system at its best. There was an adequate supply of military medical
attendants who were well organized (Fig. 17). The defects of the Roman
army medical system were, however, absence of any elastic scheme for
the ranking of medical officers, and complete subordination of the
medical to the combatant officer. These facts are of a piece with the
general Roman indifference to theoretical science, and explain
why the Roman army surgeons made no additions to knowledge. The social
status of the medical staff in the Roman military hierarchy was that of
the non-commissioned personnel, which included accountants, registrars
and secretaries.
[Illustration: FIG. 17. ROMAN ADVANCED DRESSING-STATION.
(_From Trajan’s column._)
To the left two Roman soldiers assist a wounded comrade. To the right
a Roman military surgeon bandages the wounded thigh of a friendly
ally. The costume of the surgeon is almost identical with that of the
soldiers, though he carries a case for ‘first aid’ slung over his
shoulder.
]
§ 4. _Roman Hospitals._
The great contribution of Rome to Medicine--and it is a very great
one--is the hospital system. It is a scheme that naturally arose out
of the Roman genius for organization and is connected with the Roman
military system. Among the Greeks, _iatreia_, ‘surgeries’, were well
known; they were, however, the private property of the medical man.
Larger institutions were connected with Aesculapian temples and there
is evidence of some degree of scientific medical treatment in these
places. In the Republican period the Romans were no better off and,
despite the vast numbers of slaves, there was no provision for them
when sick. A temple to Aesculapius had been established on an island of
the Tiber in Republican times. It became the custom to expose the sick
and worn-out slaves on this island of Aesculapius, to avoid the trouble
of treating them. The Emperor Claudius (A.D. 41-54) decreed that such
slaves were free, and that, if they recovered, they need not return to
the control of their masters. Thus, the island became a place of refuge
for the sick poor. We may regard it as an early form of public hospital
(Fig. 18).
Later writers speak of _valetudinaria_, ‘infirmaries’, for such
persons, and give humane directions for their management. Such
valetudinaria were in use even by free Romans. The excavations at
Pompeii show that a physician’s house might even be built somewhat on
the lines of a modern ‘nursing home’. It was probably in the provinces
that private institutions first developed into subventioned public
hospitals.
This development of public hospitals naturally early affected military
life. At first, sick soldiers had been sent home for treatment. As the
Roman frontiers spread ever wider this became impossible and military
hospitals were founded at important strategic points. The sites of
several such military hospitals have been excavated. The best explored
is near Düsseldorf and was founded about A.D. 100.
From the military valetudinarium it was no great step to the
construction of similar institutions for the numerous Imperial
officials and their families in the provincial towns. Motives of
benevolence, too, gradually came in, and public hospitals were
founded in many localities. The idea passed on to Christian times,
and the pious foundation of hospitals for the sick and outcast in the
Middle Ages is to be traced back to these Roman valetudinaria. The
first charitable institution of this kind, concerning which we have
clear information, was established at Rome in the fourth century by
a Christian lady of whom we learn from St. Jerome. The plan of such
a hospital projected at St. Gall in the early years of the ninth
century has survived. It reminds us, in many respects, of the early
Roman military hospitals. These medieval hospitals for the sick must
naturally be distinguished from the even more numerous ‘spitals’ for
travellers and pilgrims, the idea of which may perhaps be traced back
to the rest-houses along the strategic roads of the Empire.
[Illustration: FIG. 18. ISLAND OF ST. BARTHOLOMEW IN THE TIBER AT ROME.
(_From an engraving by Piranesi._)
The island was the site of a temple to Aesculapius used as a refuge
for worn-out slaves. It is the first known public hospital. The entire
island is carved in the form of a ship. On its prow can be discerned
the head of Aesculapius and his staff and serpent. ]
§ 5. _Galen._
The Latin culture, as we have seen, did not adapt itself easily to the
prosecution of scientific Medicine. Long after Greece had ceased to
exist as an independent state such medical writings as appeared were
usually in the Greek rather than in the Latin language. This is true
to the end, and the end came, so far as creative science is concerned,
with the second half of the second century. The scene is then, and for
centuries to come, mainly occupied by the huge overshadowing figure of
Galen.
