-speaking world particularly is not likely to assume that the
environment was favorable for the development of science and
philosophy. Anyone who recalls, however, the history of Spanish
intellectual influence in the Roman Empire, as we have traced it at the
beginning of this chapter, will appreciate how favorable conditions were
in Spain for the fostering of intellectual development. With the
disturbances that had come from political strife and the invasion of the
barbarians in Italy, Spain had undoubtedly come to hold the primacy in
the intellectual life of Europe at the time when the Arabs took
possession of the peninsula.
ABULCASIS
The most important of the Arabian surgeons of the Middle Ages is
Albucasis or Abulcasis, also Abulkasim, who was born near Cordova, in
Spain. The exact year of his birth is not known, but he flourished in
the second half of the tenth century. He is said to have lived to the
age of 101. The name of his principal work, which embraces the whole of
medicine, is "Altasrif," or "Tesrif," which has been translated "The
Miscellany." Most of what he has to say about medical matters is taken
from Rhazes. His work on surgery, however, in three books, represents
his special contribution to the medical sciences. It contains a number
of illustrations of instruments, and is the first illustrated medical
book that has come to us. It was translated into Latin, and was studied
very faithfully by all the surgeons of the Middle Ages. Guy de Chauliac
has quoted Albucasis about two hundred times in his "Chirurgia Magna."
Even as late as the beginning of the sixteenth century Fabricius de
Acquapendente, the teacher of Harvey, confessed that he owed most to
three great medical writers, Celsus (first century), Paul of AEgina
(seventh century), and Abulcasis (tenth century).
Abulcasis insisted that for successful surgery a detailed knowledge of
anatomy was, above all, necessary. He said that the reason why surgery
had declined in his day was that physicians did not know their anatomy.
The art of medicine, he added further, required much time.
Unfortunately, to quote Hippocrates, there are many who are physicians
in name only, and not in fact, especially in what regards surgery. He
gives some examples of surgical mistakes made by his professional
brethren that were particularly called to his attention. They are the
perennially familiar instances of ignorance causing death because
surgeons were tempted to operate too extensively.
His description of the procedure necessary to stop an artery from
bleeding is an interesting example of his method of teaching the
practical technique of surgery. Apply the finger promptly upon the
opening of the vessel and press until the blood is arrested. Having
heated a cautery of the appropriate size, take the finger away rapidly
and touch the cautery at once to the end of the artery until the blood
stops. If the spurting blood should cool the cautery, take another.
There should be several ready for the purpose. Take care, he says, not
to cauterize the nerves in the neighborhood, for this will add a new
ailment to the patient's affection. There are only four ways of
arresting arterial hemorrhage. First, by cautery; second, by division
of the artery, when that is not complete--for then the extremities
contract and the blood clots--or by a ligature, or by the application of
substances which arrest blood flow, aided by a compressive bandage.
Other means are inefficient, and seldom and, at most, accidentally
successful. His instruction for first aid to the injured in case of
hemorrhage in the absence of the physician, is to apply pressure
directly upon the wound itself.
The development of the surgical specialties among the Arabs is
particularly interesting. Abulcasis has much to say about nasal polyps.
He divided them into three classes: (1) cancerous, (2) those with a
number of feet, and (3) those that are soft and not living,--these
latter, he says, are neither malignant nor difficult to treat. He
recommends the use of a hook for their removal, or a snare for those
that cannot be removed with that instrument. His instructions for the
removal of objects from the external ear are interestingly practical. He
advises the use of bird lime on the end of a sound to which objects will
cling, or, where they are smaller, suction through a silver or copper
canula. Hooks and pincettes are also suggested. Insects should be
removed with a hook, or with a canula, or, having been killed by warm
oil, removed by means of a syringe. Some of his observations with regard
to genito-urinary surgery are quite as interesting. He even treated
congenital anomalies. He suggests cutting of the meatus when narrowed,
dilatation of strictures with lead sounds, and even suggests plans of
operations to improve the condition in hypospadias. He gives the signs
for differentiation between epitheliomata and condylomata, and
distinguishes various forms of ulceration of the penis.
Abulcasis discusses varicose veins in very much the same spirit as a
modern surgeon does. They occur particularly in people who work much on
their feet, and especially who have to carry heavy burdens. They should
not be operated on unless they produce great discomfort, and make it
impossible for the sufferer to make his living. They may be operated on
by means of incision or extirpation. Incision consists of cutting the
veins at two or three places when they have been made prominent by means
of tight bandages around the limb. The blood should be allowed to flow
freely out of the cut ends, and then a bandage applied. For extirpation,
the skin having been shaved beforehand, the vein should be made
prominent, and then carefully laid bare. When freed from all adhesions,
it should be lifted out on a hook, and either completely extirpated or
several rather long pieces removed. He lays a good deal of stress on the
necessity for freeing the vein thoroughly and lifting it well out of
tissues before incising it. In old cases special care must be taken not
to tear the vein.
