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 paranoias, 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.