Galen of Pergamum (A.D. 130-200) devoted himself to medicine from an
early age, and in his twenty-first year we hear of him studying anatomy
at Smyrna. To extend his knowledge of drugs he made long journeys
to Asia Minor. Later he proceeded to Alexandria, where he improved
his anatomical equipment, and here, he tells us, he examined a human
skeleton. His direct practical acquaintance with human anatomy was
limited to that skeleton, for dissection of the human body was no
longer carried on in his time. Thus, his physiology and anatomy were
derived mainly from animal sources.
The general medical standpoint of the Galenic is not unlike that of
the Hippocratic writings, but the noble vision of the lofty-minded,
pure-souled physician has utterly passed away. In its place we have an
acute, contentious fellow of prodigious industry, who is frequently
satisfied with a purely verbal explanation. Yet he is an ingenious
physiologist, acquainted with the internal parts, so far as this is
possible from a devotion to dissection of animals, equipped with
all the learning of the schools of Pergamum, Smyrna and Alexandria,
and rich with the experience of a vast practice at Rome. Galen is
essentially an ‘efficient’ man. He has the grace to acknowledge
constantly his indebtedness to the Hippocratic writings.
Some of Galen’s works are, however, mere drug-lists, little superior to
those of Dioscorides (p. 43). With the depression of the intelligence
that corresponded with the break-up of the Roman Empire, it was these
that were chiefly studied and distributed in the West. The Greek
medical writers after Galen were but his imitators and abstractors, and
they usually imitated and abstracted Galen at his worst. Through some
of them Galen’s works reached the West at a very early period in the
Middle Ages.
§ 6. _The Final Medical Synthesis of Antiquity._
We now turn to the theoretical content of the vast mass of Galenic
writings. These set forth a medical system of which the substance
is based on the _Hippocratic Collection_ and the form derived from
Aristotle. This synthesis, in more or less corrupted form, provided
the theoretical basis of medical practice for the next fifteen hundred
years. Galen’s view of the human body may be examined under two
aspects, which we describe as (_a_) philosophical and (_b_) descriptive.
First as to the philosophical aspect. Galen’s voluminous works are
saturated with the theory that all structures in the body have been
formed by the Creator for a known and intelligible end. In the
anatomical works, masses of explanation, based on this view, dilute
the often imperfect accounts of structures. Thus, following the
Aristotelian principle that Nature makes nought in vain, Galen seeks to
justify, the form and structure of every organ--nay, of every part of
every organ--with reference to the functions for which he believes it
is destined. To do this is to claim that in every work of Creation--of
which Man’s body is a type--and in every detail of such work, we can
demonstrate God’s design along known principles. It is to claim, in
fact, a complete knowledge of the Laws of Nature. No modern man of
science, however intoxicated with his own achievements, has as yet
arrogated such powers to himself. To conceive that such claims should
be made by a pious, theistically minded author, the reader must think
himself back into a very different philosophical environment from that
to which we are nowadays accustomed.
The prevailing philosophy of Galen’s world was the Stoic. Now in the
world of the Stoic philosopher all things were determinate, and they
were determined by forces acting wholly outside Man. The type and
origin of that determination the Stoic sought in the heavens, and found
in the majestic and overwhelming procession of the stars. The recurring
phenomena of the spheres typified, foreshadowed, nay, exhibited and
controlled, the cycle of man’s life. Man dwelt in a finite world,
bounded by a definite frontier--the sphere of the fixed stars. Within
that spherical frontier all things worked by rule--and that rule was
the rule of the heavenly bodies. Astrology had become one of the dogmas
of the Stoic creed.
To such a world Galen’s determination was in itself no strange thought.
Yet Galen’s view was far from being wholly in accord with Stoicism.
Though a determinism, it was a determinism of perfection in which all
was fixed by a wise and far-seeing God, and was a reflection of His
perfection. Now such a scheme did not ill fit the new creed which was
just beginning to raise its head and was destined to replace Stoicism
and all the other pagan schemes. Galen’s thought, in fact, made a
special appeal to the Christian point of view, and this is, doubtless,
the reason that his works have been preserved in larger bulk than
those of any other pagan writer. The Galenic standpoint appealed
equally to the theological bias of Islam, whose medical knowledge was
based almost entirely on Galen.
