Old-Time Makers of Medicine — Ch. 5 Great Arabian Physicians, part 2/2

ALI ABBAS

Rhazes lived well on into the tenth century.

His successor in prestige, though not his serious rival, was Ali Ben el-Abbas, usually spoken of in medical literature as Ali Abbas, a distinguished Arabian physician who died near the end of the tenth century.

He wrote a book on medicine which, because of its dedication to the Sultan, to whom he was body-physician, is known as the "Liber Regius," or "Royal Book of Medicine."

This became the leading text-book of medicine for the Arabs until replaced by the "Canon of Avicenna" some two centuries later.

The "Liber Regius" was an extremely practical work and, like most of the Arabian books of the early times, is simple and direct, quite without many of the objectionable features that developed later in Arabian medicine.

It is valuable mainly for its contributions to diet and the fact that Ali Abbas tested many of his medicines on ailing animals before applying them to men.

Of course, it owes much to earlier writers on medicine, and especially to Paul of AEgina.

An example of its practical value is to be found in his description of the treatment of a wound of the brachial artery, when, as happened often in venesection from the median basilic vein, it was injured through carelessness or inadvertence.

If astringent or cauterizing methods do not stop the bleeding, the artery should be exposed, carefully isolated, tied in two places above and below the wound, and then cut across between them.

He has many similar practical bits of technique.

For instance, in pulling a back tooth he recommends that the gums be incised so as to loosen them around the roots, and then the tooth itself may be drawn with a special forceps which he calls a molar forceps.

In ascites he recommends that when other means fail an opening should be made three finger-breadths below the navel with a pointed phlebotomy knife, and a portion of the fluid allowed to evacuate itself.

A tube should then be inserted, but closed.

The next day more of the fluid should be allowed to come away, and then the tube removed and the abdomen wrapped with a firm bandage.

It is easy to understand that Ali Abbas' book should have been popular, and the more we know of it the easier it is to explain why Constantine Africanus should have selected it for translation.

It contains ten theoretic and ten practical books, and gives an excellent idea of the medical knowledge and medical practice of the time.

Probably the fact that Constantine had translated it led to its early printing, so that we have an edition of it published at Venice in 1492, and another at Lyons in 1523. During the Middle Ages the book was often spoken of as "Regalis Dispositio," the "Royal Disposition of Medicine."

MOORISH PHYSICIANS

After Rhazes, the most important contributors to medical literature from among the Arabs, with the single exception of Avicenna, were born in Spain.

They are Albucasis or Abulcasis, the surgeon; Avenzoar, the physician, and Averroes, the philosophic theorist in medicine.

Besides, it may be recalled here that Maimonides, the great Jewish physician, was born and educated at Cordova, in Spain.

It might very well be a surprise that these distinguished men among the Arabs should have flourished in Spain, so far from the original seat of Arabian and Mohammedan dominion in the East, where, owing to conditions in the modern time, the English-speaking world particularly is not likely to assume that the environment was favorable for the development of science and philosophy.

Anyone who recalls, however, the history of Spanish intellectual influence in the Roman Empire, as we have traced it at the beginning of this chapter, will appreciate how favorable conditions were in Spain for the fostering of intellectual development.

With the disturbances that had come from political strife and the invasion of the barbarians in Italy, Spain had undoubtedly come to hold the primacy in the intellectual life of Europe at the time when the Arabs took possession of the peninsula.

ABULCASIS

The most important of the Arabian surgeons of the Middle Ages is Albucasis or Abulcasis, also Abulkasim, who was born near Cordova, in Spain.

The exact year of his birth is not known, but he flourished in the second half of the tenth century.

He is said to have lived to the age of 101. The name of his principal work, which embraces the whole of medicine, is "Altasrif," or "Tesrif," which has been translated "The Miscellany."

Most of what he has to say about medical matters is taken from Rhazes.

His work on surgery, however, in three books, represents his special contribution to the medical sciences.

It contains a number of illustrations of instruments, and is the first illustrated medical book that has come to us.

It was translated into Latin, and was studied very faithfully by all the surgeons of the Middle Ages.

Guy de Chauliac has quoted Albucasis about two hundred times in his "Chirurgia Magna."

