Thorax: first published as 10.1136/thx.33.3.295 on 1 June 1978. Downloaded from Thorax, 1978, 33, 295-306 The thorax in history 3. Beginning of the Middle Ages R. K. FRENCH From the Wellcome Unit for the History of Medicine, University of Cambridge The end of Hellenistic experiment and observation physicians and surgeons did not give the Alexandrians the importance that historical hind- When Galen died at the end of the second century, sight attributes to them, nor did they recognise anatomical and physiological research died with Galen as authoritative as Galen's and later ages him. We are effectively in the dark ages at once, believed him to be. To a certain extent this is for the continued, if precarious, political stability true of the East as of the West: Aretaeus of of the Roman Empire was no substitute for the Cappadocia in Asia Minor was contemporary with, loss of vigour of the Greek intellectual tradition. or slightly later than Galen, but does not mention Galen's works survived, were commented upon him. Fragments of anatomy and physiology that and summarised, but no new inquiry was under- can be gleaned from his surviving works on the taken. When Galen visited Rome, it was as far signs and causes of acute and chronic diseases3 west as anatomy and physiology came: Pergamon, come from a variety of sources, some of them Alexandria, and Ephesus were the inheritors of purely traditional. Indeed, in Aretaeus we see an intellectual climate that sustained anatomy in more clearly than in Galen's synthetic physiology any form other than that employed by the sur- a distinction between traditional, literary anatomy, http://thorax.bmj.com/ geons of the legions. No more than a vestige of and that derived practically, from dissection and the old knowledge remained in the West. observation of wounds. The two surviving anatomical and physiological From traditional anatomy comes Aretaeus's traditions, East and West, differed not only in the notion that the heart is the seat of the soul and extent of knowledge they contained but in its that the head is the location of the senses. This nature. In the West the Romans were surprisingly preserves the ancient distinction between thymos old-fashioned in their medical knowledge, and and psyche, which we have met before, and which never really understood what had been going on in Aretaeus's writings seems to ignore Galen's in Alexandria, or the extent to which Galen was closely argued physiology. Aretaeus also describes on September 25, 2021 by guest. Protected copyright. the summation of the Hellenistic tradition. a traditional origin of the vena cava in a liver Galen's predecessors in Rome refer back to Hippo- composed of extravasated blood and paralleled by crates, not Herophilus, and his own successors its analogue the spleen. The vessels of these two seem to have ignored him. The Roman writer organs are described in terms that recall the Celsus,1 compiling an encyclopaedia of useful ancient descriptions of the two fundamental knowledge of which medicine was but a part, gave vessels of the body, and his description of the a brief account of the dissections and vivisections nerves embodies the old confusion between of the Alexandrians in his introduction, but the muscular and nervous fibres, both called neura. bulk of his De Medicina depends upon a Greek No one following the authority of Galen would source that antedates Alexandrian experi- have retained such an ambiguity or allowed the mentalism. Cicero2 seems to have been entirely heart such a dominant position. Yet Aretaeus was ignorant of the Alexandrian discoveries, and he aware of the work of the Alexandrians, and the depended instead on fragments of Aristotle and hints given in his work of his knowledge of the Hippocratic writings. anatomy and physiology suggest that in some Of course, it was not Cicero's business to know respects it may have been greater than that of about the inside of the human body, although we Galen. His observation that damage to one side might expect him to have been aware, as an edu- of the spinal cord results in the loss of function cated man, of cultural advances now three or four on the same side of the body, while damage to one centuries old. However, we find that even side of the brain results in loss of function on the 295 Thorax: first published as 10.1136/thx.33.3.295 on 1 June 1978. Downloaded from 296 R. K. French other side of the body led to his description of the anciently possessed. Its anatomy is as fully de- decussation of the nerves, unknown to Galen. scribed as that of any other part (except the This is essentially anatomy derived from an uterus): it is muscular, defended by a tough empirical source and is the other side of the