We may now turn from the philosophical to the descriptive bases of
Galen’s medical system, namely to his Anatomy and Physiology.
We may begin with the bones. These Galen had studied on an actual human
skeleton at Alexandria. He divided them into long bones with a central
canal and flat bones without such a canal. He had a fairly good idea
of the bones of the skull. He regarded the teeth as bones, and he
gives a good description of their origin. He recognized twenty-four
vertebrae terminated by the _sacrum_. Galen gives accurate elementary
descriptions of the vertebrae, of the ribs, of the breastbone, of
the collar-bone, and of the bones of the limbs. He divides joints or
junctions of bones into two main orders, those with movement and those
without movement, and the titles that he gives to his main divisions
have survived in our modern nomenclature.
As regards the muscular system there can be little doubt that Galen’s
work was in large part of a really pioneer character. Throughout
his works the muscles are perhaps the structures that he describes
most accurately. His writings contain frequent references to form
and function of muscles of various animals. Thus, the dissection of
the muscles of the orbit and larynx was performed on the ox, and the
muscles of the tongue are described from the ape. Occasionally he
indicates that he is aware of the differences between certain of the
muscles he is describing from those of man. For his investigation of
muscles Galen used particularly the Barbary ape (_Macacus inuus_),
a creature anatomically near enough to man for a knowledge of its
detailed structure to be applicable to human Surgery. (Figs. 19 and 20.)
[Illustration:
FIG. 19. DISSECTION OF HAND OF MAN.
FIG. 20. DISSECTION OF HAND OF BARBARY APE.
The ape’s hand shows all the main muscular and tendinous structures
present in the human hand, though the proportional development differs
somewhat. The same is true of other parts of the body. Galen’s
anatomy, drawn from the Barbary ape, was thus quite serviceable for
many surgical procedures. Apart from proportion, the most obvious
anatomical difference in the hands of the two species is the position
of attachment of the small severed muscle indicated by the asterisk in
both cases.
]
Galen’s description of the brain and of the vascular system is inferior
to his account of the bones and muscles. His account of the nervous
system, other than the brain, occupies an intermediate position. His
account of the origin of nerves from the brain has left its traces even
in modern descriptive anatomy.
Finally we may turn to Galen’s theory of the working of the human body,
that is to his Physiology.
The basic principle of life in the Galenic physiology was a _spirit_ or
_pneuma_ drawn from the general World-spirit in the act of breathing.
It entered the body through the windpipe or _trachea_ and so passed to
the lung and thence, through the _arteria venalis_--which we now call
the ‘pulmonary vein’--to the left ventricle of the heart, where it
encountered the blood (Fig. 21). But what was the origin of the blood?
To this question his answer was ingenious, and the errors that it
involved remained till the time of Harvey (Fig. 43, p. 113).
Galen believed that food-substance from the intestines was carried as
‘Chyle’ by the portal vein to the liver. There it was converted into
blood and endowed with a particular pneuma, the _Natural Spirit_, which
bestowed the power of growth and nutrition. Part of this lower-grade
blood was carried from the liver to the right ventricle, where it gave
off impurities by way of the _vena arterialis_, our ‘pulmonary artery,’
to the lungs, whence they were exhaled in the breath. The venous
blood, thus continuously purified, ebbed to and fro in the veins
for purposes of ordinary nutrition. A very small part of this venous
blood passed through invisible pores in the muscular septum to the left
ventricle. There it mixed with air drawn in from the lung by way of the
_arteria venalis_, our ‘pulmonary vein’. From this mixture was produced
a higher-grade blood, the arterial blood, instinct with the principle
of life and charged with a second kind of pneuma, the _Vital Spirit_.
Blood containing this second kind of pneuma ebbed to and fro in the
arteries endowing the various organs with function. Such as reached the
brain became there charged with the noblest essence of all, the third
pneuma, the _Animal Spirit_ or breath of the soul. The _Animal Spirit_
was carried from the brain by the nerves--believed to be hollow--and
through them initiated the higher functions of the organism, including
motion and sensation (Fig. 21).
