Part 17

A most interesting contemporary of William of Saliceto was Thaddeus of Florence (1223-1303), who also taught at Bologna. This man perceived the importance of access to Greek sources, as distinct from Graeco-Arabic, and he encouraged the preparation of good Latin translations of medical works direct from the Greek. He stamped his personality on the whole development of Medicine at Bologna, and he is bound up with the beginning of dissection. But if Medicine owed a debt to Thaddeus for introducing better texts and better Anatomy, he did grave harm to the subject in another direction. The scholastic and argumentative form assumed by medieval Medicine is largely due to him, and it is to the assumption of this form that we owe the almost complete absence of scientific advance between the thirteenth and sixteenth centuries.

§ 5. Medieval Anatomy, Surgery and Internal Medicine.

At the very end of the thirteenth century there came to Bologna a Norman student, Henri de Mondeville (about 1270-1320). In 1301 he settled at the famous Medical School at Montpellier in Southern France, and thus transplanted to France the medical, surgical and anatomical traditions of Bologna. Those traditions were of Arabic origin, and mainly borrowed from Avicenna.

Contemporary with de Mondeville was one whose method of teaching shines as a good deed in a naughty world. Mondino di Luzzi (c. 1270-1326) was a pupil of Thaddeus and a fellow-student of Henri de Mondeville. He worked systematically at Anatomy and dissected the human body in public. His treatise on Anatomy, written in 1316, is the first modern work on the subject. Those who preceded him incorporated their anatomical work in larger treatises on Surgery, and do not refer directly to their own anatomical experiences. With Mondino this is changed. His work is essentially a practical manual of the subject and he is with justice called the ‘Restorer of Anatomy’. He had read widely among the Arabian anatomists, and naturally borrowed from them. Nevertheless, his work contains a considerable number of references to actual anatomical procedure. Moreover, he deals not only with Anatomy in our modern sense, but also includes Physiology and much discussion of the application of anatomical and physiological principles to Medicine and Surgery. His book thus gives a good deal of insight into the scientific knowledge of the day.

The professor stands in his ‘chair’, a great pulpit or ‘cathedra’, reading from his book--hence the English academic titles ‘Reader’ and ‘Lecturer’ or ‘Lector’ (that is, ‘one who reads’). The body is dissected by a menial, whose work is guided by an assistant, who, with wand, points out (Latin demonstrat, hence our modern title Demonstrator) the lines of incision. Students in academic dress stand around, but do not themselves dissect. ]

We would emphasize the fact that Mondino dissected in person. In this respect he was wiser than his successors until the time of Vesalius. As dissection gained formal inclusion in the curriculum, the professor became more haughty, further removed from the object of his study. Leaving his position by the body, where he might demonstrate to his students, he ascended his high professorial chair, a great elevated structure provided with steps and a reading-desk. From there he read from his text-book while a junior colleague pointed out the line of incision and a menial performed the actual dissection (Fig. 28). All was thus done at third-hand and according to the written word. We are in the scholastic period, and must not expect any frequent appeal to Nature. Having once got into his chair, it took a good deal to persuade the professor to descend from that dignified position. Thus, it is saying much for Mondino that he was his own demonstrator. He took the first and perhaps the greatest step. It was two centuries and more before the next step was taken.

Most typical of medieval surgeons was Guy de Chauliac (1300-68), who studied at Montpellier, Paris, and Bologna, and practised at Montpellier and afterwards at Avignon, where he was a member of the Papal Court. He was a man of much learning, and his Great Surgery became the standard treatise on the subject during the later Middle Ages. It fixed medieval practice. It is to be found in scores of manuscripts and was frequently translated and printed. Among the good points of his practice is his acceptance of responsibility for certain operations, such as those for rupture and for cataract, which at that time were usually left to wandering charlatans who regarded themselves as specialists. A famous passage in his work describes the use of a narcotic inhalation frequently used during the Middle Ages and into modern times. Of such a narcotic it is written that:

I’ll imitate the pities of old surgeons To this lost limb, who, ere they show their art, Cast one asleep, then cut the diseased part.

(Thomas Middleton, Women beware women. First acted 1622.)

