EARLY MEDICAL SCHOOLS. Ill

The Scho ol of Alexandr ia

By GEORGE E. GASK

LONDON

HE fifth century b .c . stands out Since the state of medicine and of as one of the great epochs of medical education is always intimately history, for in it was born the related to the social and economic con- idea of universal knowledge, ditions of the people it is essential to Tphilosophy, and science. know something of the civilisation of Medicine took a full share in this in- Alexandria. tellectual outburst leaving as witness The period under review may con- the monumental works to which the veniently be divided into two. The first name of Hippocrates is attached. In the or Ptolemaic period was that during third century b .c . the meteoric career which Egypt was ruled by the Ptole- of Alexander the Great astonished the mies, lasting from 323 b .c . till 30 b .c ., world. It looked for a time as if he when Cleopatra surrendered to Roman would dominate all mankind. Suddenly arms. Then Egypt became a province all was changed; Alexander died, his of the Roman Empire and remained so empire fell to pieces, and the western until 640 a .d . when it was conquered world was plunged into disaster. by the Arabs. Of the fragments into which the em- Of all the Ptolemies, and there were pire split, Egypt became the most stable. thirteen, the best and most important Here Alexander’s general. Ptolemy, es- were the two first, Ptolemy surnamed tablished himself, making Alexandria Soter and his son Philadelphus. Under his principal city and establishing there these enlightened men the School of a dynasty that endured for many centu- Alexandria was founded and put on ries. Situated conveniently on trade such a firm basis that it outlasted the routes, Alexandria soon gained a com- succeeding Ptolemies, the record of manding lead in the world of com- whose reigns is one largely of crime, merce. Wealth poured in and was used murder, and misrule. It survived even, by Ptolemy and his successors to de- though by a narrow margin, the perse- velop and beautify that city, the lines of cutions of the seventh Ptolemy, when which Alexander had traced with his many of the savants fled the country. own hands. In the course of time Alex- Ebe story of Cleopatra, the last of her andria became the first city in the Hel- line, is too well known to need repeti- lenistic world, while in the welter of tion. The great event of her reign that disorder little more is heard of the affected the School was the destruction medical schools of Cos and Cnidos. by lire of the great library. Thus the center of scientific interests Under the Romans the work in the shifts to Egypt. Museum continued, though now the president was nominated by Caesar in- reputation were invited to take up their stead of the Pharaoh. The School lacked residence in Alexandria. its former lustre but survived until the Among the famous men who accepted city itself was destroyed by the Arabs the invitation may be mentioned Eu- in the seventh century. clid, the mathematician; Apelles and That was the end of the School of Antiphilus, the painters; Philetas, the Alexandria which had lived for nine poet; Hecateus, the historian; Dio- centuries and which, with all its fail- dorus, the rhetorician; Zenotus, the ings, preserved much of the culture of grammarian; and Herophilus, the Greece and had spread the light of anatomist. This was a good start. The learning in the new countries which new school, naturally, was modelled on were rising. the lines of the Lyceum and the Acad- emy of Athens which were already Fou nd ati on of the Scho ol of famous. But Ptolemy’s school gave Alexandr ia something that had never been pro- Ptolemy had to fight hard to establish vided before, namely residential quar- his sovereignty in Egypt but once firmly ters for the professors with endowment established on the throne his mind for their subsistence and a library of turned to the encouragement of learn- magnificent proportions for their use. ing. Brought up in the court of Mace- In effect Ptolemy laid the foundation donia, the learning of Greece had the of a royal university, the germ from same fascination for him as it had for which at a later date developed the uni- his sovereigns, Philip and Alexander. versities of Europe. The culture of Athens, however, was One is sorry not to be able to give de- on the decline and its schools languish- tails of the early foundation of the in- ing when Ptolemy determined to make stitution, but they do not exist and we Alexandria a great centre of learning. are forced to rely on the scanty record The time was ripe and the opportunity given by Strabo1 in his Geography. This favourable. Athens had expelled one is what he says: of the most prominent of her citizens, The Museum is part of the palaces. It Demetrius Phalereus (c. 354-283 b .c .). has a public walk and a place furnished He was just the man Ptolemy wanted to with seats, and a large hall, in which the aid him in his plans, for he was familiar men of learning, who belong to the Mu- with the learned world of Athens. De- seum, take their common meal. Phis com- metrius was an intimate friend of The- munity possesses also property in common; ophrastus, who succeeded Aristotle as and a priest, formerly appointed by the president of the Lyceum and was the kings, but at present by Caesar, presides first of