Even as late as the beginning of the sixteenth century Fabricius de Acquapendente, the teacher of Harvey, confessed that he owed most to three great medical writers, Celsus (first century), Paul of AEgina (seventh century), and Abulcasis (tenth century).

Abulcasis insisted that for successful surgery a detailed knowledge of anatomy was, above all, necessary.

He said that the reason why surgery had declined in his day was that physicians did not know their anatomy.

The art of medicine, he added further, required much time.

Unfortunately, to quote Hippocrates, there are many who are physicians in name only, and not in fact, especially in what regards surgery.

He gives some examples of surgical mistakes made by his professional brethren that were particularly called to his attention.

They are the perennially familiar instances of ignorance causing death because surgeons were tempted to operate too extensively.

His description of the procedure necessary to stop an artery from bleeding is an interesting example of his method of teaching the practical technique of surgery.

Apply the finger promptly upon the opening of the vessel and press until the blood is arrested.

Having heated a cautery of the appropriate size, take the finger away rapidly and touch the cautery at once to the end of the artery until the blood stops.

If the spurting blood should cool the cautery, take another.

There should be several ready for the purpose.

Take care, he says, not to cauterize the nerves in the neighborhood, for this will add a new ailment to the patient's affection.

There are only four ways of arresting arterial hemorrhage.

First, by cautery; second, by division of the artery, when that is not complete--for then the extremities contract and the blood clots--or by a ligature, or by the application of substances which arrest blood flow, aided by a compressive bandage.

Other means are inefficient, and seldom and, at most, accidentally successful.

His instruction for first aid to the injured in case of hemorrhage in the absence of the physician, is to apply pressure directly upon the wound itself.

The development of the surgical specialties among the Arabs is particularly interesting.

Abulcasis has much to say about nasal polyps.

He divided them into three classes: (1) cancerous, (2) those with a number of feet, and (3) those that are soft and not living,--these latter, he says, are neither malignant nor difficult to treat.

He recommends the use of a hook for their removal, or a snare for those that cannot be removed with that instrument.

His instructions for the removal of objects from the external ear are interestingly practical.

He advises the use of bird lime on the end of a sound to which objects will cling, or, where they are smaller, suction through a silver or copper canula.

Hooks and pincettes are also suggested.

Insects should be removed with a hook, or with a canula, or, having been killed by warm oil, removed by means of a syringe.

Some of his observations with regard to genito-urinary surgery are quite as interesting.

He even treated congenital anomalies.

He suggests cutting of the meatus when narrowed, dilatation of strictures with lead sounds, and even suggests plans of operations to improve the condition in hypospadias.

He gives the signs for differentiation between epitheliomata and condylomata, and distinguishes various forms of ulceration of the penis.

Abulcasis discusses varicose veins in very much the same spirit as a modern surgeon does.

They occur particularly in people who work much on their feet, and especially who have to carry heavy burdens.

They should not be operated on unless they produce great discomfort, and make it impossible for the sufferer to make his living.

They may be operated on by means of incision or extirpation.

Incision consists of cutting the veins at two or three places when they have been made prominent by means of tight bandages around the limb.

The blood should be allowed to flow freely out of the cut ends, and then a bandage applied.

For extirpation, the skin having been shaved beforehand, the vein should be made prominent, and then carefully laid bare.

When freed from all adhesions, it should be lifted out on a hook, and either completely extirpated or several rather long pieces removed.

He lays a good deal of stress on the necessity for freeing the vein thoroughly and lifting it well out of tissues before incising it.

In old cases special care must be taken not to tear the vein.

Minute details of technique are often found in these old authors.

Abulcasis, for instance, treats of adherent fingers with up-to-date completeness.

They can occur either congenitally or from injury, as, for instance, burning.

They should be separated, and then separation maintained by means of bandages or by the insertion between them of a thin lead plate, which prevents their readhesion.

Adhesions of the fingers with the palm of the hand, which Abulcasis has also seen, should be treated the same way.

At times there is surprise at finding some rare lesion treated with modern technique, and a hint at least of our modern apparatus.

Fracture of the pubic arch, for instance, is described in Abulcasis quite as if he had had definite experience with it.

When this occurs in a woman, the reposition of the bone is often greatly facilitated by a cotton tampon in the vagina.