Among Galen’s most remarkable efforts are the investigations he made
of the physiology of the nervous system. He tells of his experiments
on the spinal cord. Injury to the cord between the first and second
vertebrae caused, he observed, instantaneous death. Section between
the third and fourth produced arrest of breathing. Below the sixth
vertebra it gave rise to paralysis of the chest muscles, breathing
being then carried on only by the diaphragm. If the lesion was lower
the paralysis was confined to the lower limbs, bladder, and intestines.
The physiology of the spinal cord is worked out most ably and in very
considerable detail.
Galen established no school, nor had he any definite followers. His
self-satisfaction and love of controversy were not of the kind that
would endear him to disciples. On his death in A.D. 200 the active
prosecution of anatomical and physiological inquiry ceased absolutely.
The curtain descends at once, and, for the subject we are discussing,
the Dark Ages have begun.
Rational medicine in the pagan world descends into darkness as surely
and even more abruptly than Philosophy. The whole system is soon to be
overwhelmed. Alexandria has long been in decline. A mob, fanatically
Christian, has destroyed her school and library, with all the hoarded
wisdom of the pagan past. Men of the new faith fix their eyes on the
wrath to come and the glory after it. In the race for salvation, who
will pause to consider this miserable tenement of clay? Antiquity is no
more. A new age has begun.
[Illustration: FIG. 21. GALEN’S PHYSIOLOGICAL SYSTEM.]
III
THE MIDDLE AGES
(FROM ABOUT A.D. 200 TO ABOUT A.D. 1500.)
§ 1. _The Period of Depression in Europe._
The observational period of Antiquity closed with Galen. The centuries
that follow exhibit progressive deterioration of the intellect. For
that deterioration many causes have been assigned. An important factor
was certainly the philosophical outlook of later paganism. Men lacked a
motive for living. Their view of the World was dreary and without hope.
It is sometimes alleged that the advent of Christianity was a factor
in the decay of Science, but Science was, in fact, in headlong decay
before Christianity was in a position to have any real effect on pagan
thought.
Christianity came to the ancient world as a protest and a revulsion
against the prevailing and extremely pessimistic pagan outlook.
Christianity brought men something for which to live. It was natural
that it should oppose the philosophical basis of pagan thought. In
this sense Christianity was certainly anti-scientific. Early Christian
thought exhibits an aversion to the view which places the whole of
man’s fate under the dominion, the inescapable tyranny, of Natural
Law. It is, however, essential to remember that the early Church, in
developing this opposition, was not dealing with living observational
Science. The conflict was simply with a philosophical tradition which
contained dead, non-progressive and misunderstood scientific elements.
For some eight centuries from the time that Christianity finally
replaced Paganism in the Roman Empire--from about A.D. 400 to about
A.D. 1200--such remains of classical learning and classical science as
survived were in monastic keeping. It was only in the monasteries that
there were any who cared at all for these things, and it was only in
the monasteries that manuscripts could be either written or preserved.
We cannot be sufficiently grateful to the monks for having succeeded in
preserving even as much as they did. Nevertheless, whether we consider
what they saved or what they lost of medical literature, we can express
no high opinion of either monastic taste or monastic judgment.
The curse of the Science of Medicine, as of all sciences, has always
been the so-called ‘practical man’, who will consider only the
immediate end of his art, without regard to the knowledge on which it
is based. Monkish medicine had no thought save for the immediate relief
of the patient. All theoretical knowledge was permitted to lapse.
Anatomy and Physiology perished. Prognosis was reduced to an absurd
rule of thumb. Botany became a drug-list. Superstitious practices crept
in, and Medicine deteriorated into a collection of formulae, punctuated
by incantations, which became less understood and further removed
from their originals at each copying. Medicine remained surrounded by
sacred associations (Fig. 22), but the scientific stream, which is its
life-blood, was dried up at its source.
[Illustration:
FIG. 22. EARLIEST KNOWN REPRESENTATION OF ST. LUKE AS A PHYSICIAN.
From a seventh-century painting in the underground basilica of Saints
Felix and ‘Adauctus’ at Rome. St. Luke, as an Evangelist, holds a
scroll between his hands; as a Physician he carries suspended from his
left arm a bag containing four instruments, one of which is a lancet.