Minute details of technique are often found in these old authors.
Abulcasis, for instance, treats of adherent fingers with up-to-date
completeness. They can occur either congenitally or from injury, as, for
instance, burning. They should be separated, and then separation
maintained by means of bandages or by the insertion between them of a
thin lead plate, which prevents their readhesion. Adhesions of the
fingers with the palm of the hand, which Abulcasis has also seen,
should be treated the same way.
At times there is surprise at finding some rare lesion treated with
modern technique, and a hint at least of our modern apparatus. Fracture
of the pubic arch, for instance, is described in Abulcasis quite as if
he had had definite experience with it. When this occurs in a woman, the
reposition of the bone is often greatly facilitated by a cotton tampon
in the vagina. This tampon must be removed at every urination. There is
another way, however, of better securing the same purpose of
counterpressure. One may take a sheep's bladder into the orifice of
which a tube is fastened. One should introduce the bladder into the
vagina, and then blow strongly through the tube, until the bladder
becomes swollen and fills up the vaginal cavity. The fracture will, as a
rule, then be readily reduced. Here is, of course, not alone the first
hint of the colpeurynter, but a very practical form of the apparatus
complete. Old-time physicians used the bladders of animals very
generally for nearly all the medical purposes for which we now use
rubber bags.
AVICENNA
Undoubtedly the most important of Abulcasis' contemporaries is the
famous physician whose Arabic name, Ibn Sina, was transformed into
Avicenna. He was born toward the end of the tenth century in the Persian
province of Chorasan, at the height of Arabian influence, and is
sometimes spoken of as the chief representative of Arabian medicine, of
as much importance for it as Galen for later Greek medicine. His
principal book is the so-called "Canon." It replaced the compendium
"Continens" of Rhazes, and, in the East, continued until the end of the
fifteenth century to be looked upon as the most complete and best system
of medicine. Avicenna came to be better known in the West than any of
the other Arabian writers, and his name carried great weight with it.
There are very few subjects in medicine that did not receive suggestive,
if not always adequate, treatment at the hands of this great Arabian
medical thinker of the eleventh century. He copied freely from his
predecessors, but completed their work with his own observations and
conclusions. One of his chapters is devoted to leprosy alone. He has
definite information with regard to bubonic plague and the _filaria
medinensis_. Here and there one finds striking anticipations of what are
supposed to be modern observations. Nothing was too small for his
notice. One portion of the fourth book is on cosmetics, in which he
treats the affections of the hair and of the nails. He has special
chapters with regard to obesity, emaciation, and general constitutional
conditions. His book, the "Antidotarium," is the foundation of our
knowledge of the drug-giving of his time.
Some idea of the popularity and influence of Avicenna, five centuries
after his time, can be readily derived from the number of commentaries
on him issued during the Renaissance period by the most distinguished
medical scholars and writers of that time. Hyrtl, in his "Das Arabische
und Hebraeische in der Anatomie," quotes some of them,--Bartholomaeus de
Varignana, Gentilis de Fulgineis, Jacobus de Partibus, Didacus Lopez,
Jacobus de Forlivio, Ugo Senesis, Dinus de Garbo, Matthaeus de Gradibus,
Nicolaus Leonicenus, Thaddaeus Florentinus, Galeatus de Sancta Sophia. A
more complete list, with the titles of the books, may be found in
Haller's "Bibliotheca Anatomica." For over three centuries after the
foundation of medical schools in Europe (and even after Mondino's book
had been widely distributed), Avicenna was still in the hands of all
those who had an enthusiasm for medical science.
AVENZOAR
Another of the distinguished Arabian physicians was Avenzoar--the
transformation of his Arabic family name, Ibn-Zohr. He was probably born
in Penaflor, not far from Seville. He died in Seville in 1162 at the
age, it is said, of ninety-two years. He was the son of a physician
descended from a family of scholars, jurists, physicians, and officials.
He received the best education of the time not only in internal
medicine, but in all the specialties, and must be counted among the
greatest of the Spanish Arabian physicians. He was the teacher of
Averroes, who always speaks of him with great respect. He is interesting
as probably being the first to suggest nutrition _per rectum_. A few
words of his description show how well he knew the technique. His
apparatus for the purpose consisted of the bladder of a goat or some
similar animal structure, with a silver canula fastened into its neck,
to be used about as we use a fountain syringe. Having first carefully
washed out the rectum with cleansing and purifying clysters, he injected
the nutriment--eggs, milk, and gruels--into the gut. His idea was that
the intestine would take this, and, as he said, suck it up, carrying it
back to the stomach, where it would be digested. He was sure that he had
seen his patients benefited by it.
