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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

ever 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.