GREAT PHYSICIANS IN EARLY CHRISTIAN TIMES

What we know of the life of the Founder of Christianity and how much He did for the ailing poor would make us expect that the religion that He established would foster the care and the cure of suffering humanity. As we have outlined in the Introduction, the first of the works of Christian service that was organized was the care of the sick. At first a portion of the bishop’s house was given over to the shelter of the ailing, and a special order of assistants to the clergy, the deaconesses, took care of them. As Christians became more numerous, special hospitals were founded, and these became public institutions just as soon as freedom from persecution allowed the Christians the liberty to give overt expression to their feelings for the poor. While hospitals of limited capacity for such special purposes as the sheltering of slaves or of soldiers and health establishments of various kinds for the wealthy had been erected before Christianity, this was the first time that anyone who was ill, no matter what the state of his pecuniary resources, could be sure to find shelter and care. The expression of the Emperor Julian the Apostate, that admission to these hospitals was not limited to Christians, is the best possible evidence of the liberal charity that inspired them.

The ordinary passing student of the history of medicine or of hospital foundation and organization, can have no idea of the magnitude of some of these institutions, and their importance in the life of the time, unless it is especially pointed out. St. Basil, about the middle of the fourth century, erected what was spoken of as “a city for the sick,” before the gates of Caesarea. Gregory of Nazianzen, his friend, says “that well built and furnished houses stood on both sides of streets symmetrically laid out about the church, and contained rooms for the sick, and the infirm of every variety were intrusted to the care of doctors and nurses.” There were separate buildings for strangers, for the poor, and for the ailing, and comfortable dwellings for the physicians and nurses. An important portion of the institution was set apart for the care of lepers, which constituted a prominent feature in Basil’s work in which he himself took a special interest. Earlier in the same century Helena, the mother of the Emperor Constantine, had built similar institutions around Jerusalem, and during this same century nearly everywhere we have evidence of organization of hospitals and of care for the ailing poor.

Not only were hospitals erected, but arrangements were made for the care of the ailing poor in their own homes and for the visitation of them, and for the bringing to places adapted for their care and treatment of such as were found on the street, or neglected in their homes. The Church evidently considered itself bound to care for men’s bodies as well as their souls, and many of the expressions in common use among Christians referred to this fact. Religion itself was spoken of as a medicine of the soul and the body. Christianity was defined as the religion of healing. The word salvation had a reference to both body and soul. Baptism was spoken of as the bath of the soul, the holy Eucharist as the elixir of immortal life, and penance as the medicine of the soul. It is not surprising to find, then, that Harnack has found among the texts that illustrate the history of early Christian literature this one: “In every community there shall be at least one widow appointed to assist women who are stricken with illness, and this widow shall be trained in her duties, neat and careful in her ways, shall not be self-seeking, must not indulge too freely in wine in order that she may be able to take up her duties at night as well as by day, and shall consider it her duty to keep the Church officials informed of all that seems necessary.”

The saving of deformed and ailing infants or children whose parents did not care to have the trouble of rearing them, required the establishment by the Christians of another set of institutions, Foundling Asylums and Hospitals for Children. Until the coming of Christianity parents were supposed to have the right of life and death over their children, and no one questioned it. In every country in the world until the coming of Christianity this had always been the case. Besides, there were institutions for the care of the old. These are the classes of mankind who are especially liable to suffer from disease, and the opportunity to study human ailments in such institutions could scarcely help but provide facilities for clinical observation such as had not existed before. Unfortunately the work of Christianity was hampered, first by the Roman persécutions, and then later by the invasion of the barbarians, who had to be educated and lifted up to a higher plane of civilization before they could be brought to appreciate the value of medical science, much less contribute to its development.

Harnack, whose writings in the higher criticism of Scripture have attracted so much attention in recent years, began his career in the study of Christian antiquities with a monograph on Medical Features of Early Christianity. He mentions altogether some sixteen physicians who reached distinction in the earliest days of Christianity. Some of these were priests, some of them bishops, as Theodotos of Laodicea; Eusebius, Bishop of Rome; Basilios, Bishop of Ancyra, and at least one, Hierakas, was the founder of a religious order. The first Christian physicians came mainly from Syria, as might be expected, for here the old Greek medical traditions were active. Among them must be enumerated Cosmas and Damian, physicians who were martyred in the persecution of Diocletian, and who have been chosen as the patrons of the medical profession. Justinian erected a famous church to them. It became the scene of pilgrimages. Organizations of various kinds since, as the College of St. Come, and medical societies, have been named after them.

Some idea of the interest of ecclesiastics in medical affairs may be gathered from a letter of Bishop Theodoret of Cyrus, directed to the prefect of the city, when he was about to leave the place. He wrote : “When I took up the Bishopric of Cyrus I made every effort to bring in from all sides the arts that would be useful to the people. I succeeded in persuading skilled physicians to take up their residence here. Among these is a very pious priest, Peter, who practises medicine with great skill, and is well known for his care for the people. Now that I am about to leave the city, some of those who came at my invitation are preparing also to go. Peter seems resolved to do this. I appeal to your highness, therefore, in order to commend him to your special care. He handles patients with great skill and brings about many cures.”

Distinguished Christian writers and scholars, and the Fathers of the Church in the early centuries, evidently paid much attention to medicine. Tertullian speaks of medical science as the sister of philosophy, and has many references to the medical doctrines discussed in his time. Lactantius, in his work, “De Opificio Dei,” has much to say with regard to the human body as representing the necessity for design in creation. His teleological arguments have much more force now than they would have had for people generally twenty years ago. We have come back to recognize the place of teleology. Clement of Alexandria was an early Christian temperance advocate, who argued that the use of wine was only justified when it did good as a medicine. The problems of embryology and of diseases of childhood interested him as they did many other of the early Christian writers.

