Chapter 9

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

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

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

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

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

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

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

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

ALI ABBAS

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