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Alexander Of Tralles

An even more striking example than the life and work of Aetius as
evidence for the encouragement and patronage of medicine in early
Christian times, is to be found in the career of Alexander of Tralles,
whose writings have been the subject of most careful attention in the
Renaissance period and in our own, and who must be considered one of the
great independent thinkers in medicine. While it is usually assumed that
whatever there was of medical writing during the Middle Ages was mere
copying and compilation, here at least is a man who could not only
judiciously select, but who could critically estimate the value of
medical opinions and procedure, and weighing them by his own experience
and observation, turn out work that was valuable for all succeeding
generations. The modern German school of medical historians have agreed
in declaring him an independent thinker and physician, who represents a
distinct link in medical tradition.

He came of a distinguished family, in which the following of medicine as
a profession might be looked upon as hereditary. His father was a
physician, and it is probable that there were physicians in preceding
generations, and one of his brothers, Dioscoros, was also a successful
physician. Altogether four of his brothers reached such distinction in
their life work that their names have come down to us through nearly
fifteen hundred years. The eldest of them was Anthemios, the builder of
the great church of Santa Sophia in Constantinople. As this is one of
the world's great churches, and still stands for the admiration of men a
millennium and a half after its completion, it is easy to understand
that Anthemios' reputation is well founded. A second brother was
Metrodoros, a distinguished grammarian and teacher, especially of the
youthful nobility of Byzantium, as it was then called, or
Constantinople, as we have come to call it. A third brother was a
prominent jurist, also in Constantinople. The fourth brother, Dioscoros,
like Alexander, a physician, remained in his birthplace, Tralles, and
acquired there a great practice.

It was with his father at Tralles that Alexander received his early
medical training. The father of a friend and colleague, Cosmas, who
later dedicated a book to Alexander, was also his teacher, while he was
in his native city. As a young man, Alexander undertook extensive
travels, which led him into Italy, Gaul, Spain, and Africa, everywhere
gathering medical knowledge and medical experience. Then he settled down
at Rome, probably in an official position, and practised medicine
successfully until a very old age. He was probably eighty years of age
when, some time during the first decade of the seventh century, he died.

Puschmann, who has made a special study of Alexander's life and work,
suggests that since some of his books have the form of academic lectures
he was probably a teacher of medicine at Rome. As might be expected from
what we know of the relations of the rest of the family to the nobility
of the time, it is easy to understand, especially in connection with
hints in Alexander's favorite modes of therapeutics, that costliness of
remedies made no difference to his patients, that he must have had the
treatment of some of the wealthiest families in Rome.

His principal work is a Treatise on the Pathology and Therapeutics of
Internal Diseases, in twelve books. The first eleven books were
evidently material gathered for lectures or teaching of some kind. The
twelfth book, in which considerable use of Aetius' writings is made, was
written, according to Puschmann, toward the end of Alexander's life, and
was meant to contain supplementary matter, comprising especially his
views gathered from observation as to the pathology of internal
diseases. A shorter treatise of Alexander is with regard to intestinal
parasites. There are many printed editions of these books, and many
manuscript copies are in existence. Alexander was often quoted during
the Middle Ages, and in recent years, with the growth of our knowledge
of medical history, he has come to be a favorite subject of study.

Alexander's first book of pathology and therapeutics treats of head and
brain diseases. For baldness, the first symptom of which is falling out
of the hair, he counsels cutting the hair short, washing the scalp
vigorously, and the rubbing in of sulphur ointments. For grey hair he
suggests certain hair dyes, as nutgalls, red wine, and so forth. For
dandruff, which he described as the excessive formation of small
flake-like scales, he recommends rubbing with wine, with certain salves,
and washing with salt water.

He 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 cases which occur in

For apoplexy and the consequent paralysis, Alexander considered
venesection the best remedy. Massage, rubbings, baths, and warm
applications are recommended for the paralytic conditions. He had
evidently had considerable experience with epilepsy. It develops either
from injuries of the head or from disturbances of the stomach, or
occasionally other parts of the body. When it occurs in nursing infants,
nourishment is the best remedy, and he gives detailed directions for the
selection of a wet nurse, and very careful directions as to her mode of
life. He emphasizes very much the necessity for careful attention to the
gastro-intestinal tract in many cases of epilepsy. Planned diet and
regular bowels are very helpful. He rejects treatment of the condition
by surgery of the head, either by trephining or by incisions, or
cauterization. Regular exercise, baths, sexual abstinence are the
foundation of any successful treatment. It is probable that we have
returned to Alexander's treatment of epilepsy much more nearly than is
generally thought. There are those who still think that remedies of
various kinds do good, but in the large epileptic colonies regular
exercise, bland diet, regulation of the bowels, and avoidance of
excesses of all kinds, with occupation of mind, constitute the mainstay
of their treatment.