AETIUS

The first great Christian physician whose works meant much for his own time, and whose writings have become a classic in medicine, was Aetius Amidenus, that is, Aetius of Amida, who was born in the town of that name in Mesopotamia, on the upper Tigris (now Diarbekir), and who flourished about the middle of the sixth century. His medical studies, as he has told us himself, were made at Alexandria. After having attracted attention by his medical learning and skill, he became physician to one of the emperors at Byzantium, very probably Justinian, (527-565). He seems to have been succeeded in the special post that was created for him at court by Alexander of Tralles, the second of the great Christian physicians. There is no doubt that Aetius was a Christian, for he mentions Christian mysteries, and appeals to the name of the Saviour and the martyrs. He was evidently a man of wide reading, for he quotes from practically every important medical writer before his time. Indeed, he is most valuable for the history of medicine, because he gives us some idea of the mode of treatment of various subjects by predecessors whose fame we know, but none of whose works have come to us. His official career and the patronage of the Emperor, the breadth of his scholarship, and the thoroughly practical character of his teaching, show how medical science and medical art were being developed and encouraged at this time.

Aetius’ work that is preserved for us is known in medical literature as his sixteen books on medical practice. In most of the manuscript it is divided into four Tetrabibloi, or four book parts, each of which consists of four sections called Logoi in Greek, Sermones in Latin. This work embraces all the departments of medicine, and has a considerable portion devoted to surgery, but most of the important operations and the chapters on fractures and dislocations are lacking. Aetius himself announces that he had prepared a special work on surgery, but this is lost. Doubtless the important chapters that we have noted as lacking in his work would be found in this. He is much richer in pathology than most of the older writers, at least of the Christian era; for instance, Gurlt says that he treats this feature of the subject much more extensively even than Paulus AEginetus, but most of his work is devoted to therapeutics.

At times those who read these old books from certain modern standpoints are surprised to find such noteworthy differences between writers on medicine, who are separated sometimes only by a generation, and sometimes by not more than a century, in what regards the comparative amount of space given to pathology, etiology, and therapeutics. Just exactly the same differences exist in our own day, however. We all know that for those who want pathology and etiology the work of one of our great teachers is to be consulted, while for therapeutics it is better to go to someone else. When we find such differences among the men of the olden time we are not so apt to look at them with sympathetic discrimination, as we do with regard to our contemporaries. We may even set them down to ignorance rather than specialization of interest. These differences depend on the attitude of mind of the physician, and are largely the result of his own personal equation. They do not reflect in any way either on his judgment or on the special knowledge of his time, but are the index of his special receptivity and teaching habit.

Aetius’ first and second books are taken up entirely with drugs. The first book contains a list of drugs arranged according to the Greek alphabet. In the third book other remedial measures, dietetic, manipulative, and even operative, are suggested. In these are included venesection, the opening of an artery, cupping, leeches, and the like. The fourth and fifth books take up hygiene, special dietetics, and general pathology. In the sixth book what the Germans call special pathology and therapy begins with the diseases of the head. The first chapter treats of hydrocephalus. In this same book rabies is treated. What Aetius has consists mainly of quotations from previous authors, many of whom he had evidently read with great care.

Concerning those “bitten by a rabid dog or those who fear water,” Gurlt has quoted the following expression, with regard to which most people will be quite ready to agree with him when he says that it contains a great deal of truth, usually thought to be of much later origin: “When, therefore, any one has been bitten by a rabid dog the treatment of the wound must be undertaken just as soon as possible, even though the bite should be small and only superficial. One thing is certain, that none of those who are not rightly treated escape the fatal effect. The first thing to do is to make the wound larger, the mouth of it being divided and dilated by the scalpel. Then every portion of it and the surrounding tissues must be firmly pressed upon with the definite purpose of causing a large efflux of blood from the part. Then the wound should be deeply cauterized, etc.”

There are special chapters devoted to eye and ear diseases, and to various affections of the face. Under this the question of tattooing and its removal comes in. It is surprising how much Aetius has with regard to such nasal affections as polyps and ulcers and bleedings from the nose. In this book, however, he treats only of their medicinal treatment. What he has to say about affections of the teeth is so interesting that it deserves a paragraph or two by itself.

He had much to say with regard to the nervous supply of the mucous membranes of the gums, tongue, and mouth, and taught that the teeth received nerves through the small hole existing at the end of every root. For children cutting teeth he advised the chewing of hard objects, and thought that the chewing of rather hard materials was good also for the teeth of adults. For fístulas leading to the roots of teeth he suggests various irritant treatments, and, if they do not succeed, recommends the removal of the teeth. He seems to have known much about affections of the gums and recognizes a benignant and malignant épulis. He thought that one form of épulis was due to inflammation of a chronic character, and suggests that if remedies do not succeed it should be removed. His work is of interest mainly as showing that even at this time, when the desire for information of this kind is usually supposed to have been in abeyance, physicians were gathering information about all sorts even of the minor ailments of mankind, gathering what had been written about them, commenting on it, adding their own observations, and in general trying to solve the problems as well as they could.

Aetius seems to have had a pretty good idea of diphtheria. He speaks of it in connection with other throat manifestations under the heading of “crusty and pestilent ulcers of the tonsils.” He divides the anginas generally into four kinds. The first consists of inflammation of the fauces with the classic symptoms, the second presents no inflammation of the mouth nor of the fauces, but is complicated by a sense of suffocation apparently our croup. The third consists of external and internal inflammation of the mouth and throat, extending towards the chin. The fourth is an affection rather of the neck, due to an inflammation of the vertebrae retropharyngeal abscess that may be followed by luxation and is complicated by great difficulty of respiration. All of these have as a common symptom difficulty of swallowing. This is greater in one variety than in another at different times. In certain affections even “drinks when taken are returned through the nose.”

