Volume XII · Spring 1957 · Number 3 Incunabula in the Medical Library--Virginia MoscripIn recent years the Edward G. Miner Library of the School of Medicine and Dentistry has made use of gift funds, especially that of Edward Mulligan, to add to its collection of incunabula on medical subjects. These books are of more than a little interest as examples of the texts on which, for several hundred years, physicians had to depend for instruction and assistance.The simple remedies of herb and flower were known to the wise women of every village, and most housewives knew how to meet accident and emergency. In the monasteries where one of the monks was responsible for the care of sick brothers and any stranger, pilgrim, or wanderer who might fall ill in the convent, there was at hand a copy of the encyclopedia of Isidore, Bishop of Seville, the Etymologiae, in the fourth book of which the bishop had collected notes on the four humors, acute and chronic diseases, drugs, remedies, and instruments. From the seventh century this served as the most accessible handbook, though from our standpoint not one of much value. Prayers, nature, and miracle found plenty of room to produce cures.Probably about the time of Charlemagne there began to appear in western Europe Latin versions of a few Greek treatises by Hippocrates and Galen. Later on some Jews and Arabs from southern Europe who had received training in Arabian schools found patrons among western dignitaries, and introduced systematic teaching through the translation of Arabic texts into Latin. These Arabic texts were based upon the Greek, but their authors added material from their own observations. The most commonly mentioned name is that of Avicenna (980-1036), who compiled the Canon (Qanun), an encyclopedia of Greco-Arabian medicine which remained in use until the seventeenth century. Its books were divided into sections called fens, and were issued with commentary and explanation, rendered necessary by the fact that the Latin translators were men who either failed to understand the Arabic or lacked the Latin to express it, and produced garbled versions with terms hazily stated or meaningless to the reader.Medical training was established in the West at Salerno in southern Italy not later than the eleventh century. This was a natural location, since Latin, Greek, and Arab met and intermingled here. The Norman rulers encouraged the development of the school, and in the thirteenth century Emperor Frederick II decreed the course of study as follows: three years of philosophy and literature, five years of medicine, one year as assistant to an experienced physician, an examination in Hippocrates and Avicenna, and recommendation by the teachers and the emperor.Constantine the African, who came from Carthage to Salerno about 1077, translated into Latin the Arabic texts on medicine and surgery which he had brought with him. A hundred years later, Roger of Parma, the chief surgeon of the school of Salerno, produced his Practica Chirurgia, a brief practical account of surgical treatment of the body in general and of the head in particular. This, as edited by Roland of Parma and Salerno, became known as the Rolandina and remained a basic text for many years.In the thirteenth century, as universities were being formed, teachers of medicine and surgery appeared in Italy at Padua and Bologna and in France at Montpellier and Paris. At Bologna an early professor was William of Saliceto (1210-1277), native of Piacenza and city physician in Verona. He wrote a textbook of medicine, Summaconservationis et curationis, and one of surgery, Chirurgia. He preferred the use of the knife to cautery, and as physician he included advice on internal medicine and on professional conduct. "That it is unwise to be too familiar with the laity, and that high fees are proper as they will cause the doctor to be more respected." (David Riesman, The Story of Medicine in the Middle Ages.) William declared surgery should not be separated from medicine, a statement contrary to the general opinion, which rested partly on the feeling that surgery was a craft and beneath the notice of the professional, and partly on the fact that the Roman church discouraged and even forbade the study of anatomy.In spite of the ecclesiastical attitude, there were several church dignitaries who pursued the art of surgery. Theodoric, Bishop of Cervia, (1205-1298), a Dominican, physician to Innocent IV, spent much of his life in Bologna, and was the author or rather compiler of a book on surgery in the introduction to which he explains that he has done the work at the request of a fellow bishop, basing it on the medical writings of the experienced physician, Hugh of Lucca, and his own knowledge of Hugh's methods, with the purpose "under the guidance of Christ, of revealing the secrets of the surgical art." He says he has added material from earlier writers, especially Galen, with whose ideas Hugh was in agreement. Theodoric is said to have made use of "spongiae somniferae," which must have been an early attempt at anesthetics.Another cleric, Guy de Chauliac (1300-1368), who was probably the greatest medieval surgeon, was born in the little town of Chaulhac, in Auvergne, and studied medicine at Toulouse, Montpellier, and Bologna, and surgery at Paris. He