membrane, shaped like a pine cone, and inclined distinction mentioned above. Aretaeus also has to the left. It has four 'veins'-two sanguineous thoroughly empirical descriptions of the differ- and two spirital.5 Medieval texts character- ences between the venous and arterial blood and istically talk of veins when arteries are also of the motions of the arteries in wounds. Such included, even though the difference between the empiricism seems to have depended on surgery, vessels was known to the classical author whose and as surgery was less dependent upon a con- work formed the basis of the medieval work. tinued intellectual Hellenistic tradition than was 'Artery' is used in Vindicianus to mean only the theoretical physiology, no doubt it suffered less trachea. According to him the two sanguineous at the eclipse of the classical world. veins from the heart reach the liver, and the two spirital reach the lungs; the heart is the source of The Western middle ages respiration. It has two 'ears' (aures),6 in which are located the mind and soul of man. By ears, we The paucity of Latin writings with anatomical should normally expect to be meant the auricles, content from the height of Roman civilisation 'little ears', but there appears to be no precedent until its final collapse is marked. The third for Vindicianus placing the soul in the auricles. century produced almost nothing in the medical The Hippocratic De Corde had spoken of ears field except minor treatises on popular medicine of the heart, but had put the soul in a ventricle. taken from Pliny. Successors to such as these Perhaps Vindicianus meant the ventricles, which would be of little importance were it not that are not otherwise mentioned; the term used for association with the rising Christian Church gave the ventricles by the second-century Greek them some permanence and importance in the lexicographer Pollux is also rendered into Latin Latin middle ages. as ears.7 It is also unusual that the mind and the An author of one such work was Vindicianus, soul, mens and animus, if Vindicianus means to a friend of St. Augustine, who flourished in the imply two different principles, should be located http://thorax.bmj.com/ second half of the fourth century. He deals with in the same organ, both in the heart. Perhaps the construction of the body briefly, intending his Vindicianus was influenced by the Christian description for those ignorant of Greek medical tradition, which had other ancient sources for writings. Vindicianus notes that the ancient such ideas-Jewish and Babylonian. Everything Alexandrians dissected bodies of the dead, 'but worthy of our attention, says Vindicianus, comes these are not available to us, for dissection is through these ears and with them is associated prohibited'.4 St. Augustine had, like Tertullian cogitation. and Celsus, accused the Alexandrians of dissection Nevertheless, the brain is more important to and vivisection, and it may be that his friend Vindicianus than it was to those in antiquity for on September 25, 2021 by guest. Protected copyright. Vindicianus supplied him with some knowledge whom the heart was the central organ, and the of the Alexandrians, and in turn was influenced opinions of the Alexandrians appear when he against dissection. Certainly it is an apt reflection observes that the human brain is more convolute of the times that it was St. Augustine and his and interspersed with venules than that of animals, Church that helped to produce a moral and and it is for this reason that we are wiser than religious climate in which dissection could not any of them. This, however, is not owing merely flourish. to the convolutions, as Herophilus said, but is It is not surprising then that Vindicianus de- because the brain has more tubes 'by which under- pends entirely on earlier sources, and what takes standing can reach us'. By the context, 'under- our interest are the sources selected, for on these standing' (intellectus) is to be listed among the and those of similar writers depend the ana- senses-sight, hearing, taste, and smell. All sense tomical ideas passed down through the Western organs are connected to the brain, the membranes middle ages-for example, to Salerno. Surprisingly of which, drawn outwards, play an important role. little attention was paid in the West at this time to This, too, seems to be an echo of the idea of some the works of Galen, Soranus appearing more popu- of the Alexandrians that the nerves were com- lar. The dependence on earlier sources gives Vindi- posed of the meningeal membranes of the brain. cianus's anatomy a predictable slant. Little Sensation involves motion of the brain, according attention is given to the nervous system, and the to Vindicianus.