Beginning of Decline--Neoplatonism--Antyllus--Oribasius--Magnus--
Jacobus Psychristus--Adamantius--Meletius--Nemesius--Ætius--
Alexander of Tralles--The Plague--Moschion--Paulus Ægineta--Decline
of Healing Art.
The death of Galen marks the beginning of the decline of medical science
in ancient times, and this decline was contemporaneous with the
overthrow of the Roman State. As everybody knows, the decline and fall
of the Roman Empire resulted from the profligacy and incapacity of the
emperors, luxurious living and vice among the people, tyranny of an
overbearing soldiery at home, and the attacks of barbarian foes
gradually increasing in strength. Rome fell quickly into the hands of
the barbarians, and her power was broken. In A.D. 395, was founded the
Byzantine Empire, also styled the East Roman, Greek, or Lower Empire,
which lasted for more than a thousand years, and took its name from the
capital, Byzantium or Constantinople. In this empire medical science
maintained a feeble and sickly existence. During this Byzantine Period
there were a few physicians of note, but they were mainly commentators,
and medical science retrograded rather than progressed.
Neoplatonism exerted a powerful influence upon the healing art. It was founded by Plotinus, and was for three centuries a formidable rival to Christianity. The Neoplatonists believed that man could intuitively know the absolute by a faculty called Ecstasy. Neoplatonism is a term which covers a very wide range of varying thought; essentially, it was a combination of philosophy and religion, arising from the intellectual movement in Alexandria. It covered a great deal of mysticism, magic and spiritualism, and the followers of the system, as it developed, became believers in the efficacy of certain exercises and symbols to cure diseases. They entered as Kingsley wrote, "the fairy land of ecstasy, clairvoyance, insensibility to pain, cures produced by the effect of what we now call mesmerism. They are all there, these modern puzzles, in those old books of the long bygone seekers for wisdom." It is wonderful how mankind in their pursuit of knowledge seem to have progressed in a circle.
The influence which Christianity exerted upon the investigation of medical science during the early centuries of our era will be considered at length in a subsequent chapter.
Antyllus was perhaps the greatest surgeon of antiquity. He lived before the end of the fourth century A.D., for he is quoted by Oribasius, but is not mentioned by Galen. The time in which he lived was about the year A.D. 300. He was a voluminous writer, but his works have perished except for quotations by later writers. The fragments of his writings were collected and published in 1799. Antyllus performed an operation for aneurism, which consisted in laying open the sac, turning out the clots, securing the vessels above and below, and allowing the wound to heal by granulation. As this operation was performed without anæsthetics or antiseptics it was attended with great mortality, and the risk of secondary hæmorrhage was very great. Antyllus had operations for the cure of stammering, for cataract, and for the treatment of contractures by the method of tenotomy. He also removed enlarged glands of the neck. It was part of the practice of Antyllus to ligature arteries before cutting them, a method which was subsequently "rediscovered" owing to neglect of the study of the history of medicine. He gave directions for avoiding the carotid artery and internal jugular vein in operations upon the neck.
A fragment of the writings of Antyllus is preserved by Paulus Ægineta,[27] and shows the quality of the work done in bygone ages. It is his description of the operation of tracheotomy, and runs as follows:--
"When we proceed to perform this operation we must cut through some part of the windpipe, below the larynx, about the third or fourth ring; for to divide the whole would be dangerous. This place is commodious, because it is not covered with any flesh, and because it has no vessels situated near the divided part. Therefore, bending the head of the patient backward, so that the windpipe may come more forward to the view, we make a transverse section between two of the rings, so that in this case not the cartilage but the membrane which unites the cartilages together, is divided. If the operator be a little timid, he may first stretch the skin with a hook and divide it; then, proceeding to the windpipe, and separating the vessels, if any are in the way, he may make the incision." This operation had been proposed by Asclepiades about three hundred years before the time of Antyllus.