became one of the great teachers at Montpellier. His Chirurgia, written in 1363, influenced surgical training for two hundred years. It discussed the topics of anatomy, described diseases, and related the means to be employed in the cure (the Antidotary). He preferred healing wounds by "coction and suppuration" as advocated by Galen, a recommendation which led to a long delay in the development of antiseptic surgery. Other "sects" of surgery, as he classified them, included "the dry treatment of wounds with washings of wine" (recommended by Theodoric); the "use of mild unguents and plasters" (William of Saliceto and Lanfranc); "those who used charms, with oil, wool and cabbage leaves and supposed God to have deposited his Grace in 'verbis, herbis et lapidibus' "; and finally "women and silly folks, who sat and folded their hands under the will of God, Amen." (Riesman)In his introduction Guy says he is writing not because of lack of books on the subject but in his desire for unity and completeness. Not everyone can possess all books written and if it were possible it would be wearisome to read them and superhuman to remember. Moreover there are additions and improvements which create knowledge. "It is not possible for the same man to begin and also to finish. We are children on the back of a giant, we can see what the giant sees and a little more."In Italy, Thaddeus of Florence (1215- c. 1300), known as Taddeo Alderotti, a famous physician and professor at Bologna, encouraged the translation of Greco-Arabic texts from Greek manuscripts. He had a number of influential pupils. Mondino dei Luzzi (1270-1326) was the first teacher of anatomy at Bologna, where he took part in dissections and produced the first real textbook of anatomy about 1316. Gentile da Foligno, who studied under Taddeo and Mondino, taught at Padua and Perugia, and among other things wrote a book on the plague, making sensible suggestions for burning refuse in cleaning up streets and houses.Another pupil of Taddeo was Lanfranc of Milan, who became professor of surgery in Paris about 1300. He had studied with William of Saliceto, and followed his recommendation for mild treatment of wounds. His career began in Milan, but when he became involved in the political conflicts of Guelph and Ghibelline he took his family to Lyons and later to Paris. Since a married man could not teach at the University of Paris, he gave his lectures as a member of the Collège de St. Côme. This was a group organized in the thirteenth century by Jean Pitard, surgeon of Louis IX and his successors, to put an end to professional quarrels by regulation of surgical training, through a course of study and service as apprentice, bachelor, and licentiate; four years more of practice might make a man a master, permitted to take apprentices. He should not receive the degree of doctor; if he did, he must give up surgery.Lanfranc's greatest work, Chirurgia magna, contains much practical advice, and includes the statement that it is "not possible to be a good physician if one is not at the same time a good surgeon, and vice versa" (Riesman), an idea unfashionable in his day. In his prologue he implores his friend Bernard, for whose benefit he is writing a summary of his years of study and experience, not to allow any untrained person to have the book for fear someone might be harmed by his work, which was compiled for the common good out of kindness to his friend.Bruno de Longobucca, a Calabrian, writing at Padua in 1252, compiled a Chirurgia from Galen, Avicenna, and other "experienced men of old." He urges his friend Andrew, who asked him to undertake the work, not to be led astray by greed, ignorance, or hindrance of his skill, for fear that his reputation and good character may be blackened by shameful spots. Bruno later made a brief version of the book for Lazarus of Padua, the Chirurgia minor.Leonard da Bertapaglia (died 1460) is known to have dissected two human bodies, and attacked the activities of barber-surgeons as opposed to trained surgeons. His book on surgery seems another compilation of Avicenna, a fen of the fourth Canon, and contains material on astrology and the influence of the stars on surgical treatment.In France, Montpellier was for centuries the center of medical instruction. Its most famous teacher, Guy de Chauliac, has already been mentioned. Another, equally important, was Arnold of Villanova (c. 1235-1311) who came from Spain. He had a varied career as physician to popes and kings, as Spanish ambassador, and as alchemist and friend of Ramón Lull and Roger Bacon, and was accused of heresy. He was the author of some sixty books on theology, philosophy, and natural science, the best known of which is the Breviarium practicae medicinae. It deals with diseases "a capite ad calcem," especially with surgery, gynecology, and poisons, a topic of peculiar interest during the later Middle Ages. His experience in alchemy led him, according to Riesman, "to recommend distilled spirit of wine impregnated with certain herbs as a valuable remedy." This in course of time was to lead to the development of chemical mixtures.Petrus de Argellata (died 1423), a pupil of Guy de Chauliac and a teacher at Bologna, produced six books on surgery, relying heavily on his predecessors. Though he was enterprising