Records: the Royal Medical College

## **Bringing RANP Standards to Medicine**

The RMC was England's answer to the other great schools, though being English, was destined to march to the beat of a different drummer. First, they were a subdivision of, and governed by, the Royal Academy, and used the systems and processes therein. This actually favored the Hippocratic experience: categorizing illnesses as acute, chronic, endemic and epidemic, and using terms such as, "exacerbation, relapse, resolution, crisis, paroxysm, peak, and convalescence," were absolutely in line the kind of organization the Royal Academy expected.

Further, Hippocrates was credited with being the first person to believe that diseases were caused naturally, not because of superstition and gods. He was credited by the disciples of Pythagoras of allying philosophy and medicine. He separated the discipline of medicine from religion, believing and arguing that disease was not a punishment inflicted by the gods but rather the product of environmental factors, diet, and living habits. Indeed there is not a single mention of a mystical illness in the entirety of the Hippocratic Corpus.

By the same token, they didn't fully subscribe to Hippocrates' convictions on Humorism (and many of his assumptions on anatomy and physiology had already been proven wrong). Further, with Hippocrates' own rejection of holy causes of disease, swearing to ancient gods seemed either disingenuous or overtly political.

For those reasons, the RMC didn't swear to the Hippocratic oath . Rather, the English swore by the non-maleficence maxim as expressed in latin: *Primum non nocere* (first, do no harm). One of the first debates was on quantifying the nature of medical ethics itself, and whether non-maleficence was their zenith, or whether they should aspire to the ethics of beneficence . Beyond that, the RMC began composing a better oath, borrowing from Galen and beyond.

### **Giving Credit Where It's Due**

One of the cited medical influences was Abū Jaʿfar Abdullāh al-Maʾmūn ibn Harūn (Al-Ma'mun). Al-Ma'mun was a caliph that had championed the sciences. He was a philosopher, leader and supported Abu Mūsā Jābir ibn Hayyān (Geber), who had  been inspirational in the study of pharmaceuticals.

In fact, Al-Ma'mun been an inspirational presence in many ways beyond his pharmaceutical or even geodesic scholarship. He'd fought religious extremism, opposing the mihna (more or less Muslim inquisitions). The controversy was exacerbated by al-Ma'mun's sympathy for Mu'tazili theology and other controversial views.

Mu'tazili theology was deeply influenced by Aristotelian thought and Greek rationalism, and stated that matters of belief and practice should be decided by reasoning. This opposed the traditionalist and literalist position of Ahmad ibn Hanbal and others, according to which everything a believer needed to know about faith and practice was spelled out literally in the Qur'an and the Hadith.

Moreover, the Mu'tazilis stated that the Qur'an was created rather than coeternal with God, a belief that was shared by the Jahmites and parts of Shi'a, among others, but contradicted the traditionalist-Sunni opinion that the Qur'an and the Divine were coeternal. The fact that the Mu'tazili school had its foundations in the paganism of Greece further disenchanted a majority of Islamic clerics – and spoke to the iconoclast in Prince Edward.

### **The Medical Library**

The foundation of the RMC was their library – and they were unparalleled. In deference, the Schola Medica Salernitana was surprisingly broad-minded for it's time, the school had been founded by four masters: the Jewish Helinus, the Greek Pontus, the Arab Adela, and the Latin Salernus. In the Salerno school, besides the teaching of medicine (in which women too were involved, as both teachers and students), there were courses of philosophy, theology, and law.

The RMC became a natural evolution of what Salerno had started (as well as building a rivalry with Montpellier before they were even fully chartered). Libraries were a trademark of Richard II and the RMC's founding had comprehensive (and controversial) selections from the Arabian and Jewish world, Indian (a particular feat considering their xenophobia), China and even ancient Egypt.

Each international selection had it's portions that were recorded for posterity's sake, but were otherwise ignored by the increasingly militant English scientific community. The Galen theory of the humours was rejected, as was the Indian Atharvaveda, which based medical procedure on concepts of the exorcism of demons and magic. Closer to home, Catholic theology held that the sick, especially the poor peasants, would also gain grace and lessen their time in purgatory through their suffering – something medicine found to be particularly egregious.

On the bright side, every foreign collection also brought insight. For instance, the Ayurvedic classics mentioned eight branches of medicine: kāyācikitsā (internal medicine), śalyacikitsā (surgery including anatomy), śālākyacikitsā (eye, ear, nose, and throat diseases), kaumārabhṛtya (pediatrics), bhūtavidyā (spirit medicine), and agada tantra (toxicology), rasāyana (science of rejuvenation), and vājīkaraṇa (aphrodisiacs, mainly for men).

Apart from learning these, the student of Āyurveda was expected to know ten arts that were indispensable in the preparation and application of his medicines: distillation, operative skills, cooking, horticulture, metallurgy, sugar manufacture, pharmacy, analysis and separation of minerals, compounding of metals, and preparation of alkalis. The teaching of various subjects was done during the instruction of relevant clinical subjects. For example, teaching of anatomy was a part of the teaching of surgery, embryology was a part of training in pediatrics and obstetrics, and the knowledge of physiology and pathology was interwoven in the teaching of all the clinical disciplines. The normal length of the student's training appears to have been seven years. But the physician was to continue to learn – a concept the growing scientific English culture wisely adopted.

