Chapter VIII: Epilogue: 351 (2)

Something should be said of the errors of Aristotle. Though an excellent Naturalist, he was in general much weaker in Physiology. Thus, he made no proper distinction between arteries and veins. He failed to trace any adequate relations between the sense organs, the nerves, and the brain. His refusal to attach great importance to the brain is remarkable. Primacy he placed with the heart, which he regarded also as the seat of the intelligence. This was contrary not only to the medical opinion of his day, but also to the popular view, voiced, for instance, by Aristophanes in his play _The Clouds_, written about 400 B.C., where we read of a man who had _concussion of the brain_. Moreover, Aristotle’s teacher Plato placed the seat of thought and feeling in the brain. From all we know of Aristotle, it seems probable that he did not take up this attitude without evidence. It seems likely that he had experimented on the brain and found it devoid of sensation. Hence his view, opposed to current belief, that it is not associated with thought. Aristotle regarded the brain simply as an agent for cooling the heart, and preventing it from being over-heated. This cooling process, he considered, was effected by the secretion of _phlegm_ (_pituita_), an idea still preserved in our anatomical term the _pituitary body_.

The views of Aristotle have had a vast influence in determining the direction of medical thought. For more than two thousand years Aristotelian philosophy, in more or less corrupted form, constituted the main intellectual food of mankind. Without some knowledge of the biological verdicts of Aristotle, it is impossible to understand the course taken by Rational Medicine. The influence of Aristotle is specially evident in certain basic biological conceptions.

The problem of the nature of Generation is one in which Aristotle never ceased to take an interest. Among the methods by which he sought to solve it was embryological investigation. His most important embryological researches were made upon the chick. His choice was most fortunate, and the chick has remained, to this day, the classical subject of embryological research. Aristotle asserts that the first signs of life in the hen’s egg are noticeable on the third day, the heart being visible as a palpitating blood-spot. As it develops, two meandering blood-vessels extend to the surrounding tunics. A little later, he observes, the body becomes distinguishable, at first very small and white, the head being clearly distinguished and the eyes very large (Figs. 46-7, p. 117). To follow the main features of the later stages was a comparatively easy task.

Aristotle was greatly impressed by these phenomena. He lays stress on the early appearance of the heart in the embryo. Corresponding to the general gradational view that he had formed of Nature, he held that the most primitive and fundamentally important organs make their appearance before the others. Among the organs all give place to the heart, which he considered the first to live and the last to die. In the heart, as we have seen, he placed the seat of the intelligence.

Thus, not only in his account of the ‘Ladder of Nature’, but also in his theories of individual development, Aristotle exhibits some approach to evolutionary doctrine. This is somewhat obscured, however, by his peculiar view of the nature of procreation. On this topic his general conclusion is that the material substance of the embryo is contributed by the female, but that this is mere passive formable material, almost as though it were the soil in which the embryo grows. The male, by giving the principle of life, the _soul_ (_psyche_), contributes the essential generative agency. But this _soul_ is not material, and it is not, therefore, theoretically necessary for anything material to pass from male to female. The material which does in fact pass with the semen of the male is, as the older philosophers would have said, an _accident_, not an _essential_. The essential contribution of the male is not matter but _form_ and _principle_.

The female then only provides the _material_, the male the _soul_, the form, the principle, that which makes life. Aristotle was thus prepared to accept instances of fertilization without material contact, i.e., in effect, _parthenogenesis_ or ‘virgin birth’. In the centuries that came after him such instances were not infrequently adduced, and this doctrine was given a special turn by Christian theologians. Belief in the ‘accidental’ character of the material contribution of the male was common among men of science till the nineteenth century. The general attitude as to the nature of fertilization set forth, for instance, by William Harvey (1578-1657, pp. 111-14) in his book, _On the Generation of Animals_, published in London in A.D. 1651, is practically identical with the views of Aristotle published in Athens about 350 B.C., just 2,000 years earlier. It is of great interest to note that very recent embryological research goes some way to confirm this view of Aristotle. Without any intervention of the male sexual element, it is possible so to stimulate the egg mechanically as to produce a perfect animal which is thus fatherless from the first. The male element is indeed unnecessary and, in fact, transmits only hereditary characters.