This tampon must be removed at every urination.

There is another way, however, of better securing the same purpose of counterpressure.

One may take a sheep's bladder into the orifice of which a tube is fastened.

One should introduce the bladder into the vagina, and then blow strongly through the tube, until the bladder becomes swollen and fills up the vaginal cavity.

The fracture will, as a rule, then be readily reduced.

Here is, of course, not alone the first hint of the colpeurynter, but a very practical form of the apparatus complete.

Old-time physicians used the bladders of animals very generally for nearly all the medical purposes for which we now use rubber bags.

AVICENNA

Undoubtedly the most important of Abulcasis' contemporaries is the famous physician whose Arabic name, Ibn Sina, was transformed into Avicenna.

He was born toward the end of the tenth century in the Persian province of Chorasan, at the height of Arabian influence, and is sometimes spoken of as the chief representative of Arabian medicine, of as much importance for it as Galen for later Greek medicine.

His principal book is the so-called "Canon."

It replaced the compendium "Continens" of Rhazes, and, in the East, continued until the end of the fifteenth century to be looked upon as the most complete and best system of medicine.

Avicenna came to be better known in the West than any of the other Arabian writers, and his name carried great weight with it.

There are very few subjects in medicine that did not receive suggestive, if not always adequate, treatment at the hands of this great Arabian medical thinker of the eleventh century.

He copied freely from his predecessors, but completed their work with his own observations and conclusions.

One of his chapters is devoted to leprosy alone.

He has definite information with regard to bubonic plague and the _filaria medinensis_.

Here and there one finds striking anticipations of what are supposed to be modern observations.

Nothing was too small for his notice.

One portion of the fourth book is on cosmetics, in which he treats the affections of the hair and of the nails.

He has special chapters with regard to obesity, emaciation, and general constitutional conditions.

His book, the "Antidotarium," is the foundation of our knowledge of the drug-giving of his time.

Some idea of the popularity and influence of Avicenna, five centuries after his time, can be readily derived from the number of commentaries on him issued during the Renaissance period by the most distinguished medical scholars and writers of that time.

Hyrtl, in his "Das Arabische und Hebraeische in der Anatomie," quotes some of them,--Bartholomaeus de Varignana, Gentilis de Fulgineis, Jacobus de Partibus, Didacus Lopez, Jacobus de Forlivio, Ugo Senesis, Dinus de Garbo, Matthaeus de Gradibus, Nicolaus Leonicenus, Thaddaeus Florentinus, Galeatus de Sancta Sophia.

A

more complete list, with the titles of the books, may be found in Haller's "Bibliotheca Anatomica."

For over three centuries after the foundation of medical schools in Europe (and even after Mondino's book had been widely distributed), Avicenna was still in the hands of all those who had an enthusiasm for medical science.

AVENZOAR

Another of the distinguished Arabian physicians was Avenzoar--the transformation of his Arabic family name, Ibn-Zohr.

He was probably born in Penaflor, not far from Seville.

He died in Seville in 1162 at the age, it is said, of ninety-two years.

He was the son of a physician descended from a family of scholars, jurists, physicians, and officials.

He received the best education of the time not only in internal medicine, but in all the specialties, and must be counted among the greatest of the Spanish Arabian physicians.

He was the teacher of Averroes, who always speaks of him with great respect.

He is interesting as probably being the first to suggest nutrition _per rectum_.

A few words of his description show how well he knew the technique.

His apparatus for the purpose consisted of the bladder of a goat or some similar animal structure, with a silver canula fastened into its neck, to be used about as we use a fountain syringe.

Having first carefully washed out the rectum with cleansing and purifying clysters, he injected the nutriment--eggs, milk, and gruels--into the gut.

His idea was that the intestine would take this, and, as he said, suck it up, carrying it back to the stomach, where it would be digested.

He was sure that he had seen his patients benefited by it.

Some light on his studies of cases that would require such treatment may be obtained from what he has to say about the handling of a case of stricture of the esophagus.

He says that this begins with some discomfort, and then some difficulty of swallowing, which is gradually and continuously increased until finally there comes complete impossibility of swallowing.

It was in these cases that he suggested rectal alimentation, but he went farther than this, and treated the stricture of the esophagus itself.

