Popular Science Monthly/Volume 85/November 1914/Arabian and Medieval Surgery
|ARABIAN AND MEDIEVAL SURGERY
By Dr. JOHN FOOTE
WASHINGTON, D. C.
AFTER the conquest of Alexandria, when the victorious Mohammedans were feeding the fires of the city baths with the priceless treasures of the Alexandrian library, a young man who had been a student at the now dismantled university was writing a medical work, the sixth volume of which dealt with surgery. Little work has been done by the Byzantine authors other than the copying of preceding works which might otherwise be lost to us, and the works of Oribasius and Ætius on surgery and the medical writings of Alexander of Tralles have little more than their Greek contact to commend them. But the work of Paul, called from his birthplace, Paul of Ægina, was more than a mere copy. The rough, untutored Arabs who conquered Asia Minor, were not long in being, in turn, conquered by Greek culture and Greek science. Rapidly as this was assimilated, it is well to remember that an important text-book on surgery had been written by one of the conquered before the Hellenization of the Arab had taken place. Gurlt considers this a momentous work, and it describes among other things original treatment for foreign bodies in the esophagus, the operation for tracheotomy, and has an article on hernia. Of course this surgeon had an operation for the radical cure, which included peritoneal suture and drainage in its technique. Paul devised a gynecological speculum, was credited with special knowledge of women's diseases, and indeed was known as "The obstetritician."
The Nestorian monks had christianized many Arabs and these Christian Arabs figure most prominently in the first period of Arabian medicine as both translators and practitioners. The Bachtischua family, the name being derived from Bocht Jesu, servant of Jesus, had several illustrious members, the first, George, being physician to the caliph El Mansur at Bagdad, and his son, as well as his grandson Gabriel, serving Haroun' al Raschid in a like capacity. This physician claimed to have received over $10,000,000 in fees, and the largest single fee on record, $125,000, is credited to him. Perhaps the best known writers of this period were Serapion, the Elder, who lived during the ninth century, and Honein Ben Ischak, or Johannitius, whose accurate translations of the old authors caused him to be called the Erasmus of the Arabian renaissance. Serapion describes an operation for stone in the kidney in which an incision is made in the groin and the pelvis incised and explored. He did a ligation operation for hemorrhoids, wrote in detail on the use of the catheter, and considered the suprapubic opening of the bladder for stone a simple procedure if we can believe him.
The Jewish physicians are important figures in this period of the history of medicine. Many of their scholars attained distinction as surgeons and writers; the best known of these, Maimonides, or Moses Ægyptius, was surgeon to Saladin and lived in the twelfth century. Spain, the rich Roman province which had produced Lucan, the Senecas, Martial and Quintillian, did not entirely lose its traditions of culture after the barbarians from the north fell upon it, and the Moors, hungry for knowledge, came to a feast of which they were soon the masters.
The most distinguished Arabian surgical writer of the ninth century was Rhazes, a Persian by birth, who was a singer until he was thirty. He was a follower of Aristotle and Galen and wrote some 200 works, including a complete system of medicine and surgery. He treated fractures with intelligence and discussed the treatment of wounds of the intestine. Vesalius thought so well of his principal work that he translated it, but later destroyed the translation. Ali Abbas, who succeeded Rhazes in prestige, wrote a book, the Liber Regis, dedicated to his patron the Sultan. This was the leading Arabian textbook until the Canons of Avicenna appeared. A method of ligating the median basilic vein in troublesome hemorrhage after venessection is described, as well as the technique of tapping the peritoneal cavity in ascites. This work was translated by Constantine, and printed in Venice in 1492.
Albucasis, a Spanish Moor, born, like Maimonides, near Cordova, was probably the greatest of the Arabian surgeons. He lived in the second half of the tenth century, and is reputed to have attained the age of 101. While his writings cover the entire field of medical knowledge, his three volumes on surgery are most original, and are the first illustrated surgical writings that have come down to us. Fabricius, Harvey's teacher, declared that he owed most of his knowledge to three writers, Celsus, Paul of Ægina and Albucasis. Albucasis emphasized the importance to the surgeon of a knowledge of anatomy. In discussing the treatment of hemorrhage he advises the use of the cautery, complete division of the partially severed artery, hemostatic applications and bandaging. He classifies nasal polyps, advises the snare for their removal, has ingenious methods for removing foreign bodies from the ear, makes some advances in genito-urinary surgery, and differentiates between epitheliomata and condylomata. He talks of the extirpation of varicose veins, but wisely says this operation should not be resorted to unless absolutely necessary. He diagnoses fracture of the pubic arch, and when it occurs in the female he advises a vaginal tampon of wool, or of a blown up sheep's bladder. Avicenna, the author of the "Canons," was a medical rather than a surgical writer, and his text-book was used for nearly five centuries after it was written.