The general character of Internal Medicine during the later Middle Ages was below that of Surgery. Modern clinical Medicine is firmly based on such sciences as Physiology, Pharmacology, Pathology, Biochemistry and Epidemiology. In the Middle Ages and far beyond, Physiology was still that of Galen, which had lost in exactness what it had gained in bulk from the Arabic and Latin commentators. Pathology was still that of the four humors. The knowledge of drugs was empirical, and the sciences of Pharmacology and Biochemistry as yet were not; while the medieval conception of the nature of epidemics was the very perversion of reason and common sense. Nevertheless, as we shall see, the Middle Ages ultimately succeeded in instituting a limited number of effective preventive measures.

§ 6. Medieval Hospitals and Hygiene.

Undoubtedly an important development of medieval Medicine is its hospital system. The public hospital arose in pagan antiquity out of the Temples of Aesculapius and the military valetudinaria (p. 49). The conception was seized on by Christianity and developed beyond all knowledge. In the early Christian centuries, hospitalia, ‘guest chambers’ or ‘guest houses’, were set aside for the numerous hospites, or ‘pilgrims’. Similar buildings under the same title came to be instituted for the care of orphans, the aged, the blind, and other victims of fortune. Thus arose the medieval hospital system, of which ours is the direct outgrowth.

In matters of Hygiene the Middle Ages are a byword. The health conditions of a medieval town were far below those of the same town under the Roman Empire. Water-supply was deficient, drains were absent, streets and houses filthy and overcrowded, rooms unventilated. Nevertheless, there is one important hygienic conception for which our own age owes a considerable debt to that which preceded it. Despite their scientific acumen in many departments, it is yet true to say that among the physicians of classical antiquity we find no consistent view of the transmission of infection by contact. Indeed the whole idea of infection was effectively absent from them, so that preventive measures based upon it could not be developed. It was reserved for the Middle Ages to conceive serious official measures against the spread of epidemics. These measures were consciously derived from the leper ritual of the Bible with its fundamental concept of isolation.

FIG. 29. A HOSPITAL WARD in sixteenth century Paris. In the left aisle, a nun folds the hands of a dying patient, while a priest gives the Sacrament to another in the same bed. In front, nuns sew shrouds. The right aisle is more cheerful. Nuns minister to two patients in one bed, while a convalescent, fortunate in having a bed to himself, vigorously takes nourishment. In the centre nuns receive postulants and a royal founder kneels in prayer.

During the early centuries of the Christian era, Leprosy, which had till then been confined to the East, crept along the Mediterranean littoral and thence northward throughout Europe. The disease was from the first regarded as contagious, and various regulations were introduced to isolate and separate the unfortunate sufferers. The medieval treatment of lepers is one of the dark incidents of man’s inhumanity to man. The leper was banished from human society. He was declared legally dead. He was excluded even from church or allowed to attend only in special seats where a special basin of holy water was assigned to him. How rigorously this segregation from the ranks of free people was carried out by law is well known. The cruel edicts were, however, effective. In the course of centuries it freed Europe from Leprosy, of which it is said there were at one time some 20,000 cases in France alone. Thus about one person in 200 would have been a leper, and the burden of the leper on the community was comparable to that, let us say, of the feeble-minded and insane with us.

Leper inspection, the regular examination of all suspects and carriers of leprosy, became a most elaborate business. It was entrusted to a special branch of the civil service and was gradually freed from ecclesiastical control.

This preventive method of combating a chronic disease, which, as we know now, has a very low infectivity, had a peculiar and unlooked-for result. The meticulous system of warding off the contagion of leprosy so occupied the attention of physicians that they came to see allied conditions in the same light. So it was that in the thirteenth century the general concept became current of disease as contagious. A number of other diseases besides leprosy were recognized as infectious. Among these were Plague, fevers with obvious rashes, Phthisis, Granular Conjunctivitis, the Itch and Erysipelas. Municipal authorities were from time to time ordered to put patients suffering from one or other such diseases outside the city gates. They were forbidden to traffic in articles of food and drink and were placed under restrictions not unlike those of lepers. The devastating epidemic of the Black Death of 1347-8 brought restrictions of this order into special force. Thus the Black Death had somewhat the same effect on the health administration of the day that the Cholera outbreaks of the thirties of the nineteenth century had upon modern Europe. The health service began to be put into more efficient order.

In the later Middle Ages there were actually instances in which the Pest was averted or successfully combated by these means. This seems to have been the case of Milan and Venice between the years 1370 and 1374. At that time the Plague was again advancing through Europe. The most drastic regulations were invoked to prevent infected persons from entering the cities, and these regulations came into force well in advance of the disease.

