In order to understand the place of the Arabs in medicine and in science, a few words as to the rise of this people to political power, and then to the cultivation of literature and of science, are necessary. We hear of the Arabs as hireling soldiers fighting for others during the centuries just after Christ, and especially in connection with the story of the famous Queen Zenobia at Palmyra. After the destruction of this city we hear nothing more of them until the time of Mohammed. During these six and a half centuries there is little question of education of any kind among them except that at the end of the sixth century, the Persian King Chosroes I, who was much interested in medicine, encouraged the medical school in Djondisabour, in Arabistan, founded at the end of the fifth century by the Nestorian Christians, who continued as the teachers there until it became one of the most important schools of the East. It was here that the first Arab physicians were trained, and here that the Christian physicians who practised medicine among the Arabs were educated.

Among the Arabs themselves, before the time of Mohammed, there had been very little interest in medicine. Gurlt notes that even the physician of the Prophet himself was, according to tradition, a Christian. Mohammed's immediate successors were not interested in education, and their people mainly turned to Christian and Jewish physicians for whatever medical treatment they needed. When the Caliphs came to be rulers of the Mohammedan Empire, they took special pains to encourage the study of philosophy and medicine; though dissection was forbidden by the Koran, most of the other medical sciences, and especially botany and all the therapeutic arts, were seriously cultivated.

Until the coming of Mohammed, the Arabs had been wandering tribes, getting some fame as hireling soldiers, but now, under the influence of a feeling of community in religion, and led by the military genius of some of Mohammed's successors, whose soldiers were inspired by the religious feelings of the sect, they made great conquests. The Mohammedan Empire extended from India to Spain within a century after Mohammed's death. Carthage was taken and destroyed, Constantinople was threatened. In 661, scarcely forty years after the hegira or flight of Mohammed, from which good Mohammedans date their era, the capital was transferred from Medina to Damascus, to be transferred from here to Bagdad just about a century later, where it remained until the Mongols made an end of the Abbasside rulers about the middle of the thirteenth century. At the beginning the followers of Mohammed were opposed to knowledge and education of all kinds. Mohammed himself had but little. According to tradition, he could not read or write. The story told with regard to the Caliph Omar and the great library of Alexandria, seems to have a foundation in reality, though such legends usually are not to be taken literally. Certainly it represents the traditional view as to the attitude of the earlier Moslem rulers to education. Omar was asked what should be done with the more than two million volumes. He said that the books in it either agreed with the Koran, or they did not. If they agreed with it they were quite useless. If they did not, they were pernicious. In either case, they should be done away with, because there was an element of danger in them. Accordingly, the precious volumes that had been accumulating for nearly ten centuries, served, it is said, to heat the baths of Alexandria for some six months—probably the most precious fuel ever used. Fortunately for posterity, the edict was not quite as universal in its application as the story would indicate, and exceptions were made for books of science.

In the course of their conquests, however, the Mohammedan Arabs captured the Greek cities of Asia Minor. They were brought closely in contact with Greek culture, Greek literature, and Greek thought. As has always been the case, captive Greece took its captors captive. What happened to the Romans earlier came to pass also among the Arabs. Inspired by Greek philosophy, science, and literature, they became ardent devotees of science and the arts. While not inventing or discovering anything new, like the Romans they carried on the old. Damascus, Basra, Bagdad, Bokhara, Samarcand all became centres of culture and of education. Large sums were paid for Greek manuscripts, and for translations from them. Under the famous Harun al-Raschid, at the end of the eighth century, whose name is better known to us than that of any others, because of the stories of his wandering by night among his people in order to see if justice were done, three hundred scholars were sent at the cost of the Caliph to the various parts of the world in order to bring back treasures of science, and especially of geography and medicine. It is an interesting historical reflection that the Japanese and Chinese are doing the same thing now.

The Arabs were very much taken by the philosophy of Aristotle, and it became the foundation of all their education. Greek thought, as always, inspired its students to higher things. Soon everywhere in the dominions of the Caliphs, philosophy, science, art, literature, and education nourished. Medicine was taken up with the other sciences and cultivated assiduously. Freind, in his "Historia MedicinÆ," says that the writings of the old Greeks which treated of medicine were saved from destruction with the other books at Alexandria, for the desire of health did not have less strength among the Arabs than among other nations. Since these books taught them how to preserve health, and were not otherwise contrary to the laws of the Prophet, that served to bring about their preservation. Freind also calls attention to the fact that grammars and books which treated of the science of language were likewise saved from destruction. Besides the library, the Arabs, after their conquest of Alexandria in the eighth century, came under the influence of the university still in existence there.