The first step in this treatment is that a canula of silver or tin should be inserted through the mouth and pushed down the throat till its head meets an obstruction, always being withdrawn when there is a vomiting movement, until it becomes engaged in the stricture.

Then _freshly milked_ milk, or gruel made from farina or barley, should be poured through it.

He says that in these cases the patient might be put in a warm milk or gruel bath, since there are some physicians who believe that through the lower parts of the body, and also through the pores of the whole body, nutrition might be taken up.

While he considers that this latter method should be tried in suitable cases, he has not very much faith in it, and says that the reasons urged for it are weak and rather frivolous.

It is easy to understand that a man who has reached the place in medicine where he can recommend manipulative treatments of this kind, and discuss nutritional modes so rationally, knew his practical medicine well, and wrote of it judiciously.

AVERROES

Among the distinguished contributors to medicine at this time, though more a philosopher than a physician, is the famous Averroes, whose full Arabic name among his contemporaries was Abul-Welid Mohammed Ben Ahmed Ibn Roschd el-Maliki.

Like Avenzoar, of whom he was the intimate personal friend, and Abulcasis and Maimonides, he was born in the south of Spain.

He was in high favor with the King of Morocco and of Spain, El-Mansur Jacub, often known as Almansor, who made him one of his counsellors.

His works are much more important for philosophy than for medicine, and his philosophical writings gave him a place only second to that of Aristotle in the Western world during the Middle Ages.

Averroism is still a subject of at least academic interest, and Renan's monograph on it and its author was one of the popular books of the latter half of the nineteenth century in philosophic circles.

In spite of his friendship with the Moorish King and with Avenzoar, he fell under the suspicion of free thinking and was brought to trial with a number of personal friends, who occupied high positions in the Moorish government.

He escaped with his life, but only after great risks, and he was banished to a suburb of Cordova, in which only Jews were allowed to live.

By personal influence he succeeded in securing the pardon of himself and friends, and then was summoned to the court of the son and successor of El-Mansur in Morocco.

He died, not long after, in 1198. Altogether there are some thirty-three works of Averroes on philosophy and science.

Only three of these are concerned with medicine.

One is the "Colliget," so-called, containing seven books, on anatomy, physiology, pathology, diagnostics, materia medica, hygiene, and therapy.

Then there is a commentary on the "Cantica of Avicenna," and a tractate on the "Theriac."

Averroes' idea in writing about medicine was to apply his particular system of philosophy to medical science.

His intimate relations with other great physicians of the time, and in particular his close friendship with Avenzoar, enabled him to get abundant medical information in faultless order so far as knowledge then went, but his theoretic speculations, instead of helping medicine, as he thought they would, and as philosophers have always been inclined to think as regards their theoretic contributions, were not only not of value, but to some extent at least hindered human progress by diverting men from the field of observation to that of speculation.

It is interesting to realize that Averroes did in his time what Descartes did many centuries later, and many another brilliant thinker has done before and since.

ARABIAN INFLUENCE

The fame of these great thinkers and writers in philosophy and in medicine came to be known not only through the distribution of their books long after their death, but during their lifetime, and in immediately subsequent generations, ardent seekers after knowledge, who were themselves afterwards to become famous by their teaching and writing, found their way into the Arabian dominions in order to take advantage of the educational opportunities afforded.

These were better than they could secure at home in Christian countries, because the process of bringing culture and devotion to literature and science into the minds of the Northern nations, who had replaced the old Romans in Europe, was not yet completed.

Bagdad and Cordova were the two favorite places of educational pilgrimage.

The names that are most familiar among the scholars in the Middle Ages in Europe are those of whom it is recorded that they made long journeys in order to get in touch with what the Arabs had preserved of the old Greek civilization and culture.

Among them are such men as Michael Scot or Scotus, Matthew Platearius, who was afterwards a great teacher at Salerno; Daniel Morley, Adelard of Bath, Egidius, otherwise known as Gilles de Corbeil; Romoaldus, Gerbert of Auvergne, who later became Pope under the name of Sylvester II; Gerard of Cremona, and the best known of them all, at least in medicine, Constantine Africanus, whose wanderings, however, were probably not limited to Arabian lands, but who seems also to have been in Hindustan.

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 alae 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.

VI