The head is tonsured like a monk’s. By courtesy of Rev. Father J. R.
Fletcher.
FIG. 23. PICTURE OF TREPHINING from a thirteenth-century manuscript.
The surgeon is using a well-known and primitive form of drill, the mode
of action of which will be understood by the accompanying diagram,
shown as Fig. 24.
]
There was just one area in the Latin West where a slightly higher
standard prevailed. In the South of Italy the Greek tongue still
continued for centuries to be spoken and written. Though civilization
had sadly deteriorated with the disorders of the times, yet there
remained here and there in that region a slightly higher intellectual
standard than prevailed elsewhere in Europe. Moreover, about the same
time as the Norman Conquest in England, there was a Norman Conquest
of South Italy also. The strong arm of the Norman administrator might
wield the weapon of a tyrant, but at least it brought order where
there had been anarchy. Learning under the Normans could lift a timid
head. Notably at the town of Salerno, not far from Naples, there arose
something resembling a medical school. At Salerno in the eleventh
century there was a certain amount of translation of medical works from
Greek into Latin. The choice of works for translation was very poor,
but it was something that enough mental energy existed for the effort.
[Illustration:
FIG. 24. Figure to illustrate the mode of action of the instrument used
by the surgeon in Fig. 23. The twist of the thong causes rapid rotation
of the axis. The rotating point is pressed on the skull and gradually
penetrates it. From a drawing of the sixteenth century.
]
Salerno differed too from other centers of learning of the time in that
instruction was not entirely under monastic auspices (Fig. 25). Some,
at least, of the Salernitan physicians were laymen. At the time of the
Norman conquest of Salerno, the school was stimulated by the advent of
a wanderer from the East, Constantine by name (died 1087). This man
brought with him medical works in Arabic which he was able to translate
into rude Latin. The Latin versions prepared by Constantine, corrupt,
confused, barbarous, often almost incomprehensible, were yet a better
intellectual fare than that on which the torpid mind of Europe had
long fed. The Salernitan medical writings of the eleventh and twelfth
centuries exhibit some faint-hearted attempts to return to Nature.
Constantine was but the harbinger of the great ‘Arabian revival’ the
further origins of which we must now seek to trace.
[Illustration:
FIG. 25. SCENE AT A SIEGE OF SALERNO from a manuscript prepared in
South Italy early in the thirteenth century. An archer transfixes two
of the defenders through the cheeks. A _medicus_ is aiding one of
them. Two nurses, bearing drugs and dressings, attend the medicus. It
illustrates the existence of lay physicians at Salerno at this date.
The medicus is not tonsured.
]
§ 2. _Arabic Medicine._
Barbarian incursions sapped and finally destroyed the Western Roman
Empire. The influence of those incursions on the Eastern Empire was
less dramatic. It is true that the intellectual outlook of the East
Roman or Byzantine Empire was no less modified, in the course of time,
than was that of the West. In the absence, however, of any collapse
of the system of government, the ancient Greek learning or rather the
documentary casing in which it was enshrined, was better preserved
than were the Latin traditions. Men in the Eastern Empire could still
read the ancient Greek medical works in the language in which they had
been written, and, if their reading was unintelligent, it was at least
persistent. Moreover, heretical Christian sects on the confines of the
East Roman Empire prepared for themselves translations of many of the
ancient Greek authors. One of these heretical sects, the Nestorians,
exhibited great missionary activity. It was perhaps on this account
that the Nestorians prepared translations of many Greek medical works
into their own language, Syriac.
In the seventh century, Islam arose and soon swept over vast areas
that had erstwhile belonged to the Emperor of the East. The territory
occupied by the Nestorians in the Near East came early under Moslem
rule. The Moslems, at first indifferent to infidel learning, came
gradually to appreciate it. In the ninth century a great and united
Moslem Empire was established with its center at Bagdad. The need for
translation of Greek scientific works into Arabic, the common language
of Islam, now asserted itself. One after another the medical writings
that had been turned into Syriac were translated into Arabic, and Greek
Science in general and Greek Medicine in particular were thus spread
far and wide in the Moslem world.