In the West, in Spain, the Arabs enjoyed the same advantages as regards contact with culture and education as their conquest of the Eastern cities and Alexandria brought them in the East. While it is not generally realized, Spain was, as we have pointed out, the province of the Roman Empire in the West that advanced most in culture before the breaking up of the Empire. The Silver Age of Latin literature owes all of its geniuses to Spain. Lucan, the Senecas, Martial, Quintilian, are all Spaniards. Spain itself was a most flourishing province, and under the Spanish CÆsars, from the end of the first to about the end of the second century, increased rapidly in population. Spain was the leader in these prosperous times, and the tradition of culture maintained itself. When Spain became Christian the first great Christian poet, Prudentius, born about the middle of the fourth century, came from there. He has been called the Horace and Virgil of the Christians.

The coming down of the barbarians from the North disturbed Spain's prosperity and the peace and culture of her inhabitants, but it should not be forgotten that the first medieval popularization of science, a sort of encyclopedia of knowledge, the first of its kind after that of Pliny in the classical period, came from St. Isidore of Seville, a Spanish bishop.

There has been considerable tendency to insist that Spanish culture and intellectuality owe nearly all to the presence of the Moors in Spain. This can only be urged, however, by those who know nothing at all of the Spanish CÆsars, the place of Spain in the history of the Roman Empire, and the continuance of the culture that then reached a climax of expression during succeeding centuries. On the contrary, the Moors who came to Spain owe most of their tendency to devote themselves to culture and education to the state of affairs existent in Spain when they came. There is no doubt that they raised standards of education and of culture above the level to which they had sunk under the weight of the invading barbarians from the North, and Spain owes much to the wise ruling and devotion to the intellectual life of her Moorish invaders. All the factors, however, must be taken together in order to appreciate properly the conditions which developed under the Arabs in both the East and the West. The Arabs invented little that was new in science or philosophy; they merely carried on older traditions. It is for that that the modern time owes them a great debt of gratitude.

RHAZES

The most distinguished of the Arabian physicians was the man whose rather lengthy Arabian name, beginning with Abu Bekr Mohammed, finished with el-Razi, and who has hence been usually referred to in the history of medicine as Rhazes. He was born about 850 at Raj, in the Province of Chorasan in Persia. He seems to have had a liberal early education in philosophy and in philology and literature. He did not take up medicine until later in life, and, according to tradition, supported himself as a singer until he was thirty years of age. Then he devoted himself to medical studies with the ardor and the success so often noted in those whose opportunity to study medicine has been delayed. His studies were made at Bagdad, where Ibn Zein el-Taberi was his teacher. He returned to his native town and was for some time the head of the hospital there. Later he was called by the Sultan to Bagdad to take charge of the renovated and enlarged hospital of the capital. His medical career, then, is not unlike that of many another successful physician, especially of the modern time. At Bagdad he had abundant opportunities for study, and the ambition to make medicine as well as to make money and gain fame.

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, AËtius, and Paul of Ægina. 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 ParÉ, 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 Ægina.

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 AverroËs, 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 Ægina (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 HebrÄische in der Anatomie," quotes some of them,—BartholomÆus de Varignana, Gentilis de Fulgineis, Jacobus de Partibus, Didacus Lopez, Jacobus de Forlivio, Ugo Senesis, Dinus de Garbo, MatthÆus de Gradibus, Nicolaus Leonicenus, ThaddÆus 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.

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 AverroËs, 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.

AVERROËS

Among the distinguished contributors to medicine at this time, though more a philosopher than a physician, is the famous AverroËs, 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 AverroËs 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." AverroËs' 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 AverroËs 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.

We are rather prone to think that this great spirit of going far afield for knowledge's sake is recent, or, at least, quite modern. As a matter of fact, one finds it everywhere in history. Long before Herodotus did his wanderings there were many visitors who went to Egypt, and many more later who went to Crete, and many more a few centuries later who went to the shores of Asia Minor seeking for the precious pearl of knowledge, and sometimes finding it without finding the even more precious pearl of wisdom, "whose worth is from the farthest coasts."

To the Arabs we owe the foundation of a series of institutions for the higher learning, like those which had existed around them in Asia Minor and in Egypt at the time they made their conquests. Alexandria, Pergamos, Cos, Cnidos, Tarsus, and many other Eastern cities had had what we would call at least academies, and many of them deserved the name of universities. The Arabs continued the tradition in education that they found, and established educational institutions which attracted wide attention. As we have said, the two most famous of these were at Bagdad and at Cordova. Mostanser, the predecessor of the last Caliph of the family of the Abbassides, built a handsome palace, in which the academy of Bagdad was housed. It is still in existence, and gives an excellent idea of the beneficent interest of this monarch and of other of the Abbasside rulers in education. Its fate at the present time is typical of the attitude of the Mohammedans towards education. Though the building is still standing, the institution of learning is no longer there. As Hyrtl remarks, it is not ideas that are exchanged in it now, but articles of commerce. It has become the chief office of the Turkish customs department in Bagdad.