We must say something concerning Aristotle’s conceptions of the nature of Life itself. He was before all things a ‘vitalist’. For him the distinction between living and not-living substance is to be sought not in material constitution, but in the presence or absence of something that he calls _psyche_, which we may translate ‘Soul’. His teaching on this topic had the profoundest influence on subsequent anatomical and physiological thought.

Aristotle’s theory as to the relation of this Soul to material things is a difficult and complicated subject. Its adequate discussion would take us beyond our theme. He holds, however, that the Soul is related to the idea of _form_. In living things the soul is that which gives form. It is the pervasion by the soul that leads to the determinate development of the body and its parts. This activity of the Soul, under the Aristotelian term _Entelechy_ (which we may perhaps translate ‘the indwelling perfectability’ or ‘purposiveness’, see _Preface_), has an important place in modern biological theory, which has, indeed, swung definitely in the direction of the Aristotelian position.

Aristotle defines Life, existing in Matter, as ‘the power of self-nourishment and of independent growth and decay’. Of the Soul, the principle of Life, he distinguishes three orders or types, the lowest _vegetative_, or nutritive and reproductive, next the _animal_ or sensitive, and highest the _rational_ or intellectual soul. The last, he at first held, was peculiar to man, but later he modified this view.

The history of the reception of Aristotle’s science by later ages is very strange to modern eyes. Of all Aristotle’s scientific teachings, men clung most firmly for many centuries not to his finely thought-out biological conceptions, but to a doctrine of the constitution of matter of which the modern student hears nothing. Aristotle, following more ancient writers, held that there were four primary and opposite fundamental _Qualities_, the _hot_ and the _cold_, the _wet_ and the _dry_. These met in binary combination to constitute the four Essences or Existences which entered in varying proportions into the constitution of all Matter. The four Essences, or, to give them their usual name, _Elements_, were _earth_, _air_, _fire_, and _water_. Thus, water was wet and cold, fire hot and dry, and so forth. With this theory later writers combined the somewhat similar Hippocratic doctrine which held that the body was composed of the four ‘Humors’ or liquids: _blood_, _phlegm_, _black bile_ (melancholy), and _yellow bile_ (choler). Some of the Hippocratic physicians had associated excess of the Humors with various types of bodily constitution. Their followers made much of the ‘temperaments’ resulting therefrom, and according to the prevailing humor they distinguished the sanguine, phlegmatic, melancholy or choleric temperament (Fig. 34, p. 97).

These conceptions, now departed altogether from our scientific discipline, still persist embedded in our language. Poetry still uses such ideas as the ‘raging of the elements’ and ‘elemental forces’. We may yet speak of a ‘fiery nature’ or an ‘aerial spirit’. We know what is meant by a _sanguine_ or a _phlegmatic_ temperament, and a _melancholy_ or _choleric_ disposition, and such words conjure up real pictures in our minds (Fig. 34). Until it began to be undermined by Robert Boyle (1627-91) and others in the seventeenth century, the doctrine of the four elements persisted in its entirety, while ideas and terms derived from the old humoral pathology can, in fact, be traced in the medicine of the twentieth century.

The biological activity of the school of Aristotle was continued after his death by his pupil Theophrastus (372-287 B.C.). Especially the writings on plants of Theophrastus are instinct with a thoroughly scientific spirit, and are rightly regarded as the basic documents of the science of Botany. Nevertheless, his works had little effect or influence on his contemporaries and successors. With Theophrastus the purely biological school of Aristotle may be said to come to an end. The biological sciences ceased, for many centuries, to be studied for their own sake and became mere handmaidens of Medicine. Neither mistress nor servant was the better for the change.

II

THE HEIRS OF GREECE

(300 B.C. TO A.D. 200.)

§ 1. _The Alexandrian School._

Soon after Aristotle, about 300 B.C., a great medical school was founded at Alexandria in Egypt. That country had been conquered by Alexander the Great, after whom the town was named. On Alexander’s death, Egypt came under the rule of one of his generals, Ptolemy, who established a dynasty which became extinct with the famous Queen Cleopatra, thirty years before the Christian era. Alexandria was a favorite residence of this Greek dynasty and became more Greek than Egyptian. Ptolemy and his successors were patrons of learning, and at the Alexandrian school remarkable anatomical and physiological researches were made. These were the work of Greek physicians who, in the tradition of their people, were only too wont to associate their discoveries with sweeping theoretical generalizations, often on very inadequate bases.