Some light on his studies of cases that would require such treatment may
be obtained from what he has to say about the handling of a case of
stricture of the esophagus. He says that this begins with some
discomfort, and then some difficulty of swallowing, which is gradually
and continuously increased until finally there comes complete
impossibility of swallowing. It was in these cases that he suggested
rectal alimentation, but he went farther than this, and treated the
stricture of the esophagus itself.
The first step in this treatment is that a canula of silver or tin
should be inserted through the mouth and pushed down the throat till its
head meets an obstruction, always being withdrawn when there is a
vomiting movement, until it becomes engaged in the stricture. Then
_freshly milked_ milk, or gruel made from farina or barley, should be
poured through it. He says that in these cases the patient might be put
in a warm milk or gruel bath, since there are some physicians who
believe that through the lower parts of the body, and also through the
pores of the whole body, nutrition might be taken up. While he considers
that this latter method should be tried in suitable cases, he has not
very much faith in it, and says that the reasons urged for it are weak
and rather frivolous. It is easy to understand that a man who has
reached the place in medicine where he can recommend manipulative
treatments of this kind, and discuss nutritional modes so rationally,
knew his practical medicine well, and wrote of it judiciously.
AVERROES
Among the distinguished contributors to medicine at this time, though
more a philosopher than a physician, is the famous Averroes, whose full
Arabic name among his contemporaries was Abul-Welid Mohammed Ben Ahmed
Ibn Roschd el-Maliki. Like Avenzoar, of whom he was the intimate
personal friend, and Abulcasis and Maimonides, he was born in the south
of Spain. He was in high favor with the King of Morocco and of Spain,
El-Mansur Jacub, often known as Almansor, who made him one of his
counsellors. His works are much more important for philosophy than for
medicine, and his philosophical writings gave him a place only second to
that of Aristotle in the Western world during the Middle Ages. Averroism
is still a subject of at least academic interest, and Renan's monograph
on it and its author was one of the popular books of the latter half of
the nineteenth century in philosophic circles. In spite of his
friendship with the Moorish King and with Avenzoar, he fell under the
suspicion of free thinking and was brought to trial with a number of
personal friends, who occupied high positions in the Moorish
government. He escaped with his life, but only after great risks, and he
was banished to a suburb of Cordova, in which only Jews were allowed to
live. By personal influence he succeeded in securing the pardon of
himself and friends, and then was summoned to the court of the son and
successor of El-Mansur in Morocco. He died, not long after, in 1198.
Altogether there are some thirty-three works of Averroes on philosophy
and science. Only three of these are concerned with medicine. One is the
"Colliget," so-called, containing seven books, on anatomy, physiology,
pathology, diagnostics, materia medica, hygiene, and therapy. Then there
is a commentary on the "Cantica of Avicenna," and a tractate on the
"Theriac." Averroes' idea in writing about medicine was to apply his
particular system of philosophy to medical science. His intimate
relations with other great physicians of the time, and in particular his
close friendship with Avenzoar, enabled him to get abundant medical
information in faultless order so far as knowledge then went, but his
theoretic speculations, instead of helping medicine, as he thought they
would, and as philosophers have always been inclined to think as regards
their theoretic contributions, were not only not of value, but to some
extent at least hindered human progress by diverting men from the field
of observation to that of speculation. It is interesting to realize that
Averroes did in his time what Descartes did many centuries later, and
many another brilliant thinker has done before and since.
ARABIAN INFLUENCE
The fame of these great thinkers and writers in philosophy and in
medicine came to be known not only through the distribution of their
books long after their death, but during their lifetime, and in
immediately subsequent generations, ardent seekers after knowledge, who
were themselves afterwards to become famous by their teaching and
writing, found their way into the Arabian dominions in order to take
advantage of the educational opportunities afforded. These were better
than they could secure at home in Christian countries, because the
process of bringing culture and devotion to literature and science into
the minds of the Northern nations, who had replaced the old Romans in
Europe, was not yet completed. Bagdad and Cordova were the two favorite
places of educational pilgrimage. The names that are most familiar among
the scholars in the Middle Ages in Europe are those of whom it is
recorded that they made long journeys in order to get in touch with what
the Arabs had preserved of the old Greek civilization and culture. Among
them are such men as Michael Scot or Scotus, Matthew Platearius, who was
afterwards a great teacher at Salerno; Daniel Morley, Adelard of Bath,
Egidius, otherwise known as Gilles de Corbeil; Romoaldus, Gerbert of
Auvergne, who later became Pope under the name of Sylvester II; Gerard
of Cremona, and the best known of them all, at least in medicine,
Constantine Africanus, whose wanderings, however, were probably not
limited to Arabian lands, but who seems also to have been in Hindustan.