These institutions of the higher learning, founded by the Arabs, at first as rather strict imitations of the museums or academies of Egypt and Asia Minor, gradually changed their character under the Arabs. Their courses became much more formal, examinations became much more important. Scholarship was sought not so much for its own sake, as because it led to positions in the civil service, to the favor of princes, and, in general, to reputation and pecuniary reward. Formal testimonials proclaiming education, signed by the academic authorities, were introduced and came to mean much. Lawyers could not practise without a license, physicians also required a license. These formalities were adopted by the Western medieval universities to a considerable degree and have been perpetuated in the modern time. Undoubtedly they did much to hamper real education among the Arabs by setting in place of the satisfaction of learning for its own sake and the commendation of teachers the formal recognition of a certain amount of work done as recognized by the educational authorities. There was always a tendency among the Arabs to formulate and formalize, to over-systematize what they were at; to think that new knowledge could be obtained simply by speculating over what was already acquired, and developing it. There are a number of comparisons between this and later periods of education that might be suggested if comparisons were not odious.

The influence of Arabian medicine on modern medicine can, perhaps, best be judged from the number of words in our modern nomenclature, which, though bearing Latin forms, often with suggestion of Greek origins, still are not derived from the old Latin or Greek authors, but represent Arabic terms translated into Latin during the Renaissance period. Hyrtl, without pretence of quoting them all, gives a list of these which is surprising in its comprehensiveness. For instance, the mediastinum, the sutura sagittalis, the scrobiculus cordis, the marsupium cordis, the chambers of the heart, the velum palati, the trochanter, the rima glottidis, the fontanelles, the alÆ of the nose, all have their present names, not from original Latin expressions, but from the translation of Arabic terms. For all such words the Greeks and Romans have quite other expressions, in which the sense of our modern terms is not contained. This has given rise to many misunderstandings, and to many attempts in the modern times to return to the classic terminology rather than preserve what in many cases are the barbarisms introduced through the Arabic, but it is doubtful whether any comprehensive reform in the matter can be effected, so strongly entrenched in medical usage have these terms now become.

Freind, in his "History of Medicine," already cited, calls attention to the fact that the Arabs had an unfortunate tendency to change by addition or subtraction of their own views the authors that they studied, and wished to translate to others. This seems to have been true even of some of the most distinguished of them. Of course, the idea of preserving an author's text untouched, and making it clear just where note and commentary came in, had not yet come to men's view, but quite apart from this the Arabs apparently often tried to gain acceptance for their own ideas by having them masquerade as the supposed ideas of favorite classic authors.

Another unfortunate tendency among the Arabs was their liking for the discussion of many trivial questions. Hyrtl, in his volume on "Arabian and Hebrew Words in Anatomy,"[6] declares that it is almost incredible how earnestly some trivial questions in anatomy and physiology were discussed by the Arabs. He gives some examples. Why does no hair grow on the nose of men? Why does the stomach not lie behind the mouth? Why does the windpipe not lie behind the esophagus? Why are the breasts not on the abdomen? Why are not the calves on the anterior portion of the legs? Even such men as Rhazes and Avicenna discuss such questions.

It was this tendency of the Arabs that passed over to the Western Europeans with Arabian commentaries on philosophy and science, and brought so many similar discussions in the scholastic period. These trivialities have usually been supposed to originate with the scholastics themselves, for they are not to be found in the Greek authors on whom the scholastics were writing commentaries, but they are typically Oriental in character, and it must be remembered that during the twelfth and early thirteenth centuries, at least, Greek philosophy found its way largely into Europe in Arab versions, and these characteristically Arabian additions of the discussion of curious trivial questions came with them and produced an imitative tendency among the Europeans.

As a rule the more careful has been the study of Arabian writers in the modern time, particularly by specialists, the clearer has it become that they lacked nearly all originality. Especially were they faulty in their observations; besides, they had a definite tendency to replace observation by theory, a fatal defect in medicine. The fine development of surgery that came at the end of the Arabian period of medicine in Europe could never have come from the Arabs themselves. Gurlt has brought this out particularly, but it will not be difficult to cite many other good authorities in support of this opinion.

Hyrtl, in his "Thesis on the Rarer Old Anatomists,"[7] says that "the Arabs paid very little attention to anatomy, and, of course, because of the prohibition in the Koran, added nothing to it. Whatever they knew they took from the Greeks, and especially Galen. Not only did they not add anything new to this, but they even lost sight of much that was important in the older authors. The Arabs were much more interested in physiology; they could study this by giving thought to it without soiling their hands. They delighted in theory, rather than in observation."

While we thus discuss the lack of originality and the tendency to over-refinement among the Arabian medical writers, it must not be thought that we would make little of what they accomplished. They not only preserved the old medical writers for us, but they kept alive practical medicine with the principles of the great Greek thinkers as its basis. There are a large number of writers of Arabian medicine whose names have secured deservedly a high place in medical history. If this were a formal history of Arabian medicine, their careers and works would require discussion. For our purpose, however, it seems better to confine attention to a few of the most prominent Arabian writers on medicine, because they will serve to illustrate how thoroughly practical were the Arabian physicians and how many medical problems that we are prone to think of as modern they occupied themselves with, solving them not infrequently nearly as we do in the modern time.