enough to practice "operatic obstetrics," neglected since the Greeks, he was, as Riesman says, "otherwise reactionary and timid, refraining from interfering with nature and treating head injuries with a dusting powder and the Lord's Prayer."A topic which required serious attention was the plague. Guy de Chauliac caught the disease in Avignon, recovered after six weeks, and wrote a long account of his sufferings and cure.Rolandus Capellutus, a physician in Parma during the plague of 1468, described the symptoms and treatment in a brief account addressed to Master Peter, surgeon of Parma. He begins by urging Peter to look to the result rather than to follow what seems easy at the beginning but turns out to be bitter at the end; to see to it that he does not ruin himself by desiring to heap up gold. How many, he says, have been led to destruction by avarice! Why set one's mind on gain in this city, one most unfortunate and filled with misery? "I declare, even though you say that while this epidemic reigned physicians received great rewards from the sufferers, yet it is much better to gain a 'solidus' without danger than a 'ducatus' with danger." He goes on to say that he was in the city during the plague, "such as I believe was never before seen... No love, no charity existed among the people of Parma, but every monstrosity and cruelty. Neighbor refused to help neighbor, brother brother, husbands wives and wives husbands; parents deserted children, and children parents. Men died not so much of plague as of necessity. Parish priests were unwilling to receive confessions and give the sacrament of communion or extreme unction to the sick. Proper burial was refused. On the report of illness officials hastened to the house with furious speed, and either shut up the sick man or expelled him and sent him to St. Leonard's, which was a human market, where more cruelty and robbery were to be found than love and charity. After the epidemic ceased, the physicians who had aided the sick were arrested and imprisoned by the officials and charged with a thousand robberies and murders, and were deprived of whatever money they had gained by hard work and great danger." As to the disease itself, "we saw the plague appear in men's bodies from corrupted air and neglect and stench of corpses and contagion. The secrets of nature which were unknown to the most skilled physicians of ancient and modern times, only God knows. And so we ought not to despise, but should rather note, the signs which appear in human bodies in death and after death." This leads to a discussion of symptoms of the disease, its manifestations, and possible remedies, and the conclusion is a second earnest appeal to strive to attain a good end.Illnesses from head to foot, wounds, fractures, poisons, and the methods of treatment and remedies for all of them must be the subject of study, but all such knowledge may fail unless supported by the aid of the stars. Belief in their influence goes back to the earliest observation of them, and the men of the Middle Ages accepted it without question.Isidore of Seville in the Etymologiae provided a brief discussion of the topic. Bartholomew the Englishman produced, about 1246, an encyclopedia in fifteen books. The fifth book deals with anatomy as described by Isidore, and the seventh with medicine, including a discussion of leprosy, one of the best of its period. The eighth book, after describing the physical heavens and the regions of angels and saints, proceeds to the visible galaxy and zodiac, and the influence of the planets and signs of the zodiac, especially the evil influence of the moon. Astrology comes into the surgical text of Guy de Chauliac, who names the days of the moon on which blood may be let. Leonard of Bertapaglia, one of the first real anatomists, includes in his work a section on signs granted by heavenly bodies, depending on the position of the sun and the rest of the planets in relation to the signs of the zodiac.Even when physicians had freed themselves from the tyranny of the stars, ordinary men still regulated their actions in accordance with the celestial decrees. The Library possesses a broadside, believed to be the only copy of this particular printing in the United States (only three are recorded in Europe), an "Almanach fuer Nuernberg" printed in 1487. It names the days and hours for the new and full moons throughout the year, and indicates for each week the zodiacal sign in power. When Aries prevails you may bleed from the veins of the head; under Cancer from the breast, and give medicine in an electuary; under Libra, let blood from the loins; under Scorpio, give medicine with liquids; under Sagittarius, let blood from the thigh; under Aquarius from the shin, and give medicine in every manner; and under Pisces, let blood from the foot, and give medicine in pills. Young people should be let blood and given medicine in accordance with these signs while the moon is waxing, and older people while it is waning.The Edward G. Miner Library has examples of most of the authors mentioned in editions which are of some interest in themselves.Among the earliest are copies of the two encyclopedias, both printed in 1483. That of Isidore of Seville was printed in Venice by Peter Löslein, who was active as printer during the years 