the Peripatetics. No doubt he over the Museum.1 must have frequented the Temple of The Museu m the Muses and walked in the Grove philosophising with the successors of In order to understand what was Plato. None could have been found bet- meant by the term museum it is neces- ter fitted to advise Ptolemy in his sary to rid one’s mind of our present scheme. The brilliant inspiration was conception of a museum, that is, a carried into effect. Ptolemy established building for storing and exhibiting col- in Alexandria his Museum and Library lections. The Greek Museum was origi- and a number of scholars of established nally the Temple of the Muses, the sis- ter-goddesses, the inspirers of learning tony to Cleopatra to make up for the and of the arts. Such was the Museum loss of the main library. This library in Athens to which Theophrastus refers was finally burnt by order of the Caliph in his will.2 Later a museum became a Omar in 640 a .d . place dedicated to the study of the works From this description of the build- of the Muses, and it is in this light that ings we may turn to the activities of the we should regard the new foundation of School. These may be divided roughly Alexandria. into four sections, poetry, mathematics, I he layout had many points of simi- astronomy and medicine. larity with the schools of Athens. It had its promenades, groves and seats. But The School of Medic ine now appeared for the first time the new A word of warning is necessary at the feature, the large dining hall where outset lest one gets a wrong idea of the members could take their meals to- word school. When one speaks of the gether, as in a college hall in one of our School of Medicine or of the School of own universities. At the head of the Alexandria it is not right to think of Museum was a priest nominated by the them as we do when speaking, say, of the king, and, in appointing a member of School of Edinburgh, of Bart's or of the priesthood as president, Ptolemy Guy’s with their class rooms, dissecting was perhaps making concessions to rooms, and laboratories. Those had not Egyptian tradition for there already ex- appeared yet. What is meant is the de- isted centres of learning at Thebes, velopment of learning, with all the Memphis and Heliopolis. ideas and theories which sprang from it. Ptolemy was fortunate in securing The Libr ary two first class physicians to commence A most important adjunct for the his medical school. These were He- scholars working in the Museum was rophilus and Erasistratus, both of the Library which became world fa- whom made outstanding advances in mous and in fact more famous than anatomy and physiology and quickly the Museum. put the School on a firm basis. The two foundations were close to- Herophilus was the elder of the two. gether, connected with the theatre and He was a pupil of that able anatomist the palaces by long colonnades adorned and surgeon, Praxagoras of Cos, and with obelisks and sphinxes taken from no doubt it was his influence that led the Pharaonic cities.3 The collection of Herophilus to study anatomy. Beyond books was begun by Ptolemy 1 and his scientific ability practically nothing added to by his successors, for even the is known of the personality of Herophi- bad Ptolemies were patrons of litera- lus except one anecdote, which shows ture, until it reached the number of that he had a sense of humour. One of 400,000 volumes or perhaps even 700,- his fellow workers in the Museum, Dio- 000. This was the library which was dorus Cronos, had the misfortune to destroyed by fire when Julius Caesar dislocate his shoulder. Now Diodorus was besieged in Alexandria. There was used to deny the existence of motion, also a second library housed in the saying: “If matter moves, it is either in Serapeum. Here were deposited the the place where it is, or in the place 200,000 books collected by the kings of where it is not; but it cannot move in Pergamos and presented by Mark An- the place where it is and certainly not in the place where it is not; therefore structure, and so he may be called a it cannot move at all.” physiologist. He is credited with having Herophilus, when called in, began to divided the nerves into those of sensa- chaff Diodorus and prove by his own tion and those of motion, and it seems argument that it was impossible for the also that he was very near to antici- humerus to move out of its socket. Poor pating Harvey in the discovery of the Diodorus was forced to beg him to quit circulation of the blood, which he quibbling and reduce the dislocation. might have done but for an obsession Erasistratus, the grandson of Aris- that the arteries contained “pneuma” totle, was a Cnidian by birth and edu- and not blood. Further he had some cation, who came to Alexandria with notion of metabolism and devised the an established reputation. He had been first crude calorimeter, a jar in which physician at the court of Seleucus, king he kept fowls, weighing them and their of Syria, when the king’s son, Anti- excreta. In his later years he left Alex- ochus, fell ill of love for his step- andria and died in Asia Minor though mother, Stratonice, and was like to die. his memory was kept alive by a medical By a clever piece of psycho-analysis school founded at Smyrna by his fol- Erasistratus diagnosed the complaint lowers. and induced Seleucus to give up