Oribasius was born at Pergamos, the birthplace of Galen, about A.D. 326. He studied under Zenon, who lectured and practised at Alexandria, and was expelled by the bishop, but afterwards reinstated by command of the Emperor Julian (A.D. 361). When Julian was kept in confinement in Asia Minor, Oribasius became acquainted with him, and they were soon close friends. When Julian was raised to the rank of Cæsar, Oribasius accompanied him into Gaul. During this journey Oribasius, at the request of his patron, made an epitome of the writings of Galen, and then extended the work by including a collection of the writings of all preceding medical authors. When this work was finally completed it consisted of seventy books under the title "Collecta Medicinalia." He wrote also for his friend and biographer Eunapius two books on diseases and their treatment, and treatises on anatomy and on the works of Galen. He earned for himself the title of the Ape of Galen. In the "Life of Oribasius," by Eunapius, we find that Julian created Oribasius Quæstor of Constantinople, but after the death of Julian, Oribasius was exiled, and practised among the "barbarians," attaining great fame. In his exile he married a rich woman of good family, and to one of his sons, Eustathius by name, he addressed an abridgment of his first great book, the smaller work being called the "Synopsis." He ultimately returned from exile, and again reached a very honourable position, to which he was well entitled in virtue of the great fortitude with which he had borne adversity.
An edition of Oribasius was published at Paris between 1851 and 1876, in six volumes, by Daremberg and Bussemaker, under the patronage of the French Government. The authors of this edition took infinite pains to show the sources from which the writings of Oribasius had been derived, chief of which were the original writings of Galen, Hippocrates, Soranus, Rufus, and Antyllus. Oribasius was almost entirely a compiler, but also did some original work. To him is due the credit of describing the drum of the ear and the salivary glands. He described also the strange disease called lycanthropy, a form of insanity in which the patient thinks himself a wolf, and leaves his home at night to wander amongst the tombs.
Oribasius was held to be the wisest man of his time. There was something very charming in his manner and conversation, and the barbarians considered him as little less than a god.
Magnus, a native of Mesopotamia, was a pupil of Zenon and lectured at Alexandria. He was famous for his eloquence and dialectical skill, and wrote a book on "Urine" which is referred to by Theophilus.
Jacobus Psychristus was a famous physician who practised at Constantinople, A.D. 457-474. He was called "the Saviour" because of the great success of his treatment.
Adamantius of Alexandria both taught and practised medicine. He was a Jewish physician who was expelled from Alexandria in A.D. 415, and settled in Constantinople.
Meletius was a Christian monk who lived in the fourth century, according to some authorities, but it is probable that he belonged to a later period, the sixth or seventh century. He wrote on the nature of man, but the book is of no value as a contribution to physiology.
Nemesius, Bishop of Emissa, at the end of the fourth century wrote a book called "De Natura Hominis," and came very close to two important discoveries, namely, the functions of the bile and the circulation of the blood. Of the former, he wrote, "The yellow bile is constituted both for itself and for other purposes; for it contributes to digestion and promotes the expulsion of the excrements; and therefore it is in a manner one of the nutritive organs, besides imparting a sort of heat to the body, like the vital power. For these reasons, therefore, it seems to be made for itself; but, inasmuch as it purges the blood, it seems to be made in a manner for this also."[28]
With reference to the circulation of the blood, Nemesius wrote: "The motion of the pulse (called also the vital power) takes its rise from the heart and chiefly from its left ventricle. The artery is with great vehemence dilated and contracted, by a sort of constant harmony and order, the motion commencing at the heart. While it is dilated it draws with force the thinner part of the blood from the neighbouring veins, the exhalation or vapour of which blood becomes the aliment for the vital spirit. But while it is contracted it exhales whatever fumes it has through the whole body and by secret passages, as the heart throws out whatever is fuliginous through the mouth and nose by expiration."[29]
This book was first translated into English in 1636.
Nemesius also wrote on religion and philosophy. In regard to his medical writings, although he did not go far enough to anticipate the discovery of Harvey, his contribution to medical science was remarkable.
Ætius was born in Mesopotamia and lived at the end of the fifth or the beginning of the sixth century. He studied at Alexandria, and settled at Constantinople, where he attained to the honour of court chamberlain, and physician to the Emperor Justinian. He was the first notable physician to profess Christianity. In compounding medicines, he recommended that the following prayer should be repeated in a low voice: "May the God of Abraham, the God of Isaac, and the God of Jacob deign to bestow upon this medicament such and such virtues." To extract a piece of bone sticking in the throat, the physician should call out loudly: "As Jesus Christ drew Lazarus from the grave, and as Jonah came out of the whale, thus Blasius, the martyr and servant of God, commands, 'Bone, come up or go down.'"
