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 (see
Puschmann, Vol. I., p. 494): "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 fistulas 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 epulis.
He thought that one form of epulis 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 cele, 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,"[2] 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.