The two earliest medical teachers at Alexandria were also the greatest, Herophilus of Chalcedon, who flourished about 300 B.C., and his slightly younger contemporary Erasistratus of Chios. Herophilus may be regarded as the father of Anatomy, Erasistratus as the father of Physiology.

Herophilus was probably the first to dissect the human body in public. He recognized the brain as the central organ of the nervous system and regarded it as the seat of the intelligence, thus reversing the verdict of Aristotle on the primacy of the heart. He was the first to grasp the nature of the nerves, which he distinguished as connected with motion and sensation (Fig. 98), though he did not separate them clearly from tendons and sinews. He greatly extended the knowledge of the parts of the brain. Certain parts of the brain still bear titles which are translations of those which he gave them. He also made the first clear distinction between arteries and veins.

At the time of the institution of the Alexandrian medical school, and for long after, there flourished that view of the structure of the world known as _atomic_, propounded by the philosopher Democritus (_c._ 400 B.C.). The chief exponent of the theory was Epicurus (342-270), whose philosophy was of the order which we should now call ‘materialistic’. For it the only ultimate realities were atoms and ‘the void’, and everything was ultimately expressible in these terms. Epicurean philosophy was not without its reactions on Medicine at Alexandria, where its leading exponent was Erasistratus of Chios.

Erasistratus was essentially a rationalist and professed himself a foe to all mysticism. In the last resort, however, he had to invoke the idea of Nature as a great artist acting as an external power, shaping the body according to the ends to which it must act. This is in contrast with Aristotle’s view of the ‘soul’ as an _Entelechy_ (p. 33), an innate and inherent factor. Erasistratus sought to express his views in atomic terms, but, to make physiology intelligible, he added a conception, _Pneumatism_, found also among older thinkers. Pneumatism is the belief that the phenomena of life are associated with the existence of a subtle vapor, ‘pneuma’ or spirit, which permeates the organism, and causes its movements. This subtle vapor is held to have some affinities with the air we breathe. Pneumatism is, in fact, a primitive attempt to explain the phenomena of respiration.

Erasistratus observed that every organ is equipped with a threefold system of ‘vessels’, vein, artery, and nerve, which divide to the very limits of vision, and he considered that the process of division continues beyond those limits. The minute divisions of these vessels, plaited together, he believed to make up the tissues. Veins, arteries, and nerves are, for him, made of minute tubes of the same nature as themselves, through which they are nourished. Blood and two kinds of pneuma are the essential sources of nourishment and movement. The blood is carried by veins. Air, on the other hand, is taken in by the lungs and passes to the heart, where it becomes changed into a peculiar pneuma, the _Vital Spirit_, which is sent to the various parts of the body by the arteries. This spirit is carried to the brain, in the cavities or ‘ventricles’ of which it is further changed to a second kind of pneuma, the _Animal Spirit_. The animal spirit is conveyed to different parts of the body by the nerves, which are hollow.

In the brain Erasistratus observed the convolutions, noted that they were more elaborate in man than in animals, and associated this complexity with the higher intelligence of man. He distinguished between the main parts of the brain, the ‘cerebrum’ and ‘cerebellum’ (Fig. 100, p. 210), and gave a detailed description of the ‘cerebral ventricles’ or cavities within the brain and of the ‘meninges’ or membranes that cover the brain. He considered that the cerebral ventricles were filled with _Animal Spirit_. (Compare Galen’s scheme, p. 58.)

Erasistratus attained to a clear view of the action of muscles in producing movement. He regarded the shortening of muscles as due to distension by _Animal Spirit_ conveyed to the muscles by the nerves. We may note that similar theories as to the nature of muscular action were again set forth, on theoretical grounds, in the seventeenth century by Descartes (1596-1650, pp. 127-8) and by Borelli (1608-79, pp. 129-30), but were rebutted by the experiments of Swammerdam (1637-80, p. 123). We may recall that we are still in the dark as to the mechanism of contraction of muscle fiber, the structure of which was first revealed by Leeuwenhoek (1632-1723, Figs. 55-56A, p. 121).