Hypertrophy of the tonsils Aetius speaks of them as glands is to be treated by various astringent remedies, but if these fail the structures should be excised. His description of the excision is rather clear and detailed. The patient should be put in a good full light, and the mouth should be held open and each gland pulled forward by a hook and excised. The operator should be careful, however, only to excise those portions that are beyond the natural size, for if any of the natural substance of the gland is cut into, or if the incision is made beyond the projecting portion of the tonsil, there is grave danger of serious hemorrhage. After excision a mixture of water and vinegar should be kept in the mouth for some time. This should be administered cold in order to prevent the flow of blood. After this very cold water should be taken.

In this same book, Chapter L, he treats of foreign bodies in the respiratory and upper digestive tracts. If there is anything in the larynx or the bronchial tubes the attempt must be made to secure its ejection by the production of coughing or sneezing. If the foreign body can be seen it should be grasped with a pincers and removed. If it is in the esophagus, Aetius suggests that the patient should be made to swallow a sponge dipped in grease, or a piece of fat meat, to either of which a string has been attached, in order that the foreign body may be caught and drawn out. If it seems preferable to carry the body on into the stomach, the swallowing of large mouthfuls of fresh bread or other such material is recommended.

With regard to goitre, Aetius has some interesting details. He says that “all tumors occurring in the throat region are called bronchoceles, for every tumor among the ancients was called a cèle, and, though the name is common to them, they differ very much from one another.” Some of them are fatty, some of them are pultaceous, some of them are cancerous, and some of them he calls honey tumors, because of a honey-like humor they contain. “Sometimes they are due to a local dilatation of the blood vessels, and this is most frequently connected with parturition, apparently being due to the drawing of the breath being prevented or repressed during the most violent pains of the patient. Such local dilatation at this point of the veins is incurable, but there are also hard tumors like scirrhus and malignant tumors, and those of great size. With the exception of these last, all the tumors of this region are easily cured, yielding either to surgery or to remedies. Surgery must be adapted to the special tumor, whether it be honey-like or fatty, or pultaceous.” The prognosis of goitrous tumors is much better than might be expected, but evidently Aetius saw a number of the functional disturbances and enlargements of the thyroid gland, which are so variable in character as apparently to be quite amenable to treatment.

Aetius’ treatment of the subject of varicosities is quite complete in its suggestions. “The term varices,” he says, “is applied to dilated veins, which occur sometimes in connection with the testes and sometimes in the limbs. Operations on testicular varices patients do not readily consent to; those on the limbs may be cured in several ways. First, simple section of the skin lying above the dilated vessel is made, and with the hook it is separated from the neighboring tissues and tied. After this the dilated portion is removed and pressure applied by means of a bandage. The patient is ordered to remain quiet, but with the legs higher than the head. Some people prefer treatment by means of the cautery.” Gurlt, in his “History of Surgery,” calls attention to the fact that two of our modern methods of treating varicose veins are thus discussed in Aetius, that by ligation and that by the cautery. The cautery was applied over a space the breadth of a finger at several points along the dilated veins.

Aetius’ chapters on obstetrics and gynaecology are of special interest, because, while we are prone to think that gynaecology particularly is a comparatively modern development of surgery, this surgical authority of the early Middle Ages treats it rather exhaustively. His sixteenth book is for the most part (one hundred and eleven chapters of it) devoted to these two subjects. He has a number of interesting details in the first thirty-six chapters with regard to conception, pregnancy, labor, and lactation, which show how practical were the views of the physicians of the time. Gurlt has given us some details of his chapters on diseases of the breast. Aetius differentiates phagedenic and rodent ulcers and cancer. All the ordinary forms of phagedenic ulcer yield to treatment, while malignant growths are rendered worse by them. Where ulcers are old, he suggests the removal of their thickened edges by the cautery, for this hastens cure and prevents hemorrhage. With regard to cancer, he quotes from Archigenes and Leonides. He says that these tumors are very frequent in women, and quite rare in men. Even at this time cancer had been observed and recognized in the male breast. He emphasizes the fact that cancerous nodules become prominent and become attached to surrounding tissues. There are two forms, those with ulcer, and those without. He describes the enlargement of the veins that follows, the actual varicosities, and the dusky or livid redness of the parts which seem to be soft, but are really very hard. He says that they are often complicated by very painful conditions, and that they cause enlargement of the glands and of the arms. The pain may spread to the clavicle and the scapula, and he seems to think that it is the pain that causes the enlargement of the glands at a distance.

His description of ulcerative cancer of the breast is very striking. He says that it erodes without cause, penetrating ever deeper and deeper, and cannot be stopped until it emits a secretion worse than the poison of wild beasts, copious and abominable to the smell. With these other symptoms pains are present. This form of cancer is especially made worse by drugs and by all manner of manipulation. The paragraph from Leonides quoted by Aetius gives a description of operation for cancer of the breast, in which he insists particularly on the extensive removal of tissue and the free use of the cautery. “The cautery is used at first in order to prevent bleeding, but also because it helps to destroy the remains of diseased tissues. When the burning is deep, prognosis is much better. Even in cases where indurated tumors of the breast occur that might be removed without danger of bleeding, it is better to use the cautery freely, though the amputation of such a portion down to the healthy parts may suffice.” Aetius quotes this with approval.