Alexander has much to say with regard to phrenitis, a febrile condition
complicated by delirium, which, following Galen, he considers an
affection of the brain. It is evidently the brain fever of the
generations preceding the last, an important element of which was made
up of the infectious meningitises. Alexander suggests its treatment by
opiates after preliminary venesection, rubbings, lukewarm baths, and
stimulating drinks. Every disturbance of the patient must be avoided,
and visitors must be forbidden. The patient's room should rather be
light than dark. His teaching crops up constantly in the centuries after
his time, until the end of the nineteenth century, and while we now
understand the causes of the condition better, we can do little more for
it than he did.

Alexander divided mental diseases into two, the maniacal and
melancholic. Mania was, however, really a further development of
melancholia, and represented a high grade of insanity. Under melancholy
he groups not only what we denominate by that term, but also all
depressed conditions, and the paranoias, as also many cases of
imbecility. The cause of mental diseases was to be found in the blood.
He counselled the use of venesection, of laxatives and purgatives, of
baths and stimulant remedies. He insisted very much, however, on mental
influence in the disease, on change of place and air, visits to the
theatre, and every possible form of mental diversion, as among the best
remedial measures.

After his book on diseases of the head, his most important section is on
diseases of the respiratory system. In this he treats first of angina,
and recommends as gargles at the beginning light astringents; later
stronger astringents, as alum and soda dissolved in warm water, should
be employed. Warm compresses, venesection from the sublingual veins, and
from the jugular, and purgatives in severe cases, are the further
remedies. He treats of cough as a symptom due to hot or cold, dry or wet
dyscrasias. Opium preparations carefully used are the best remedies.
The breathing in of steam impregnated with various ethereal resins, was
also recommended.

He gives a rather interestingly modern treatment of consumption. He
recommends an abundance of milk with a strong nutritious diet, as
digestible as possible. A good auxiliary to this treatment was change of
air, a sea voyage, and a stay at a watering-place. Asses' and mares'
milk are much better for these patients than cows' and goats' milk.
There is not enough difference in the composition of these various milks
to make their special consumption of import, but it is probable that the
suggestive influence of the taking of an unusual milk had a very
favorable effect upon patients, and this effect was renewed frequently,
so that much good was ultimately accomplished. For hemoptysis,
especially when it was acute and due as Alexander thought to the rupture
of a blood vessel in the lungs, he recommended the opening of a vein at
the elbow or the ankle--in order to divert the blood from the place of
rupture to the healthy parts of the circulation. He insisted that the
patients must rest, that they should take acid and astringent drinks,
that cold compresses should be placed upon the chest (our ice bags), and
that they should take only a liquid diet at most lukewarm, or, better,
if agreeable to them, cold. When the bleeding stopped, a milk cure was
very useful for the restoration of these patients to strength.

It is not surprising, then, to find that Alexander suggests a thoroughly
rational treatment for pleurisy. He recognizes this as an inflammation
of the membrane covering the ribs, and its symptoms are severe pain,
disturbance of breathing, and coughing. In certain cases there is severe
fever, and Alexander knows of purulent pleurisy, and the fact that when
pus is present the side on which it is is warmer than the other.
Pleurisy can be, he says, rather easily confounded with certain liver
affections, but there is a peculiar hardness of the pulse characteristic
of pleurisy, and there is no expectoration in liver cases, though it
also may be absent in many cases of pleurisy. Sufferers from liver
disease usually have a paler color than pleuritics. His treatment
consists in venesection, purgatives, and, when pus is formed, local
incision. He recommends the laying on of sponges dipped in warm water,
and the internal use of honey lemonade. Opium should not be used unless
the patient suffers from sleeplessness.

Some of the general principles of therapeutics that Alexander lays down
are very interesting, even from our modern standpoint. Trust should not
be placed in any single method of treatment. Every available means of
bringing relief to the patient should be tried. The duty of the
physician is to cool what is hot, to warm what is cold, to dry what is
moist, and to moisten what is dry. He should look upon the patient as a
besieged city, and try to rescue him with every means that art and
science places at his command. The physician should be an inventor, and
think out new ways and means by which the cure of the patient's
affection and the relief of his symptoms may be brought about. The most
important factor in his therapeutics is diet. Watering-places and
various forms of mineral waters, as well as warm baths and sea baths,
are constantly recommended by him. He took strong ground against the use
of many drugs, and the rage for operating. The prophylaxis of disease is
in Alexander's opinion the important part of the physician's duty. His
treatment of fever shows the application of his principle: cold baths,
cold compresses, and a cooling diet, were his favorite remedies. He
encouraged diaphoresis nearly always, and gave wine and stimulating
drugs only when the patient was very weak. He differentiates two kinds
of quartan fever. One of these he attributes to an affection of the
spleen, because he had noticed that the spleen was enlarged during it,
and that, after purgation, the enlarged spleen decreased in size.