Ætius wrote the "Sixteen Books on Medicine," and these contain original matter, but are of value mainly as being a compilation of the medical knowledge of his time. He was the first writer to mention certain Eastern drugs, such as cloves and camphor, and had a great knowledge of the spells and charms used in the East, more especially by the Egyptian Christians. All the nostrums, amulets and charms that were used at the time are enumerated, and display a gloomy picture of the superstition and ignorance that prevailed. The surgical and gynæcological sections of the writings of Ætius are, in most parts, excellent. He treated cut arteries by twisting or tying, and advised the irrigation of wounds with cold water. In the operation of lithotomy he recommended that the blade of the knife should be guarded by a tube. He used the seton and the cautery, which was much in vogue in his day, especially in cases of paralysis. He quotes Archigenes, who wrote: "I should not at all hesitate to make an eschar in the nape of the neck, where the spinal marrow takes its rise, two on each side of it ... and if the ulcers continue running a good while, I should not doubt of a perfect recovery."
Alexander of Tralles lived from A.D. 525 to 605. He was the son of a physician, and one of five brothers, who were all distinguished for scholarship. He studied philosophy as well as medicine, and travelled in France, Spain, and Italy to extend his knowledge. He took up permanent residence in Rome, and became very celebrated. When he became too old to continue active practice, he found leisure to write twelve books on medical diseases, following to some extent the teaching of Galen. The style of these books is elegant, and his description of diseases accurate. Alexander of Tralles was the first to open the jugular vein in disease, and employed iron and other useful remedies, but he lived in superstitious times, and was very credulous. For epilepsy, he recommended a piece of sail from a wrecked vessel, worn round the arm for seven weeks.[30] For colic, he recommended the heart of a lark attached to the right thigh, and for pain in the kidneys an amulet depicting Hercules overcoming a lion. To exorcise gout, he used incantations, these being either oral or written on a thin sheet of gold during the waning of the moon. Writing a suitable inscription on an olive leaf, gathered before sunrise, was his specific for ague. Alexander appears at times to have doubted the efficacy of such remedies as amulets, for he explains that his rich patients would not submit to rational treatment, and it was necessary, therefore, to use other methods reputed to be curative.
In the age of Justinian great scourges devastated the world. In A.D. 526 Antioch was destroyed by an earthquake, and it is said that 250,000 people perished, but the most dreadful visitation on mankind was the great plague which raged in A.D. 542 and the following years, and, as Gibbon writes, "depopulated the earth in the time of Justinian and his successors." Procopius, who was versed in medicine, was the historian of the period. This fell disease began between the Serbonian bog and the eastern channel of the Nile. "From thence, tracing as it were a double path, it spread to the east, over Syria, Persia, and the Indies, and penetrated to the west, along the coast of Africa, and over the continent of Europe. In the spring of the second year, Constantinople, during three or four months, was visited by the pestilence; and Procopius, who observed its progress and symptoms with the eyes of a physician, has emulated the skill and diligence of Thucydides in the latter's description of the plague of Athens. The infection was sometimes announced by the visions of a distempered fancy, and the victim despaired as soon as he had heard the menace and felt the stroke of an invisible spectre. But the greater number, in their beds, in the streets, in their usual occupation, were surprised by a slight fever, so slight, indeed, that neither the pulse nor the colour of the patient gave any signs of the approaching danger. The same, the next, or the succeeding day, it was declared by the swelling of the glands, particularly those of the groin, of the armpits, and under the ear; and when these buboes or tumours were opened they were found to contain a coal, or black substance, of the size of a lentil. If they came to a first swelling and suppuration, the patient was saved by this kind and natural discharge of the morbid humour. But if they continued hard and dry, a mortification quickly ensued, and the fifth day was commonly the term of his life. The fever was often accompanied with lethargy or delirium; the bodies of the sick were covered with black pustules or carbuncles, the symptoms of immediate death; and in the constitutions too feeble to produce an eruption, the vomiting of blood was followed by a mortification of the bowels. To pregnant women the plague was generally mortal; yet one infant was drawn alive from its dead mother, and three mothers survived the loss of their infected foetus. Youth was the most perilous season: and the female sex was less susceptible than the male; but every rank and profession was attacked with indiscriminate rage, and many of those who escaped were deprived of their speech, without being secure from a return of the disorder. The physicians of Constantinople were zealous and skilful, but their art was baffled by the various symptoms and pertinacious vehemence of the disease; the same remedies were productive of contrary effects and the event capriciously disappointed their prognostics of death or recovery. The order of funerals and the right of sepulchres were confounded; those who were left without friends or servants lay unburied in the streets, or in their desolate houses; and a magistrate was authorized to collect the promiscuous heaps of dead bodies, to transport them by land or water, and to inter them in deep pits beyond the precincts of the city.... No facts have been preserved to sustain an account, or even a conjecture, of the number that perished in this extraordinary mortality. I only find, that during three months 5,000, and at length 10,000, persons died each day at Constantinople; that many cities of the East were left vacant, and that in several districts of Italy the harvest and the vintage withered on the ground."[31]
The spread of disease from East to West was again exemplified in the Middle Ages, in the time of the Crusades, when the Crusaders carried home diseases to their native lands. The Knights of St. John, it is interesting to observe, superintended hospitals at home, and wore the white dress which in earlier times had distinguished the Asclepiades.