1476-1500. It has a few diagrams of the phases of the moon, and a full-page "family tree" illustrating the Latin words for all one's relatives for several generations. The encyclopedia of Bartholomew the Englishman was printed in Cologne by Johann Koelhoff of Lübeck, whose first dated book appeared in 1472. Both books have the initial letters added by hand; those in the work by Isidore being attractively done in red and brown.The Summa conservationis and Cyrurgia of William of Saliceto are found in an edition of 1490, printed in Venice. It follows a text which, William says, he completed and corrected while retained by the commune of Verona in 1275. Space was left for the insertion by hand of the capital letters in headings, but few were supplied and only in the first part.Arnold of Villanova's Practica medicine is an edition of 1497, printed in Venice by Otinus de Luna, who printed three other medical textbooks in the same year.Anatomy is illustrated by Mondino dei Luzzi's Anathomia, printed in 1493 by Martin Landsberg in Leipzig. Dr. Martin Mellerstadt, the editor, added a critical comment on the work written by Mondino's student, Gentile da Foligno. This copy has as frontispiece an interesting hand-colored woodcut showing the author lecturing at a dissection, and the capital letters are worked out in red and blue.A commentary on Avicenna's fen on fevers by Giovanni Arcolani (Herculanus) of Verona was printed in Venice in 1496 by Benitus Locatellus for Octavianus Scotus, one of the most prominent Venetian publishers, whose monogram appears on the last page.Surgery is represented by several authors. The volume Cirurgia by Petrus de Argellata was printed in Venice in 1499, an edition which "looks like an imitation, by some unknown printer, of the medical classics printed by Saracenus about ten years previously." (Catalogue of Books Printed in the XVth Century Now in the BritishMuseum. Part V, p. 588.) It has woodcut capitals in Venetian style at the head of each section.Guy de Chauliac's Cyrurgia appears in an edition of 1499, printed in Venice by Simon de Luere at the expense of Andrea Torresanus. Printed along with it are a number of other treatises on surgery: the Practica of Roger of Parma with the edition by Roland called the Rolandina; the Cyrurgia of Theodoric; Lanfranc's Parva Cyrurgia; Leonard's Cyrurgia; Bruno's Cyrurgia magna and Cyrurgia minor. The volume includes two treatises on the eye and its diseases by Canamusali of Baldach and Jesus Hali, Arabian authorities. Canamusali cites the Arabic writers from whom he has selected and translated with a great deal of effort "just as bees gather bitter flowers and make from them a very sweet honey." There is also an account of the baths of Porretta near Bologna by Tura di Castello. He sets forth their remarkable powers of healing, describes the waters and their flow through the baths, and says the water may be carried away in wooden vases but it is less effective and loses its sulphuric savor.Giovanni Michele Savonarola, a distinguished physician from Padua, wrote a number of treatises, Practica medica, De aqua ardenti, De balneis et thermis, etc. He is represented in the Medical Library by his De pulsibus, urinis, et egestionibus, printed in Venice in 1497 by Master Cristoforo de Pensis.Roland Capellutus' account of the plague, De curatione pestiferorum apostematum, is a small book printed about 1485 by Stephen Plannck in Rome, where he was active from 1479 till after 1500.Whoever looks through these ten volumes will have an excellent idea of the amount of information available to the student and the physician in the years 1000 to 1500. The material is limited by the lack of scientific training and observation as we understand it, but almost all of the writers, in spite of their dependence on earlier authorities and the influence exercised by astrology, show a sympathetic interest in their work and a commendable desire to be of service to the sick and injured.The Edward G. Miner Library possesses one other fifteenth-century book, a copy of the works of Lactantius Firmianus, a folio printed in Venice in 1490 by Theodorus de Ragazonibus. Lactantius, who lived at the end of the third century and the beginning of the fourth century, has been called the Christian Cicero because of his pure Latin style. His chief work, De divinis institutionibus, a manual of Christian doctrine written to defend the religion to which he had been converted, fills most of this book. This volume includes, near the end, the text of Lactantius' first book, De opificio dei velformatione hominis, which is largely a description of human anatomy and is probably the reason for the presence of this work in the Medical Library.From notes added in handwriting in this volume it appears that at one time it belonged to a monastery, apparently S. Spirito in Bergamo, where it was placed on a restricted shelf because it lacked a title page and might therefore be a copy of the prohibited edition produced by Servais Gallé. This is really a shame, for Gallé, a Dutch scholar who died in 1709, published his book, an octavo, in Leyden in 1660. While this volume does not contribute as much to the history of medicine as do the others, it is an interesting example of fifteenth-century printing and fourth-century Christian writing.