Alexander was a strong opponent of drastic remedies of all kinds. He did
not believe in strong purgatives, nor in profuse and sudden
blood-lettings. He opposed arteriotomy for this reason, and refused to
employ extensive cauterization. His diagnosis is thorough and careful.
He insisted particularly on inspection and palpation of the whole body;
on careful examination of the urine, of the feces, and the sputum; on
study of the pulse and the breathing. He thought that a great deal might
be learned from the patient's history. The general constitution is also
of importance. His therapeutics is, above all, individual. Remedies must
be administered with careful reference to the constitution, the age, the
sex, and the condition of the patient's strength. Special attention must
always be paid to nature's efforts to cure, and these must be
encouraged as far as possible. Alexander had no sympathy at all with
the idea that remedies must work against nature. His position in this
matter places him among the dozen men whose name and writings have given
them an enduring place in the favor of the profession at all times, when
we were not being carried away by some therapeutic fad or imagining that
some new theory solved the whole problem of the causation and cure of

Gurlt, in his History of Surgery, has abstracted from Alexander
particularly certain phases of what the Germans call external pathology
and therapeutics. For instance, Alexander's treatment of troubles
connected with the ear is very interesting. Gurlt declares that this
chapter alone provides striking evidence for Alexander's practical
experience and power of observation, as well as for his knowledge of the
literature of medicine. He considers that only a short abstract is
needed to show that.

For water that has found its way into the external ear, Alexander
suggests a mode of treatment that is still popularly used. The patient
should stand upon the leg corresponding to the side on which there is
water in his ear, and then, with head leaning to that side, should hop
or kick out with the other leg. The water may be drawn out by means of
suction through a reed. In order to get foreign bodies out of the
external auditory canal, an ear spoon or other small instrument should
be wrapped in wool and dipped in turpentine, or some other sticky
material. Occasionally he has seen sneezing, especially if the mouth and
nose are covered with a cloth, and the head leant toward the affected
side, bring about a dislodgment of the foreign body. If these means do
not succeed, gentle injections of warm oil or washing out of the canal
with honey water should be tried. Foreign bodies may also be removed by
means of suction. Insects or worms that find their way into the ear may
be killed by injections of acid and oil, or other substances.

Gurlt also calls attention to Alexander's careful differentiation of
certain very dangerous forms of inflammation of the throat from others
which are rather readily treated. He says, Inflammation of the throat
may, under certain circumstances, belong to the severest diseases. The
patients succumb to it as a consequence of suffocation, just as if they
were choked or hanged. For this reason, perhaps, the affection bears the
name synanche, which means constriction. He then points out various
other forms of inflammation of the throat, acute and chronic, suggesting
various names and the differential diagnostic signs.

One of the most surprising chapters of Alexander's knowledge of
pathology and therapeutics is to be found in his treatment of the
subject of intestinal worms, which is contained in a letter sent by him
to his friend, Theodore, whose child was suffering from them. He
describes the oxyuris vermicularis with knowledge manifestly derived
from personal observation. He dwells on the itching in the region of the
anus, caused by the oxyuris, and the fact that they probably find
their way into the upper part of the digestive tract because of the
soiling of the hands. He knew that the tapeworms often reached great
length,--he has seen one over sixteen feet long,--and also that they had
a life cycle, so that they existed in two different forms. He describes
the roundworms as existing in the intestines, but occasionally wandering
into the stomach to be vomited. His vermifuges were the flowers and the
seeds of the pomegranate, the seeds of the heliotrope, castor-oil, and
certain herbs that are still used, by country people, at least, as worm
medicines. For roundworms he recommended especially a decoction of
artemisia maritima, coriander seeds, and decoctions of thyme. Our
return to thymol for intestinal parasites is interesting. For the
oxyuris he prescribed clysters of ethereal oils. We have not advanced
much in our treatment of intestinal worms in the fifteen hundred years
since Alexander's time.

Next: Paul Of Aegina

Previous: Aetius

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