Erasistratus considered the chief cause of disease to be excess of blood or _Plethora_. Diseases thus caused differ according to their site. Among them are coughing of blood, epilepsy, pneumonia, tonsillitis, &c. Most of these diseases could be treated by diminishing the local supply of blood by starvation. Among his contemporaries and successors blood-letting was an habitual practice applied to almost every condition. Erasistratus employed it but rarely, and his followers banned it altogether. He was consistently opposed to violent remedies. Among the therapeutic measures which he favored were regulated exercise, diet, and the vapor bath.

Erasistratus complained that many physicians of his time were not interested in Hygiene. He therefore wrote a treatise on the subject. Though he regarded Hygiene as a means of substituting prevention for cure, this did not prevent him from being extremely careful and precise in his treatment of cases.

After the first generation or two, the activity of the Alexandrian medical school flagged, though the city long remained a great teaching center, and minor medical advances were made. Surgery (cf. Fig. 14) seems to have languished less than Medicine. The stagnation in medical matters at Alexandria is in contrast to the continued activity there in Mathematics, Astronomy, Mechanics and Geography.

With the absorption of Egypt into the Roman Empire in 50 B.C. and the extinction of the Ptolemaic dynasty by the death of Cleopatra in 30 B.C., Alexandria ceased to have great scientific importance. The school continued for centuries with restricted activity and devoid of all originality. Intellectually, it had become subordinate to the Metropolis. Rome was now mistress of the world and the future of Medicine must be considered from the point of view of the Roman Empire.

FIG. 14. INSCRIBED TABLET OF ABOUT 100 B.C. from the wall of the temple of Kom-Ombos in Upper Egypt. The temple itself was built by Ptolemy VII (181-146 B.C.), but the carving is later. It is divided into four partitions. These illustrate the surgical instruments in use in Egypt during Alexandrian times.

In the partition to the extreme left can be seen two cupping-glasses (cf. Fig. 8), a case of instruments (cf. Fig. 15), a pair of shears, a sponge, a probe, a pair of fine forceps, and two knives (cf. Fig. 9).

In the next partition to the right can be seen two large forceps, two bags or flasks, a strigil, two magic eyes, a pair of scales, and two growing plants.

In the next partition to the right can be seen several hooks of different forms, several knives, and two or three pairs of forceps.

In the partition to the extreme right can be seen a bifid probe, a pair of tongs, a long-bladed knife, probes, a double hook, a saw, a cautery, and several objects probably intended to represent bandages. ]

§ 2. _Medical Teaching in the Roman Empire._

The original native Roman medical system was quite devoid of scientific elements and was that of a people of the lower culture. Interwoven, as is all primitive Medicine, with ideas that trespass on the domains of religion and magic, it possessed that multitude of ‘specialist deities’ which was so characteristic of the Roman cults. The entire external aspect of Roman medicine was changed by the advent of Greek science. Yet, notwithstanding the large medical field that the Western Empire provided, and the wide acceptance of Greek medicine by the upper classes, it is remarkable that the Latin-speaking peoples produced no eminent physician.

At first scientific medical education at Rome was entirely a matter of private teaching. The earliest important scientific teacher there was the Greek Asclepiades of Bithynia (died _c._ 40 B.C.), a contemporary of the poet Lucretius and, like him, an Epicurean. Asclepiades, like Erasistratus, imported the atomic view of Democritus into Medicine. He deeply influenced the course of later medical thought, ridiculed the Hippocratic attitude of relying on the ‘healing power of nature’ which he regarded as a mere ‘meditation on death’, and urged that active measures were needed for the process of cure to be ‘seemly, swift and sure’. He founded a regular school at Rome which continued after him.

At first the school was the mere personal following of the physician, who took his pupils and apprentices round with him on his visits. At a later stage such groups combined to form societies or colleges, where problems of the art were debated. Towards the end of the reign of Augustus (27 B.C.-14 A.D.) or the beginning of that of Tiberius (14 A.D.-37 A.D.), these societies constructed for themselves a meeting-place on the Esquiline Hill. Finally the emperors built halls or _auditoria_ for the teaching of Medicine. The professors at first received only the pupils’ fees. It was not until the time of the Emperor Vespasian (reigned A.D. 70-9) that medical teachers were given a salary at the public expense. The system was extended by later emperors.