Much of Arabian medicine had actually been based on Galen as well, having long since translated his Greek into Arabic (while the west hadn't). The humours notwithstanding, Galen had been an anatomical master and one of the greatest surgeons to ever live. The RMC translated him to both latin and English.

Further, Galen's writings illuminated the works of Herophilus of Chalcedon and Erasistratus of Ceos, two great Alexandrians that laid the foundations for the scientific study of anatomy and physiology. Other Alexandrian surgeons gave us ligature (hemostasis), lithotomy, hernia operations, ophthalmic surgery, plastic surgery, methods of reduction of dislocations and fractures, tracheotomy, and mandrake as anesthesia.

However, nearly all the learning at the great schools, from Montpellier to the universities of Padua and Bologna  – and even Salerno – were from lectures and readings in Hippocrates, Galen, Avicenna and Aristotle. There was little clinical work or dissection. That's where England was different.

The RMC was training students to become doctors and various levels of medical practitioners, including women (mostly catholic nuns to be nurses). Part of their training included dissection and autopsies, with eventual publishing of updated anatomy (nearly 200 years before the University of Padua might've done it otherwise).

Religion played a huge role in medicine, but a minimal role in the RMC. Catholic elites provided hospital services (or cash endowments) because of their theology of salvation that good works were the route to heaven (escaping purgatory). Protestant reformers would rejected that notion, but also the idea that the poor patients earned grace and salvation through their suffering. What Catholic money was later lost on English monasteries, Protestant money more than made up for in hospitals to cure the sick, heal the injured and ease the suffering.

One thing was certain, the RMC brought a change in the quality and duration of life for the average Englishman. Eventually, the Sanitation Initiative was rolled into the RMC's responsibility to organize, but the attribution to the Crown was never lost.

## **Pharmacopoeia and Apothecaries**

Up to this point, there wasn't a great deal of homegrown knowledge, though there was extensive foreign research on pharmacopoeia. The RMC was not afraid to dip into it, translate it, experiment with it and finally utilize it if effective. There was an obvious level of crossover with the medicine itself, but this was dealing not just with the assessment but rather the cure or relief of symptoms.

From antiquity, pharmacies dated back to 2600 BC to ancient Babylon. Clay tablets were found with medical texts recording symptoms, the prescriptions, and the directions for compounding it. From ancient Egypt were the Ebers Papyrus, written around 1500 B.C., contain a collection of more than 800 prescriptions, or ancient recipes for the apothecaries of the time. It mentions over 700 different drugs.

Pliny’s pharmacopoeia were consulted, as well as De Materia Medica ( Περί ύλης ιατρικής ), a five volume book originally written in Greek by Pedanius Dioscorides. The latter is considered to be precursor to all modern pharmacopoeias, and is one of the most influential herbal books in history. In fact it remained in use until about CE 1600.

From the arabian world, whose pharmacists had operated the first known drugstore in Baghdad in 754, came Abū ʿAlī al-Ḥusayn ibn ʿAbd Allāh ibn Sīnā (or "Avicenna"). The Persians could claim Avicenna as well, and did: he was a scholar on multiple levels, including rational philosophy which Richard had a great deal of respect for. One of the key contributions, though, were his works on Medicine and pharmacology. LIkewise, Serapion the Younger brought a book of medico-botany while Ibn al-Baytar contributed scientific classification and a wealth of medicines (and whom Richard was already aware of, having used the name "snow of China" to describe saltpetre while writing about gunpowder. Also from the area were works by Ibn Zuhr (Avenzoar), 12th century, while Ibn Baytar was nearly a 14th century contemporary.

Farther yet, the Atharvaveda, a sacred text of Hinduism dating from the Early Iron Age, is the first Indian text dealing with medicine, including prescriptions of herbs for various ailments. The use of herbs to treat ailments would later form a large part of Ayurveda.

From the farthest ends was a treatise written by several officials of Emperor Gaozong of Tang (c. 628-683). The pharmacopoeia contained 850 sorts of crude medicines, revising the treatises written by ancient Chinese pharmacists.

All of these sources were considered, the materials scoured for, tested, rated and listed by the RMC for specialists to dispense once prescribed by doctors. Such was the rise of the Apothecaries.

The RMC relied on a Livery Company (a chartered guild, more or less) to ensure proper training and licensing. Richard created the Worshipful Society of Apothecaries, splintering the medical group from the Grocers' Company (founded 1345), itself an offshoot of the Guild of Pepperers (formed sometime prior to 1180).

The apothecary itself entered the Royal Academy not only for the identification and analysis of potential drugs, but helped blaze trails into botany and chemistry.

Further, as the market for analgesics, anesthetics and even recreationals took off, parliament made sure this exploding industry was both well regulated and heavily taxed. Considering the unprecedented relief and relaxation that could be had in London (and eventually the British isles), even as early as July of 1381, the tax was never an issue.