Bagdad and Cordova had now become the destination of many a European scholar. The number of anatomical terms of Arabian origin translated into Latin, according to Hyrtl, is surprising, and this more especially in view of his assertion that "the Arabs paid very little attention to anatomy, and, of course, because of the prohibition of the Koran, added nothing to it." He continues:
Whatever they knew they took from the Greeks and from Galen. . . . They delighted in theory rather than practise.
This is a terse summing up of the general influence of Arabian medicine. Taken as a whole, the Arabs were copyists and dialecticians; by their very virtues of erudition and scholarship they impressed upon their medieval successors the supremity of Galenical tradition rather than the desire for anatomical and bedside inquiry into the cause of disease.
Constantine Africanus, who was first a traveler and a student, next a professor in the University of Salerno, and finally a Benedictine monk in the great abbey of Monte Cassino, is the connecting link between Arabian and western medicine. His familiarity with oriental languages, and his connection later with the great Benedictine order celebrated for its libraries and zeal in copying books, gave him unique opportunities for the translation and circulation of his medical writings. He was born at Carthage early in the eleventh century, and died near its close. After his travels he acted as physician and secretary to Duke Robert of Salerno, and was made professor of medicine at the university. After teaching for ten years he retired to the monastery, obtaining there both the quiet and the material assistance which he needed in order to pass his heritage of knowledge on to succeeding generations. The "Liber Pantegni," a translation of Ali-Ben-el Abbas, as well as certain works of Hippocrates and Galen, were among his best-known books. His original work is better known through the writings of his students Afflacius, Bartholemew and numerous others.
In view of this it is a seeming contradiction to have Gurlt assert that the surgery of the Salernitian school was not a continuation of Arabian surgery and that the surgeons of Salerno were not influenced by the Arabian commentators. Yet he cites Roger's writings in evidence, and declares that such authorities as are quoted come directly from the Greek, while a good portion of the work rests on the writer's own experiences.
Contrary to popular belief, surgery at this time was not an unlearned profession, for there were many surgeons connected with the early universities. The degradation of the surgeon comes later in the middle ages. The greatest surgical teacher of the early thirteenth century was Roger, who wrote about 1180. His work was annotated by his pupil Poland, and the work of both edited later by the Four Masters. Gurlt says of the latter:
This volume constitutes one of the most important sources for the history of surgery in the later Middle Ages, and makes it very clear that these writers drew their opinions from a very rich experience.
Their diagnosis of fractures of the skull is quite modern, subdural hemorrhage is described, and the technique is given for a decompression operation for depressed fractures, the old writers saying:
In elevating the cranium, be solicitous lest you infect the dura mater.
Suturing with silk, and drainage, are recommended for scalp wounds, and the prognosis of infected wounds is considered at length. The surgeon was told that he must keep his hands clean and that he must especially avoid not only menstruating women, but all women, if he would operate successfully.
Bruno da Longoburgo, Theodoric, Hugo of Lucca, and William of Salicet are a famous group of North Italian surgeons of this period. Mondino, the author of the first book on dissection, Lanfranc, who taught at Paris, and, in the words of Pagel, "gave that primacy to French surgery which it maintained all the centuries down to the nineteenth/' as well as de Mondeville and Guy de Chauliac, belong to the early fourteenth century.