Others before Aetius had suggested the connection between hypertrophy of the clitoris and certain exaggerated manifestations of the sexual instinct, and the development of vicious sexual habits. As might be expected from this first great Christian physician and surgeon, he emphasizes this etiology for certain cases, and outlines an operation for it. This operation had been suggested before, but Aetius goes into it in detail and describes just how the operation should be done, so as to secure complete amputation of the enlarged organ, yet without injury. He warns of the danger of removing more than just the structure itself, because this may give rise to ugly and bothersome scars. After the operation a sponge wet with astringent wine should be applied, or cold water, especially if there is much tendency to bleeding, and afterwards a sponge with manna or frankincense scattered over it should be bound on. He treats of other pathological conditions of the female genitalia, varicose veins, growths of various kinds, hypertrophy of the portio vaginalis uteri, an operation for which is described, and of various tumors. He describes epithelioma very clearly, enumerates its most frequent locations in their order, lays down its bad prognosis, and hence the necessity for early operation with entire removal of the new growth whenever possible. He feared hemorrhage very much, however, and warns with regard to it, and evidently had had some very unfortunate experiences in the treatment of these conditions.

Aetius seems to have had as thoroughly scientific an interest in certain phases of chemistry apart from medicine as any educated physician of the modern time might have. Mr. A.P. Laurie, in his “Materials of the Printer’s Craft," calls attention to the fact that the earliest reference to the use of drying oil for varnish is made by the physician Aetius.

Aetius, or Aetios, to use for the nonce the Greek spelling of his name, which sometimes occurs in medical literature, and should be known, has been the subject of very varied estimation at different times. About the time of the Renaissance he was one of the first of the early writers on medicine accorded the honor of printing, and then was reprinted many times, so that his estimation was very high. With the reawakening of clinical medicine in the seventeenth century his reputation waxed again, and Boerhaave declared that the works of Aetius had as much importance for physicians as had the Pandects of Justinian for lawyers. This high estimation had survived almost from the time of the Renaissance, when Cornelius went so far as to say: “Believe me, that whoever is deeply desirous of studying things medical, if he would have the whole of Galen abbreviated and the whole of Oribasius extended, and the whole of Paulus (of AEgina) amplified, if he would have all the special remedies of the old physicians as well in pharmacy as in surgery boiled down to a summa for all affections, he will find it in Aetius.” Naturally enough, this exaggerated estimation was followed by a reaction, in which Aetius came to be valued at much less than he deserved. After all is taken into account in the vicissitudes of his fame, it is clear, however, that he is one of the most important links in the chain of medical tradition, and himself worthy to be classed among makers of medicine for his personal observations and efforts to pass on the teachings of the old to succeeding generations.

ALEXANDER OF TRALLES

An even more striking example than the life and work of Aetius as evidence for the encouragement and patronage of medicine in early Christian times, is to be found in the career of Alexander of Tralles, whose writings have been the subject of most careful attention in the Renaissance period and in our own, and who must be considered one of the great independent thinkers in medicine. While it is usually assumed that whatever there was of medical writing during the Middle Ages was mere copying and compilation, here at least is a man who could not only judiciously select, but who could critically estimate the value of medical opinions and procedure, and weighing them by his own experience and observation, turn out work that was valuable for all succeeding generations. The modern German school of medical historians have agreed in declaring him an independent thinker and physician, who represents a distinct link in medical tradition.

He came of a distinguished family, in which the following of medicine as a profession might be looked upon as hereditary. His father was a physician, and it is probable that there were physicians in preceding generations, and one of his brothers, Dioscoros, was also a successful physician. Altogether four of his brothers reached such distinction in their life work that their names have come down to us through nearly fifteen hundred years. The eldest of them was Anthemios, the builder of the great church of Santa Sophia in Constantinople. As this is one of the world’s great churches, and still stands for the admiration of men a millennium and a half after its completion, it is easy to understand that Anthemios’ reputation is well founded. A second brother was Metrodoros, a distinguished grammarian and teacher, especially of the youthful nobility of Byzantium, as it was then called, or Constantinople, as we have come to call it. A third brother was a prominent jurist, also in Constantinople. The fourth brother, Dioscoros, like Alexander, a physician, remained in his birthplace, Tralles, and acquired there a great practice.

It was with his father at Tralles that Alexander received his early medical training. The father of a friend and colleague, Cosmas, who later dedicated a book to Alexander, was also his teacher, while he was in his native city. As a young man, Alexander undertook extensive travels, which led him into Italy, Gaul, Spain, and Africa, everywhere gathering medical knowledge and medical experience. Then he settled down at Rome, probably in an official position, and practised medicine successfully until a very old age. He was probably eighty years of age when, some time during the first decade of the seventh century, he died.

Puschmann, who has made a special study of Alexander’s life and work, suggests that since some of his books have the form of academic lectures he was probably a teacher of medicine at Rome. As might be expected from what we know of the relations of the rest of the family to the nobility of the time, it is easy to understand, especially in connection with hints in Alexander’s favorite modes of therapeutics, that costliness of remedies made no difference to his patients, that he must have had the treatment of some of the wealthiest families in Rome.

His principal work is a Treatise on the Pathology and Therapeutics of Internal Diseases, in twelve books. The first eleven books were evidently material gathered for lectures or teaching of some kind. The twelfth book, in which considerable use of Aetius’ writings is made, was written, according to Puschmann, toward the end of Alexander’s life, and was meant to contain supplementary matter, comprising especially his views gathered from observation as to the pathology of internal diseases. A shorter treatise of Alexander is with regard to intestinal parasites. There are many printed editions of these books, and many manuscript copies are in existence. Alexander was often quoted during the Middle Ages, and in recent years, with the growth of our knowledge of medical history, he has come to be a favorite subject of study.

Alexander’s first book of pathology and therapeutics treats of head and brain diseases. For baldness, the first symptom of which is falling out of the hair, he counsels cutting the hair short, washing the scalp vigorously, and the rubbing in of sulphur ointments. For grey hair he suggests certain hair dyes, as nutgalls, red wine, and so forth. For dandruff, which he described as the excessive formation of small flake-like scales, he recommends rubbing with wine, with certain salves, and washing with salt water.