Thus Rome became a center of medical instruction. After a time subsidiary centers were established in other Italian towns. From Italy the custom spread and we meet traces of such schools at the half-Greek Marseilles as well as at Bordeaux, Arles, Nîmes, Lyons, and Saragossa. For the most part these provincial schools produced workaday medical men, few of whose writings have come down to us. They were perhaps largely training-places for the army surgeons. That class seldom had scientific interests, though Dioscorides, one of the most prominent physicians of antiquity, one who earned the respect of Galen and has deeply influenced the modern pharmacopoeia, served in the army under Nero. His book is, in fact, an extremely useful though ill-arranged compendium of drugs. Dioscorides wrote in Greek, and his work was not translated into Latin until the sixth century of our era.

The earliest scientific medical work in Latin is the _De re medica_ of Celsus, which was prepared about A.D. 30. It is in many ways the most readable and well-arranged ancient medical work that we have. It is, however, not an original work but a compilation from the Greek, and the sole surviving part of a complete encyclopaedia of knowledge. Many of its phrases are closely reminiscent of the _Hippocratic Collection_. The ethical tone is high and the general line of treatment sensible and humane. Celsus, though almost forgotten in the Middle Ages, was the first classical medical writer to be printed (A.D. 1476).

The treatise of Celsus opens with an interesting account of the History of Medicine. It then passes on to deal with diet and the general principles of therapeutics and pathology, next it discusses internal disease, and then turns to external diseases. The last part of the work is devoted to surgery, and is perhaps the most valuable of the whole.

Celsus professes himself a follower of Asclepiades of Bithynia (p. 41), but, unlike his master, he by no means despises the Hippocratic _expectant_ method of ‘waiting on the disease’. In many matters we are struck with

his boldness as a surgeon. Thus he describes plastic operations on the face and mouth, and the removal of polypus from the nose. He tells too of the very dangerous operation for extirpating a goiter (p. 303), and of cutting for stone. He gives an excellent account of what might be thought the modern operation for removal of tonsils. Noteworthy also is his description of dental practice which includes the wiring of loose teeth and an account of a dental mirror. An idea of the surgical instruments in use in his time can be obtained from those recovered from Pompeii (Fig. 15).

_a._ Forceps, probably for extracting teeth.

_b._ Small pocket-case of instruments containing sharp spoon,
probe, &c.

_c._ Fine-toothed forceps.

_d._ Trocar and cannula for tapping fluids confined in cavities.

_e._ Speculum for examining orifices and cavities.

_f._ Instrument for dilating wounds that they may be more fully
examined.
]

§ 3. _Medical Services of the Roman Empire._

If, in Medicine itself, the Roman achieved but few advances, in the organization of medical service, and especially in the department which deals with public health, his position is far more noteworthy. All Latin writers on architecture give much attention to the orientation, position and drainage of buildings. From an early date sanitation and public health drew the attention of statesmen. Considering the dread of the neighborhood of marshes on the part of these practical sanitarians of Ancient Rome, and in view of modern knowledge of the mosquito-borne character of Malaria (pp. 284-5), it entertaining to find the mosquito net ridiculed by the poets Horace, Juvenal and Propertius!

Sanitation was a feature of Roman life. Rome was already provided with _cloacae_ or subterranean sewers in the age of the Tarquins (6th cent. B.C.). The _Cloaca Maxima_ itself, the main drain of Rome, which is still in use, dates back to that period.

The antiquity of hygienic ideas is seen in an interdict, by a law of about 450 B.C., against burials within the city walls and in the instructions issued to the town officials to attend to the cleanliness of the streets and to the distribution of water. Among these ancient laws we may note one attributed to the first king of Rome, which directed the opening of the body in the hope of extracting a living child in the case of a woman dying in pregnancy. It is the origin of the so-called ‘Caesarean section’ on the living mother, the method by which Caesar himself is said to have been brought into the world. At the date of these decrees physicians in Rome were either slaves or in an entirely subordinate position. Their status was improved by Julius Caesar (102-44 B.C.), who conferred citizenship on all who practised Medicine at Rome, in order to induce physicians to settle there.

(_From an engraving by Piranesi._)]

The finest monument to the Roman care for the public health stands yet for all to see in the remains of the fourteen great aqueducts which supplied the city with 300,000,000 gallons of potable water daily. No modern city is better equipped (Fig. 16).