There is one incident in this medieval attempt to prevent Plague that has left a mark on our language. The Republic of Ragusa, on the eastern side of the Adriatic, adopted and extended the regulations that had been so successful at Venice. A landing-station was established far from the city and the harbor. There incoming suspects had to spend thirty days in the open air and sunlight, and any who had traffic with them were isolated. The period of thirty days was spoken of as the Trentina. Later this was found to be not long enough. The thirty days became forty days, the Quarantina, whence we have the word Quarantine. The system of quarantine gradually spread through Europe. It was accompanied by very drastic destruction, by burning, of all goods belonging to the infected.

These attempts to arrest epidemic disease were sometimes successful and the elaboration of quarantine measures was among the few advances with which we may credit the Middle Ages. The fact that we can now dispense with quarantine must not blind us to its value in conditions other than our own.

THE REBIRTH OF SCIENCE

(FROM ABOUT 1500 TO ABOUT 1700)

§ 1. The Anatomical Awakening.

During the Middle Ages beliefs about physiology were always based on Galen. They were frequently confused and often the result of a misunderstanding of his work. In the fifteenth century, however, took place the so-called Renaissance or Revival of Learning. Greek works which had been trickling in since the thirteenth century began to be recovered more rapidly, and to be more accurately studied. The first step towards any improvement on the views of Galen was naturally a proper understanding of what he had really said. For that there was needed a better knowledge of Greek than had been possessed by the Middle Ages. In the fifteenth century Greek scholarship made great advances and there was enthusiasm for classical learning. Accurate translations of the Greek works of Galen were made. The printing press was invented about the middle of the fifteenth century. Towards its end printed copies of the improved translations began to appear. So it came about that the Revival of Learning produced a revival of the ancient scientific knowledge.

This scientific revival led to a new interest in Anatomy. During the Middle Ages the occasional dissections at the Universities were merely supposed to illustrate Avicenna and Galen (Fig. 28 and p. 72). Dissection became much more widely practised in the fifteenth century, but it was nearly the middle of the sixteenth century before any real and open discussion of Galen’s views took place in the Universities.

There were, moreover, other influences at work. Along with the revival of learning there was also a renaissance of art. Some of the great Renaissance artists--Michelangelo, Raphael and Dürer among them--began to study the human form very closely. They soon found that to represent it accurately some knowledge of Anatomy, and especially of the bones and muscles, was needed. The artists, therefore, began also to dissect. Among these great artists were some who took more than a purely artistic interest in the structure and workings of the body. Of these the most important for us was Leonardo da Vinci (1452-1518). He was a man of enormously powerful and inquiring mind, and his achievements in science are at least as remarkable as his works of art. He had determined to write a text-book of anatomy and physiology. Though he did not publish it, many of his beautifully illustrated note-books on these subjects have survived.

Leonardo was the first to question the views of Galen. He made careful first-hand investigations on the bodies of men and animals, and performed many physiological experiments. Though a man of the most lofty genius, centuries ahead of his time, yet his outlook is, in many respects, typical of his age. His interest in anatomical investigation is therefore not surprising, for such inquiries were then astir. It happened that he was particularly interested in the heart and blood-vessels. He reached the correct conclusion that, contrary to Galen, the branches of the air-tubes in the lungs do not come into relation with the heart, but, after branching and gradually diminishing in size, they finally end blindly. He inflated the lungs with air and found that, whatever the force used, air could not be driven from the air-tubes into the heart. He therefore inferred quite correctly that Galen’s arteria venalis (our ‘pulmonary vein’) did not convey air to the heart, as the followers of Galen believed.

Leonardo then turned to examine the structure and form of the heart itself. He prepared more accurate drawings of it than had been made by any before him, making sections and dissections and examining its valves (Fig. 30). Ultimately he succeeded in grasping the nature and action of the valves at the root of the great arteries as they arise from the heart, and he verified his view by remarkable experiments. He proved that the valves allowed the blood to pass in only one direction, and prevented its regurgitation. Yet Leonardo gives no complete or clear description of the action of the heart. He could not emancipate himself from the old idea of the passage of the blood from the right ventricle through the septum into the left ventricle (Fig. 21), though he sometimes seems doubtful about it.