He gives a good deal of attention to diseases of the nervous system. He has a rather interesting chapter on headache. The affection occurs in connection with fevers, after excess in drinking, and as a consequence of injury to the skull. Besides, it develops as a result of disturbances of the natural processes in the head, the stomach, the liver, and the spleen. Headache, as the first symptom of inflammation of the brain, is often the forerunner of convulsions, delirium, and sudden death. Chronic or recurrent headache occurs in connection with plethora, diseases of the brain, biliousness, digestive disturbances, insomnia, and continued worry. Hemicrania has its origin in the brain, because of the presence of toxic materials, and specially their transformation into gaseous substances. It also occurs in connection with abdominal affections. This latter remark particularly is directed to the cases which occur in women.

For apoplexy and the consequent paralysis, Alexander considered venesection the best remedy. Massage, rubbings, baths, and warm applications are recommended for the paralytic conditions. He had evidently had considerable experience with epilepsy. It develops either from injuries of the head or from disturbances of the stomach, or occasionally other parts of the body. When it occurs in nursing infants, nourishment is the best remedy, and he gives detailed directions for the selection of a wet nurse, and very careful directions as to her mode of life. He emphasizes very much the necessity for careful attention to the gastro-intestinal tract in many cases of epilepsy. Planned diet and regular bowels are very helpful. He rejects treatment of the condition by surgery of the head, either by trephining or by incisions, or cauterization. Regular exercise, baths, sexual abstinence are the foundation of any successful treatment. It is probable that we have returned to Alexander’s treatment of epilepsy much more nearly than is generally thought. There are those who still think that remedies of various kinds do good, but in the large epileptic colonies regular exercise, bland diet, regulation of the bowels, and avoidance of excesses of all kinds, with occupation of mind, constitute the mainstay of their treatment.

Alexander has much to say with regard to phrenitis, a febrile condition complicated by delirium, which, following Galen, he considers an affection of the brain. It is evidently the brain fever of the generations preceding the last, an important element of which was made up of the infectious meningitises. Alexander suggests its treatment by opiates after preliminary venesection, rubbings, lukewarm baths, and stimulating drinks. Every disturbance of the patient must be avoided, and visitors must be forbidden. The patient’s room should rather be light than dark. His teaching crops up constantly in the centuries after his time, until the end of the nineteenth century, and while we now understand the causes of the condition better, we can do little more for it than he did.

Alexander divided mental diseases into two, the maniacal and melancholic. Mania was, however, really a further development of melancholia, and represented a high grade of insanity. Under melancholy he groups not only what we denominate by that term, but also all depressed conditions, and the paranoïas, as also many cases of imbecility. The cause of mental diseases was to be found in the blood. He counselled the use of venesection, of laxatives and purgatives, of baths and stimulant remedies. He insisted very much, however, on mental influence in the disease, on change of place and air, visits to the theatre, and every possible form of mental diversion, as among the best remedial measures.

After his book on diseases of the head, his most important section is on diseases of the respiratory system. In this he treats first of angina, and recommends as gargles at the beginning light astringents; later stronger astringents, as alum and soda dissolved in warm water, should be employed. Warm compresses, venesection from the sublingual veins, and from the jugular, and purgatives in severe cases, are the further remedies. He treats of cough as a symptom due to hot or cold, dry or wet dyscrasias. Opium preparations carefully used are the best remedies. The breathing in of steam impregnated with various ethereal resins, was also recommended.

He gives a rather interestingly modern treatment of consumption. He recommends an abundance of milk with a strong nutritious diet, as digestible as possible. A good auxiliary to this treatment was change of air, a sea voyage, and a stay at a watering-place. Asses’ and mares’ milk are much better for these patients than cows’ and goats’ milk. There is not enough difference in the composition of these various milks to make their special consumption of import, but it is probable that the suggestive influence of the taking of an unusual milk had a very favorable effect upon patients, and this effect was renewed frequently, so that much good was ultimately accomplished. For hemoptysis, especially when it was acute and due as Alexander thought to the rupture of a blood vessel in the lungs, he recommended the opening of a vein at the elbow or the ankle in order to divert the blood from the place of rupture to the healthy parts of the circulation. He insisted that the patients must rest, that they should take acid and astringent drinks, that cold compresses should be placed upon the chest (our ice bags), and that they should take only a liquid diet at most lukewarm, or, better, if agreeable to them, cold. When the bleeding stopped, a milk cure was very useful for the restoration of these patients to strength.

It is not surprising, then, to find that Alexander suggests a thoroughly rational treatment for pleurisy. He recognizes this as an inflammation of the membrane covering the ribs, and its symptoms are severe pain, disturbance of breathing, and coughing. In certain cases there is severe fever, and Alexander knows of purulent pleurisy, and the fact that when pus is present the side on which it is is warmer than the other. Pleurisy can be, he says, rather easily confounded with certain liver affections, but there is a peculiar hardness of the pulse characteristic of pleurisy, and there is no expectoration in liver cases, though it also may be absent in many cases of pleurisy. Sufferers from liver disease usually have a paler color than pleuritics. His treatment consists in venesection, purgatives, and, when pus is formed, local incision. He recommends the laying on of sponges dipped in warm water, and the internal use of honey lemonade. Opium should not be used unless the patient suffers from sleeplessness.