Moschion probably lived in the sixth century, and was a specialist in diseases of women. His writings were studied when Soranus was forgotten, but in course of time it was discovered that Moschion's work was nothing but an abbreviated translation of the works of Soranus. "Further, it is held by Weber and Ermerins that even the original Moschion is not based directly on Soranus, but on a work on diseases of women written in the fourth century by Cælius Aurelianus, who in his turn drew from Soranus.... It is interesting to follow the history of this book through its various stages in the light of these different editions, and we would suggest that the first Latin version, for the use of Latin-speaking matrons and midwives, was produced before the fall of the Western Empire in the fifth century; its Greek sister just fits in with the development of Eastern or Greek-speaking Empire at Constantinople in the sixth century; and the version in barbarous Latin points to a later period, when learning was beginning to make way again in Western Europe."[32] Moschion's book is a catechism consisting of 152 questions and answers.
Paulus Ægineta was the last, and one of the most famous, of the Greek physicians. He was born probably in the seventh century in the island of Ægina, but there is some doubt as to the exact period in which he lived. He quotes Alexander of Tralles and Ætius, and therefore lived at a later period than they did, either in the sixth or seventh century. The works of Paulus are compilations, but reveal the skill and learning of the author. He wrote several books, but only one, and that the principal, remains, and is known by the title of "De Re Medica Libri Septem." Dr. Adams, of Banchory, translated this book for the Sydenham Society, and the introduction shows the scope of the work: "In the first book you will find everything that relates to hygiene, and to the preservation from, and correction of, distempers peculiar to the various ages, reasons, temperaments, and so forth; also the powers and use of the different articles of food, as is set forth in the chapter of contents. In the second is explained the whole doctrine of fevers, an account of certain matters relating to them being premised, such as excrementitious discharges, critical days, and other appearances, and concluding with certain symptoms which are the concomitants of fevers. The third book relates to topical affections, beginning from the crown of the head and descending down to the nails of the feet, and so on. Briefly, the fourth book treats of external diseases; the fifth, of wounds and bites from venomous animals; the sixth book is the most important and is devoted to surgery, and contains original observations, and the seventh book contains an account of the properties of medicines." Paulus wrote a famous book on obstetrics, which is now lost, but it gained for him among the Arabs the title of "the accoucheur."
The sixth book on surgery, as has justly been observed by Adams, "contains the most complete system of operative surgery which has come down to us from ancient times." Many important surgical principles are enunciated, such, for instance, as local depletion as against general, and the merit of a free external incision. He first described varicose aneurism, and performed the operation of bronchotomy as described by Antyllus. He favoured the lateral operation for removal of stone from the bladder, and amputated the cancerous breast by crucial incision. He also had an operation, like that of Antyllus, for the cure of aneurism. In brief, Paulus performed many of the operations that are practised at the present day. He travelled in the practice of his calling, and not only had great fame in the Byzantine Empire and in Arabia in his lifetime, but exercised great influence for some centuries. His writings inspired Albucassis, one of the few surgeons and teachers of the Middle Ages.
After the time of Paulus Ægineta the practice of medicine and surgery suffered a very rapid decline, and for five centuries no progress was made. The Middle Ages form a dark and melancholy period in the history of medicine, and we have to come to comparatively recent times before we find the skill and knowledge of the Ancients equalled, while it is only at the present day that they are rapidly being excelled.
Footnotes:
[27] "De re Med.," vi, 33.
[28] c. 28, p. 260, ed. Matth.
[29] c. 24, p. 242.
[30] Lib. 1, c. 20.
[31] Gibbon, "The Decline and Fall of the Roman Empire."
[32] Barbour, Edinburgh Medical Journal, vol. xxxiv, p. 331.