Under the early Empire a definite public medical service was constituted. Public physicians were appointed to the various towns and institutions. A statute of the Emperor Antoninus of about the year A.D. 160 regulates the appointment of these physicians, whose main duty was to attend to the poor. In the code of the Emperor Justinian (A.D. 533) is an article urging them to give this service cheerfully rather than the more subservient attendance on the wealthy. Their salaries were fixed by the municipal councillors. They were encouraged to undertake the training of pupils. Inscriptions attest the respect in which these state physicians were held in many towns.

It is in connection with the army that we see the Roman medical 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.

(_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.

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.)

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.

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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.

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.

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.

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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.

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.

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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.

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.

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§ 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.

Greek science in the Arabic version came in time to be better understood by Arabic-speaking students than it had been by any since Galen. Nor were the Arabic-speaking peoples content to rest on the texts that had thus descended to them from antiquity. A considerable number of Arabic writers produced works of their own, some not wholly devoid of originality. Unfortunately these men were without effective anatomical or physiological basis for their medical knowledge, though many of them were acute clinical observers, and, even from the modern point of view, some of their works are not wholly contemptible. Thus Rhazes (860-932), a native of Basra on the Persian Gulf, wrote a work containing the first known description of Measles, which he carefully distinguishes from Small-pox. The Persian Avicenna (980-1036) composed a vast encyclopaedia of medical knowledge, the so-called _Canon_, which served as the main text-book of Medicine both among the Arabic-speaking peoples and in the Latin West until the seventeenth century. The Jew, Isaac of Kairouan (852-952), composed a treatise on fevers which was the best account of the subject available in Europe during the entire Middle Ages. The Moor, Albucasis (11th cent.), left a text-book of surgery which was an important element in the revival of the subject in Italy and France.

These are only prominent members of a vast school of writers who flourished in Arabic-speaking countries between the ninth and thirteenth centuries. The bulk and number of their writings is portentous. Many of their works were translated into Latin, often by Jewish translators (Fig. 26). These Latin translations caused a reawakening of the intellect of Europe, and provided the staple reading in the medieval universities throughout the Middle Ages.

FIG. 26. A JEWISH TRANSLATOR receiving an Arabic medica volume from an Eastern potentate (right) and handing it, translated into Latin, to a Western monarch (left). From a thirteenth-century manuscript.

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§ 3. _The Medieval Awakening._

The Spanish peninsula had been inundated by the Islamic tide as early as the eighth century. After a while the waters began to recede. The speech and culture of Islam had become stamped upon the natives of the peninsula, and were only gradually replaced by the Latin civilization and dialect which we now call Spanish. During the centuries of Islamic retreat, there was thus a bilingual population in the peninsula, so that access to the Arabic learning became possible. The translations that were to have influence on Europe were always into Latin. To make or to obtain such translations many adventurous spirits journeyed from Christian Europe into Spain, or sometimes into Sicily where conditions were very similar. These men were aided in their work by native Jews or by Mohammedans. The heretical company which they kept, together with the strange and mysterious material which they brought back with them, earned them a reputation as magicians. The memory, for instance, of Michael Scot is connected with the Black Art, and has been presented by Sir Walter Scott in his poem _The Lay of the Last Minstrel_.

The wizard Michael Scot (died 1235) journeyed in both Spain and Sicily, learned Arabic and Hebrew, and had commerce with Mohammedans and Jews. He turned a number of Arabic works into Latin, and, in particular, he prepared versions of the biological works of Aristotle (pp. 28-33) which, though corrupt and second-hand, had much influence in determining the direction of medical thought during the Middle Ages.

There was a large class of such translators and commentators who made Arabic Medicine accessible to the West. This Arabic-Latin literature is generally characterized by the qualities most often associated with the words _medieval_ and _scholastic_. It is extremely verbose and almost wholly devoid of the literary graces. An immense amount of attention is paid to the mere arrangement of the material, which often occupies its authors more than the ideas that are to be conveyed. Great stress is laid on argument, especially in the form of the syllogism, while observation of Nature is entirely in the background. Above all, there is a constant appeal to the authority of the ancient masters, especially Aristotle and Galen. Lip service is often paid to Hippocrates, but his spirit is absent from these windy discussions.