Alexander Of Tralles
( Originally Published 1911 )
An even more striking example than the life and work of Aetius as evidence for the encouragement and patronage of medicine in early Christian times, is to be found in the career of Alexander of Tralles, whose writings have been the subject of most careful attention in the Renaissance period and in our own, and who must be considered one of the great independent thinkers in medicine. While it is usually assumed that whatever there was of medical writing during the Middle Ages was mere copying and compilation, here at least is a man who could not only judiciously select., but who could critically estimate the value of medical opinions and procedure, and weighing them by his own experience and observation, turn out work that was valuable for all succeeding generations. The modern German school of medical historians have agreed in declaring him an independent thinker and physician, who represents a distinct link in medical tradition.
He came of a distinguished family, in which the following of medicine as a profession might be looked upon as hereditary. his father was a physician, and it is probable that there were physicians in preceding generations, and one of his brothers, Dioscoros, was also a successful physician. Altogether four of his brothers reached such distinction in their life work that their names have come down to us through nearly fifteen hundred years. The eldest of them was Anthemios, the builder of the great church of Santa Sophia in Constantinople. As this is one of the world's great churches, and still stands for the admiration of men a millennium and a half after its completion, it is easy to understand that Atathemios' reputation is well founded. A second brother was Metrodoros, a distinguished grammarian and teacher, especially of the youthful nobility of Byzantium, as it was then called, or Constantinople, as we have come to call it. A third brother was a prominent jurist, also in Constantinople. The fourth brother, Dioseoros, like Alexander, a physician, remained in his birthplace, Tralles, and acquired there a great practice.
It was with his father at Tralles that Alexander received his early medical training. The father of a friend and colleague, Comas, who later dedicated a book to Alexander, was also his teacher, While lie was in his native city. As a young man, Alexander undertook extensive travels, which led him into Italy, Gaul, Spain, and Africa, everywhere gathering medical knowledge and medical experience. Then he settled down at Home, probably in an official position, and practised medicine successfully until a very old age. He was probably eighty years of age when, some time during the first decade of the seventh century, he died.
Puschmann, who has made a special study of Alexander's life and work, suggests that since some of his books have the form of academic lectures he was probably a teacher of medicine at Rome. As might be expected from what we know of the relations of the rest of the family to the nobility of the time, it is easy to understand, especially in connection with hints in Alexander's favorite /nodes of therapeutics, that costliness of remedies made no difference to his patients, that lie must have had the treatment of some of the wealthiest families in Home.
His principal work is a Treatise on the Pathology and Therapeutics of Internal Diseases, in twelve books. The first eleven books were evidently material gathered for lectures or teaching of some kind. The twelfth book, in which considerable use of Aetius' writings is made, was written, according to Puschmann, toward the end of Alexander's life, and was meant to contain supplementary matter, comprising especially his views gathered from observation as to the pathology of internal diseases. A shorter treatise of Alexander is with regard to intestinal parasites. There are many printed editions of these books, and many manuscript copies are in existence. Alexander was often quoted during the Middle Ages, and in recent years, with the growth of our knowledge of medical history, lie has come to be a favorite subject of study.
Alexander's first book of pathology and therapeutics treats of head and brain diseases. For baldness, the first symptom of which is falling out of the hair, he counsels cutting the hair short, washing the scalp vigorously, and the rubbing in of sulphur ointments. For grey hair he suggests certain hair dyes, as nutgalls, red wine, and so forth. For dandruff, which he described as the excessive formation of small flake-like scales, he recommends rubbing with wine, with certain salves, and washing with salt water.
lie gives a good deal of attention to diseases of the nervous system. He 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 eases 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. Ile 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 melanchohia, 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. lie counselled the use of venesection, of laxatives and purgatives, of baths and stimulant remedies. lie insisted very much, however, on mental influence in the disease, on chauge 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 he 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 cousumption. 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 hcalthy parts of the circulation. He insisted that the patients must rcst, that they should take acid and astringent drinks, that cold compresses should he 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 rationah 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 corn-presses, 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 bad 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 kg. 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 eanal with honey watcr should be tried. Foreign bodies may also he 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 subjcct 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 vernicularis 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 especialhy 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.