Some of the general principles of therapeutics that Alexander lays down are very interesting, even from our modern standpoint. Trust should not be placed in any single method of treatment. Every available means of bringing relief to the patient should be tried. “The duty of the physician is to cool what is hot, to warm what is cold, to dry what is moist, and to moisten what is dry. He should look upon the patient as a besieged city, and try to rescue him with every means that art and science places at his command. The physician should be an inventor, and think out new ways and means by which the cure of the patient’s affection and the relief of his symptoms may be brought about.” The most important factor in his therapeutics is diet. Watering-places and various forms of mineral waters, as well as warm baths and sea baths, are constantly recommended by him. He took strong ground against the use of many drugs, and the rage for operating. The prophylaxis of disease is in Alexander’s opinion the important part of the physician’s duty. His treatment of fever shows the application of his principle: cold baths, cold compresses, and a cooling diet, were his favorite remedies. He encouraged diaphoresis nearly always, and gave wine and stimulating drugs only when the patient was very weak. He differentiates two kinds of quartan fever. One of these he attributes to an affection of the spleen, because he had noticed that the spleen was enlarged during it, and that, after purgation, the enlarged spleen decreased in size.

Alexander was a strong opponent of drastic remedies of all kinds. He did not believe in strong purgatives, nor in profuse and sudden blood-lettings. He opposed arteriotomy for this reason, and refused to employ extensive cauterization. His diagnosis is thorough and careful. He insisted particularly on inspection and palpation of the whole body; on careful examination of the urine, of the feces, and the sputum; on study of the pulse and the breathing. He thought that a great deal might be learned from the patient’s history. The general constitution is also of importance. His therapeutics is, above all, individual. Remedies must be administered with careful reference to the constitution, the age, the sex, and the condition of the patient’s strength. Special attention must always be paid to nature’s efforts to cure, and these must be encouraged as far as possible. Alexander had no sympathy at all with the idea that remedies must work against nature. His position in this matter places him among the dozen men whose name and writings have given them an enduring place in the favor of the profession at all times, when we were not being carried away by some therapeutic fad or imagining that some new theory solved the whole problem of the causation and cure of disease.

Gurlt, in his “History of Surgery,” has abstracted from Alexander particularly certain phases of what the Germans call external pathology and therapeutics. For instance, Alexander’s treatment of troubles connected with the ear is very interesting. Gurlt declares that this chapter alone provides striking evidence for Alexander’s practical experience and power of observation, as well as for his knowledge of the literature of medicine. He considers that only a short abstract is needed to show that.

For water that has found its way into the external ear, Alexander suggests a mode of treatment that is still popularly used. The patient should stand upon the leg corresponding to the side on which there is water in his ear, and then, with head leaning to that side, should hop or kick out with the other leg. The water may be drawn out by means of suction through a reed. In order to get foreign bodies out of the external auditory canal, an ear spoon or other small instrument should be wrapped in wool and dipped in turpentine, or some other sticky material. Occasionally he has seen sneezing, especially if the mouth and nose are covered with a cloth, and the head leant toward the affected side, bring about a dislodgment of the foreign body. If these means do not succeed, gentle injections of warm oil or washing out of the canal with honey water should be tried. Foreign bodies may also be removed by means of suction. Insects or worms that find their way into the ear may be killed by injections of acid and oil, or other substances.

Gurlt also calls attention to Alexander’s careful differentiation of certain very dangerous forms of inflammation of the throat from others which are rather readily treated. He says, “Inflammation of the throat may, under certain circumstances, belong to the severest diseases. The patients succumb to it as a consequence of suffocation, just as if they were choked or hanged. For this reason, perhaps, the affection bears the name synanche, which means constriction.” He then points out various other forms of inflammation of the throat, acute and chronic, suggesting various names and the differential diagnostic signs.

One of the most surprising chapters of Alexander’s knowledge of pathology and therapeutics is to be found in his treatment of the subject of intestinal worms, which is contained in a letter sent by him to his friend, Theodore, whose child was suffering from them. He describes the oxyuris vermicularis with knowledge manifestly derived from personal observation. He dwells on the itching in the region of the anus, caused by the oxyuris, and the fact that they probably find their way into the upper part of the digestive tract because of the soiling of the hands. He knew that the tapeworms often reached great length, he has seen one over sixteen feet long, and also that they had a life cycle, so that they existed in two different forms. He describes the roundworms as existing in the intestines, but occasionally wandering into the stomach to be vomited. His vermifuges were the flowers and the seeds of the pomegranate, the seeds of the heliotrope, castor-oil, and certain herbs that are still used, by country people, at least, as worm medicines. For roundworms he recommended especially a decoction of artemisia maritima, coriander seeds, and decoctions of thyme. Our return to thymol for intestinal parasites is interesting. For the oxyuris he prescribed clysters of ethereal oils. We have not advanced much in our treatment of intestinal worms in the fifteen hundred years since Alexander’s time.

PAUL OF AEGINA

Another extremely important writer in these early medieval times, whose opportunities for study in medicine and for the practice of it, were afforded him by Christian schools and Christian hospitals, was Paul of AEgina. He was born on the island of AEgina, hence the name AEginetus, by which he is commonly known. There used to be considerable doubt as to just when Paul lived, and dates for his career were placed as widely apart as the fifth and the seventh centuries. We know that he was educated at the University of Alexandria. As that institution was broken up at the time of the capture of the city by the Arabs, he cannot have been there later than during the first half of the seventh century. An Arabian writer, Abul Farag, in “The Story of the Reign of the Emperor Heraclius,” who died 641, says that “among the celebrated physicians who flourished at this time was Paulus AEginetus.” In his works Paul quotes from Alexander of Tralles, so that there seems to be no doubt now that his life must be placed in the seventh century.