Hugo of Lucca and his son Theodoric used opium and mandragora to produce anesthesia, and also used a mixture to be inhaled from a sponge, the composition of which is not definitely known. Fifteen great universities arose in Italy from the tenth to the fourteenth centuries, and in all of these surgery was taught. Bruno was the first of the Italian surgeons to quote Arabian as well as Greek authorities. He worked at the universities of Vicenza, Padua and Verona. His "Chirurgia Magna" was completed at Padua in 1252. He insisted that surgery was largely handwork, and must therefore be learned from practical experience and observation. He sums up three important offices of surgery as: "to bring together separated parts, to separate those abnormally united and to extirpate what is superfluous." He discusses wounds, healing by first and second intention, indications for suturing and for drainage. He advised against the use of water in wounds, especially the water in camps and battlefields. Wounds of the intestine he directed to be cleansed with warm wine and closed with fine silk sutures.
Hugh of Lucca was city physician to Bologna, and his writings were edited by his son Theodoric. Theodoric studied medicine, entered the Dominican order at the age of 23, but continued to practise surgery in Bologna, devoting his fees to charity. At 50 he was made a bishop. In his text-book, finished about 1226, he says:
All wounds should be treated only with wine and bandaging.
He emphasized the importance of diet in assisting in wound repair, warned against the wounding of nerves, and suggests bringing ends of cut nerves in proximity to favor repair. It is surprising to find these old surgeons writing of union by first intention, and insisting on cleanliness and antiseptic dressings, such as strong wine. With regard to their treatment of wounds, Professor Allbutt, of Oxford, undoubtedly our greatest English authority on the history of medicine, writes as follows:
They washed the wounds with wine, scrupulously removing every foreign particle; then they brought the edges together, not allowing wine nor anything else to remain within—dry adhesive surfaces were their desire. Nature, they said, produces the means of union in a viscous exudation, or natural balm, as it was afterwards called by Pare and Wurtz. In older wounds they did their best to secure union by cleansing, desiccation and refreshing of the edges. Upon the outer surface they laid lint steeped in wine. Powders they regarded as too desiccating, for powder shuts in decomposing matters; wine, after washing, purifying and drying the raw surface, evaporates.
Theodoric was six centuries in advance of his time when he wrote:
For it is not necessary, as Roger and Roland have written, and as many of their disciples teach, and as all modern surgeons profess, that pus should be generated in wounds. No error can be greater than this. Such a practise is indeed to hinder nature, to prolong the disease, and to prevent the conglutination and consolidation of the wound.
Theodoric, like our present-day surgeons, was proud of his small and beautiful scars produced without using salves "Pulcherrias cicatrices sine unguento aliquo inducebat," while poultices, oils and powders on wounds, he said, incarcerated foul material, "saniem incarcerare," evidence enough that this writer knew not only the art, but also the fundamental principles of good surgery.
William of Salicet passed his early life at Bologna, and later was municipal and hospital physician to Verona. Being himself both a physician and a surgeon, he believed that these two branches of medicine should not be separated. In his book he quotes previous authorities less than his predecessors, and he condemns the abuse of the cautery popularized by Arabian writings, and advocates the use of the knife. He describes operations for the relief of hydrocephalus, various eye conditions, nasal polypi and tumors of the mouth. He relates the history of a tumor, probably an epulis, larger than a hen's egg, which he removed from the gums of the upper jaw, and says that he performed the operation in four steps, the last being the resection of a portion of the jaw bone. He did not hesitate to operate on cystic goiter, but he describes the large veins encountered in certain types of goiter and he warns against hemorrhage from them.
Lanfranc practised at Milan until his banishment about 1290. He then practised at Lyons, and later taught at Paris, where he attracted great numbers of students by his fame as a teacher and an operator. He completed his "Chirurgia Magna" in 1296. Ten years later he died, but meanwhile he had transferred the center of the surgical world from Italy to France. Lanfranc was probably the first surgeon to absolutely distinguish between nerve and tendon, and he was the first to advocate and practise nerve suture.
Henry de Mondeville, or Henricus, was a Norman, little known until modern times. The first printed edition of his book was edited by Professor Pagel, in Berlin, in 1892. Mondeville was a scholar and a traveler. Born in France, he studied under Theodoric in Italy, and later at Montpellier and Paris. He afterwards lectured in both of these universities. He was a very busy man—a teacher, a consultant and one of the physicians to King Philip le Bel. We see in him the not unfamiliar picture of the famous surgeon trying to make time for his writing. He died before he was forty of some lung disease—probably tuberculosis. He sketched the earlier chapters of his work on his sick bed, but wrote the practical portion at length in the last chapter so that his students might profit by his experience. He was a shining example of the wide culture and erudition of the university-trained surgeon of his day, quoting, as he did, not only from the Latin, Greek and Arabian authorities on medicine, but also from Cato, Diogenes, Horace, Ovid, Plato, Seneca and other classics not popularly known until the Renaissance. Mondeville used a large magnet to extract portions of iron from tissues, and invented an instrument for extracting barbed arrows from the flesh. He wrote intelligently on the nursing problem, and spoke of the difficulties to the surgeon when wives nursed their husbands. A chapter on the history of surgery is a novel feature of his book. He was one of the first, if not the very first, to use illustrations in teaching anatomy.
