Part 15

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.

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