The most important portion of Paul’s work for the modern time is contained in his sixth book on surgery. In this his personal observations are especially accumulated. Gurlt has reviewed it at considerable length, devoting altogether nearly thirty pages to it, and it well deserves this lengthy abstract. Paul quotes a great many of the writers on surgery before his time, and then adds the results of his own observation and experience. In it one finds careful detailed descriptions of many operations that are usually supposed to be modern. Very probably the description quoted by Gurlt of the method of treating fishbones that have become caught in the throat will give the best idea of how thoroughly practical Paul is in his directions. He says: “It will often happen in eating that fishbones or other objects may be swallowed and get caught in some part of the throat. If they can be seen they should be removed with the forceps designed for that purpose. Where they are deeper, some recommend that the patient should swallow large mouthfuls of bread or other such food. Others recommend that a clean soft sponge of small circumference to which a string is attached be swallowed, and then drawn out by means of the string. This should be repeated until the bone or other object gets caught in the sponge and is drawn out. If the patient is seen immediately after eating, and the swallowed object is not visible, vomiting should be brought on by means of a finger in the throat or irritation with the feather, and then not infrequently the swallowed object will be brought up with the vomit.”

In the chapter immediately following this, XXXIII, there is a description of the method of opening the larynx or the trachea, with the indications for this operation. The surgeon will know that he has opened the trachea when the air streams out of the wound with some force, and the voice is lost. As soon as the danger of suffocation is over, the edges of the wound should be freshened and the skin surfaces brought together with sutures. Only the skin without the cartilage should be sutured, and general treatment for encouraging union should be employed. If the wound fails to heal immediately, a treatment calculated to encourage granulations should be undertaken. This same method of treatment will be of service whenever we happen to have a patient who, in order to commit suicide, has cut his throat. Paul’s exact term is, perhaps, best translated by the expression, slashed his larynx.

One of the features of Paul’s “Treatise on Surgery” is his description of a radical operation for hernia. He describes scrotal hernia under the name enterocele, and says that it is due either to a tearing or a stretching of the peritoneum. It may be the consequence either of injury or of violent efforts made during crying. When the scrotum contains only omentum, he calls the condition epiplocele; when it also contains intestine, an epiplo-enterocele. Hernia that does not descend into the scrotum he calls bubonocele. For operation the patient should be placed on the back, and, the skin of the inguinal region being stretched by an assistant, an oblique incision in the direction in which the blood vessels run should be made. The incision should then be stretched by means of retractors, until the contents of the sac can be lifted out. All adhesions should be broken up and the fat be removed, and the hernia replaced within the abdomen. Care should be taken that no loop of intestine is allowed to remain. Then a large needle with double thread made of ten strands should be run through the middle of the incision in the end of the peritoneum, and tied firmly in cross sutures. The outer structures should be brought together with a second ligature, and the lower end of the incision should have a wick placed in it for drainage, and the site of operation should be covered with an oil bandage.

The Arab writer, Abul Farag, to whose references we owe the definite placing of the time when Paul lived, said that “he had special experience in women’s diseases, and had devoted himself to them with great industry and success. The midwives of the time were accustomed to go to him and ask his counsel with regard to accidents that happen during and after parturition. He willingly imparted his information, and told them what they should do. For this reason he came to be known as the Obstetrician.” Perhaps the term should be translated the man-midwife, for it was rather unusual for men to have much knowledge of this subject. His knowledge of the phenomena of menstruation was as wide and definite. He knew a great deal of how to treat its disturbances. He seems to have been the first one to suggest that in metrorrhagia, with severe hemorrhage from the uterus, the bleeding might be stopped by putting ligatures around the limbs. This same method has been suggested for severe hemorrhage from the lungs as well as from the uterus in our own time. In hysteria he also suggested ligature of the limbs, and it is easy to understand that this might be a very strongly suggestive treatment for the severer forms of hysteria. It is possible, too, that the modification of the circulation to the nervous system induced by the shutting off of the circulation in large areas of the body might very well have a favorable physical effect in this affection. Paul’s description of the use of the speculum is as complete as that in any modern text-book of gynaecology.

FURTHER CHRISTIAN PHYSICIANS

Another distinguished Christian medical scientist was Theophilus Protosbatharius, who belonged to the court of the Greek Emperor Heraclius, in the seventh century. He seems to have had a life very full of interest and surprisingly varied duties. He was a bishop, and, at the same time, commander of the imperial bodyguard, and the author of a little work on the fabric of the human body. The most surprising chapter in the history of the book is that for some two centuries, in quite modern times, it was used as a text-book of anatomy at the University of Paris. It was printed in a number of editions early in the history of printing, at least one very probably before 1500, and several later.

There are very interesting phases of medicine delightfully surprising in their modernity to be found here and there in many of these early Christian writers on medicine. For instance, in a compend of medicine written by one Leo, who, under the Emperor Theophilus, seems to have been a prominent physician of Byzantium (the compend was written for a young physician just beginning practice), we find the following classification of hydrops or abdominal dilatation: “There are three kinds; the first is ascites, due to the presence of watery fluid, for which we do paracentesis; second, tympany, when the abdomen is swollen from the presence of air or gas. This may be differentiated by percussion of the belly. When air is present the sound given forth is like that of a drum, while in the first form ascites the sound is like that from a sack [the word used is the same as for a wine sack]; the third form is called anasarca, when the whole body swells.”

It has often been the subject of misunderstanding as to why medicine should have developed among the Latin Christian nations so much more slowly than among the Arabs during the early Middle Ages. Anyone who knows the conditions in which Christianity came into existence in Italy will not be surprised at that. The Arabs in the East were in contact with Greek thought, and that is eminently prolific and inspiring. At the most, the Christians in Italy got their inspiration at second hand through the Romans. The Romans themselves, in spite of intimate contact with Greek physicians, never made any important contributions to medical science, nor to science of any kind. Their successors, the Christians of Rome and Italy, then could scarcely be expected to do better, hampered especially, as they were, by the trying social conditions created by the invasion of the barbarians from the North. Whenever the Christians were in contact with Greek thought and Greek medicine, above all, as at Alexandria, or in certain of the cities of the near East, we have distinguished contributions from them.