Yperman, who was sent by the town of his name in Belgium to Paris in order to learn surgery, fulfilled his mission, and returning to his native town, practised and wrote two books on surgery in Flemish. John Ardern, an Englishman, studied at Montpellier, and, returning to England, practised and wrote on surgery. The "Practica" is a comprehensive work by this English surgeon, containing many case histories. He was a skillful operator, especially famed as a proctologist, and was the first surgeon to collect careful statistics of his eases. His book is illustrated, and he writes on what we now recognize as appendicitis under the title "Against Colic and the Iliac Passion." Ardern was the first great English surgeon.
We are inclined to deny to the middle ages anything approaching our tolerance of thought in the domain of education. The idea of coeducation, and women in the learned professions, would seem to be essentially modern. Coeducation was tried in the middle ages and found wanting, and women taught in the medieval universities, and were eminent as physicians, gynecologists and obstetricians. Salerno admitted women to the study of medicine, and women's diseases were taught entirely by women teachers. The most famous of these was Trotula, said to have been the wife of one of the professors. She wrote two books, the most important one being called "Trotula's Wonderful Book of Experience in the Diseases of Women, Before, During and After Labor, with All Other Details Likewise Eelating to Labor." Prenatal care, nursing and the care of mother and child during the puerperium are considered. In the chapter on the perineum a description is given of a complete tear, together with directions for a radical cure in which sutures with silk thread are employed. This author writes:
The woman is then placed in bed with the feet elevated, and must remain in that position even for eating and drinking and all the necessaries of life, for eight or nine days. During this period, also, there should be even no bathing, and care must be taken to avoid everything that might cause coughing, and all indigestible material.
All students of obstetrics might read with profit her directions for care of the perineum during labor. She says:
In order to avoid the aforesaid danger, care should be taken. . . somewhat as follows: a cloth should be folded somewhat in oblong shape and placed on the anus, so that, during every effort for the expulsion of the child, that should be pressed firmly in order that there may not be any solution of the continuity of tissue.
Her works were printed at Strassburg in 1544, and in Leipsig as late as 1778. Nicaise, Chauliac's biographer, says:
Women continued to practise medicine in Italy for centuries, and the names of some who attained great renown have been preserved to us. Their works are still quoted from in the fifteenth century. . . .
Chauliac criticized women surgeons of his day for being too timid in taking chances, and refusing to operate on dangerous cases. There were at least seven women professors at Salerno who wrote works that have survived. One of these, Mercuriade, was a surgeon, and wrote "On the Cure of Wounds." Another one, Abella, wrote "On the Nature, of Seminal Fluid" and "Black Bile." Rebecca Guarna wrote on "Fevers," "The Urine" and "The Embryo."
The last great name in medieval surgery is Guy de Chauliac, that brilliant man who, both chronologically and in virtue of his methods, may be looked upon as the father of modern surgery, if indeed that distinction may be conferred upon any one individual. Born in southern France late in the thirteenth century, he was educated at Montpellier, and then journeyed down to Bologna in Italy, to do post-graduate work in surgery, finally finishing his studies in Paris. One of his teachers at Montpeliier was Bernard Gordon, author of "Lillium Medicinæ," and a fellow student was John of Gaddesden, the first English Royal Physician, who is mentioned by Chaucer in his "Doctor of Physic." Guy did not like John's Book, "Rosæ Angliæ" because it lacked originality and clung to authority unsupported by experience. At Bologna he studied under Bertruccius, and he relates how "very often" to quote his exact words, his master dissected dead bodies in four lessons. His attitude toward anatomical study is shown by his expression, "The surgeon ignorant of anatomy carves the human body as a blind man carves wood." He practised first in his native province, later in Lyons, and finally was physician and chamberlain to three successive popes at Avignon. He occupied the latter part of his life with writing his "Chirurgia Magna," his "Solatium senectutis," he called it. Nicaise emphasizes the freshness and originality of Guy's viewpoint, and quotes him concerning the surgeons of his own and preceding generations as follows:
One thing is especially a source of annoyance to me, in what these surgeons have written, and it is that they follow one another like so many cranes. For one always says what the other says. I do not know whether it is from fear or from love that they do not deign to listen except to such things as they have been accustomed to, and as have been proven by authorities. They have to my mind understood very badly Aristotle's second book of metaphysics when he shows that these two things, fear and love, are the greatest obstacles on the road to the knowledge of the truth. Let them give up such friendships and such fears.
For while Socrates or Plato may be a friend, truth is a greater friend.
. . . Let them follow the doctrine of Galen which is entirely made up of experience and reason, and in which one investigates things and despises words.
In writing on surgery of the brain he records the loss of brain substance with recovery, and notes the recovery, under expectant treatment, of many patients with suspected fracture of the skull. His study of the surgical anatomy of the ribs and diaphragm as applied in opening the thorax, shows sound surgical sense. In wounds of the intestines he gives an unfavorable prognosis unless the abdomen be quickly opened and the wounds sewed up. He describes his sutures and his special needle-holder, like any modern surgeon. In his chapter on amputations he writes on the use of opium, morel, hyoscyamus, mandragora, ivy, hemlock and lettuce to abolish pain during operations, and also refers to inhalation anesthesia, from a sponge soaked in various sleep-producing drugs. Taxis and reduction in hernia were developed by him, and he invented several trusses. Many operations for hernia, he wrote, benefited the surgeon more than the patient. In strangulation he insisted upon immediate operation. He describes six hernia operations, and criticizes all of them, easily enough, since all of the operations at this time included removal of the testicle. He alludes to the use of gold wire, a forerunner of the silver wire of our day. His inventions for the reduction of fractures and dislocations were far in advance of his day and many of these cases were cared for in hospitals. Virchow has told us of the excellence of the hospitals in the thirteenth century, and of the good care given to the patients. How Chauliac and later generations of surgeons came to accept the doctrine of the formation of laudable pus in wound healing, when at this period surgical cleanliness, the use of antiseptic wine dressings, and the possibility of natural union by viscous exudate were written on and discussed, is difficult to understand. But even in Chauliac's time, surgery was becoming more and more divorced from medicine, and the surgeons were ceasing to be students.
Chauliac was a genius living in an age of remarkable achievement. Dante's "Divine Comedy" and Petrarch's sonnets were written in his lifetime. Boccaccio and Chaucer were of his day. Giotto was painting wonderful pictures, the great cathedrals were building and the universities were flourishing, and as Professor Huxley said in his rectorial address at Aberdeen, in 1847, "probably educating in the real sense of the word better than we do now." Portal in his "History of Anatomy and Surgery" says:
Finally, it may be averred that Guy de Chauliac said nearly everything which modern surgeons say, and that his work is of infinite price, but unfortunately too little read, too little pondered.
This obviously extravagant praise is not discounted by Albutt who writes:
This great work [the "Chirurgia Magna"] I have studied carefully and not without prejudice: yet I can not wonder that Fallopius compared the author to Hippocrates or that John Friend called him the Prince of Surgeons. It is rich, aphoristic, orderly and precise.
Decadence in surgery began after Chauliac's death. His successors seemed to think that they had little more to learn, and boasted, as each generation does, of their progress. Wars and political disturbances also came to distract men's minds, and study and achievement ebbed away from the standard set by Guy and his immediate predecessors, until the great flood tide of knowledge that came with the Renaissance.
Nuburger. Gesch. Medizen. Tr. by Playfair (London, 1911).
Walsh, Jas. J. Makers of Old Time Medicine (N. Y., 1911).
Garrison, F. H. History of Medicine (Philadelphia, 1914).
Original manuscripts, reprints and Aldine editions of the works of Arabian and medieval surgeons were loaned for reference and exhibition through the kindness of the Surgeon General's Library, U. S. A.
- Read before the Medical History Club of Washington, D. C, December 27, 1913.