ARABIAN CHRISTIAN PHYSICIANS

That this is not a partial view suggested by the desire to make out a better case for Christianity in its relation to science will be very well understood, besides, from the fact that a number of the original physicians of Arab stock who attracted attention during the first period of Arabian medicine, that is, during the eighth and ninth centuries, were Christians. There are a series of physicians belonging to the Christian family Bachtischua, a name which is derived from Bocht Jesu, that is, servant of Jesus, who, from the middle of the eighth to the middle of the eleventh century, acquired great fame. The first of them, George (Dschordschis), after acquiring fame elsewhere, was called to Bagdad by the Caliph El-Mansur, where, because of his medical skill, he reached the highest honors. His son became the body-physician of Harun al-Raschid. In the third generation Gabriel (Dschibril) acquired fame and did much, as had his father and grandfather, for the medicine of the time, by translations of the Greek physicians into Arabian.

These men may well be said to have introduced Greek medicine to the Mohammedans. It was their teaching that aroused Moslem scholars from the apathy that had characterized the attitude of the Arabian people toward science at the beginning of Mohammedanism. As time went on, other great Christian medical teachers distinguished themselves among the Arabs. Of these the most prominent was Messui the elder, who is also known as Janus Damascenus. Both he and his father practised medicine with great success in Bagdad, and his son became the body-physician to Harun al-Raschid either after or in conjunction with Gabriel Bachtischua. Like his colleague or predecessor in official position, he, too, made translations from the Greek into Arabic. Another distinguished Arabian Christian physician was Serapion the elder. He was born in Damascus, and flourished about the middle of the ninth century. He wrote a book on medicine called the “Aggregator,” or “Breviarium,” or “Practica Medicinae,” which appeared in many printed editions within the century after the invention of printing. During the ninth century, also, we have an account of Honein Ben Ischak, who is known in the West as Johannitius. After travelling much, especially in Greece and Persia, he settled in Bagdad, and, under the patronage of the Caliph Mamum, made many translations. He translated most of the old Greek medical writers, and also certain of the Greek philosophic and mathematical works. The accuracy of his translations became a proverb. His compendium of Galen was the text-book of medicine in the West for many centuries. It was known as the “Isagoge in Artem Parvam Galeni.” His son, Ishac Ben Honein, and his nephew, Hobeisch, were also famous as medical practitioners and translators.

Still another of these Arabian Christians, who acquired a reputation as writers in medicine, was Alkindus. He wrote with regard to nearly everything, however, and so came to be called the philosopher. He is said altogether to have written and translated about two hundred works, of which twenty-two treat of medicine. He was a contemporary of Honein Ben Ischak in the ninth century. Another of the great ninth-century Christian physicians and translators from the Greek was Kostaben Luka. He was of Greek origin, but lived in Armenia and made translations from Greek into Arabic. Nearly all of these men took not alone medical science, but the whole round of physical science, for their special subject. A typical example in the ninth century was Abuhassan Ben Korra, many of whose family during succeeding generations attracted attention as scholars. He became the astronomer and physician of the Caliph Motadhid. His translations in medical literature were mainly excerpts from Hippocrates and Galen meant for popular use. These Christian translators, thoroughly scientific as far as their times permitted them to be, were wonderfully industrious in their work as translators, great teachers in every sense of the word, and they are the men who formed the traditions on which the greater Arabian physicians from Rhazes onward were educated.

It would be easy to think that these men, occupied so much with translations, and intent on the re-introduction of Greek medicine, might have depended very little on their own observations, and been very impractical. All that is needed to counteract any such false impression, however, is to know something definite about their books. Gurlt, in his “History of Surgery,” has some quotations from Serapion the elder, who is often quoted by Rhazes. In the treatment of hemorrhoids Serapion advises ligature and insists that they must be tied with a silk thread or with some other strong thread, and then relief will come. He says some people burn them medicinis acutis (touching with acids, as some do even yet), and some incise them with a knife. He prefers the ligature, however. He calmly discusses the removal of stones from the kidney by incision of the pelvis of the kidney through an opening in the loin. He considers the operation very dangerous, however, but seems to think the removal of a stone from the bladder a rather simple procedure. His description of the technique of the use of a catheter and of a stylet with it, and apparently also of a guide for it in difficult cases, is extremely interesting. He suggests the opening of the bladder in the median line, midway between the scrotum and the anus, and the placing of a canula therein, so as to permit drainage until healing occurs.

Even this brief review of the careers and the writings of the physicians of early Christian times shows how well the tradition of old Greek medicine was being carried on. There was much to hamper the cultivation of science in the disturbances of the time, the gradual breaking up of the Roman Empire, and the replacement of the peoples of southern Europe by the northern nations, who had come in, yet in spite of all this, medical tradition was well preserved. The most prominent of the conservators were themselves men whose opinions on problems of practical medicine were often of value, and whose powers of observation frequently cannot but be admired. There is absolutely no trace of anything like opposition to the development of medical science or medical practice, but, on the contrary, everywhere among political and ecclesiastical authorities, we find encouragement and patronage. The very fact that, in the storm and stress of the succeeding centuries, manuscript copies of the writings of the physicians of this time were preserved for us in spite of the many vicissitudes to which they were subjected from fire, and war, and accidents of various kinds for hundreds of years, until the coming of printing, shows in what estimation they were held. During this time they owed their preservation to churchmen, for the libraries and the copying-rooms were all under ecclesiastical control.