his One cannot leave these historic per- wife to his son. This gave him a great sons without referring to the cruel ac- reputation and a large practice which cusations made against them. They he seems to have abandoned to take up were accused of using living men for whole time work at Alexandria. dissection, though why on earth they These two men had the incalculable should want to beats comprehension. advantage of dissecting the body of However the accusation was made and man, a practice strangely neglected by still seems to be believed. the Greeks. They made good use of It is difficult to get to the bottom of their opportunity and with the scalpel the story for which there is no contem- laid bare many of the secrets of the porary evidence but the words of Ter- body, hidden from their predecessors. tullian and Celsus both of whom were They both published a number of writing hundreds of years later. Ter- works, of which, unfortunately, only a tullian (c. 150-230 a .d .) describes He- few scraps have survived. The frag- rophilus as, “that physician or butcher ments of the writings of Herophilus who cut up six hundred men on the have been collected and set out by J. F. plea of the investigation of Nature.”3 Dobson.4 It is sufficient here to state But Tertullian is regarded by scholars that Herophilus differentiated the cere- as an untrustworthy witness so we need brum from the cerebellum and that not pay much attention to what he says. several of the names he gave to various Celsus who lived in the first century of structures remain in use to this day, for our era is a witness of a different order. instance the “torcular herophili,” the His statement cannot be ignored “calamus scriptorious” and the “duo- though it need not be accepted. denum.” The following is the accusing passage Erasistratus also paid much attention in Celsus: to the anatomy of the central nervous They (implying those who prefer a rea- system but he interested himself in the soned theory of medicine) hold that no function of the body as well as in its one can apply remedies for these who is ignorant about the parts themselves; son for taxing Herophilus of dissecting hence it is necessary to lay open the bodies living men than there is of accusing the of the dead and to scrutinise their viscera modern scientific surgeon of experi- and intestines. They hold that Herophilus menting on his patients or of torturing and Erasistratus did this in the best way dogs. by far, when they laid open men whilst The substantial advances in anat- alive—criminals received out of prison omy and surgery made by these two from the kings—and whilst these were still breathing, observed parts which be- men quickly established the renown of forehand nature had concealed, their posi- the School of Alexandria and students tion, colour, shape, size, arrangement, came flocking in from all parts and hardness, smoothness, relations, processes they were greatly encouraged and stim- and depressions of each. . . . ulated by the second Ptolemy, Philadel- phus, who by the way was born at Cos. And later on he says: This new king was a different to lay open the bodies of men is as cruel character from that hard-bitten old as it is needless; that of the dead is a neces- Macedonian warrior, his father. The sity for learners, who should know posi- softening of the fibre which became tions and relations, which the dead body pronounced in the later kings was al- exhibits better than does a living and ready showing. It was something like wounded man. As for the remainder, the contrast between David and Solo- which can only be learnt from the living, mon, the magnificent voluptuary with actual practice will demonstrate it in the intellectual and artistic interests suc- course of treating the wounded in a some- ceeding the man of war.7 what slower but much milder way.® Life in Egypt became gay under Such is the evidence, which some Philadelphus. Magnificent processions people have been willing to believe. initiated his reign, far outdoing our It may seem adventurous for a mere own Coronation celebrations, and his surgeon to intrude an opinion, but he court has been likened in brilliance, may be allowed to ask what possible opulence, and extravagance to that of object could be gained by using living Louis Quatorze. men as subjects. Anyone who has done “The free man’s best paymaster, In- any dissection must realize how ex- dulgent too, the Muses darling, a true tremely embarrassing it would be to do lover, the top of good company. . . so, especially when following out the So he is described by Theocritus in his course of a nerve as Herophilus must fourteenth Idyll. But Philadelphus was have done. Then there is another point. a good friend to the physicians, and It will be remembered that Erasistratus favoured the study of medicine, on ac- thought that the arteries contained air count perhaps of the bodily infirmities and not blood. It is inconceivable that which according to Strabo afflicted him. he could have made that mistake if he He took an active interest in the work had dissected live men. Is it not much of the Museum, joined in the discus- more likely that criminals were handed sions of the professors, and it is easy to over to the anatomist immediately believe that he was pleased to watch after execution even as they were in our Herophilus demonstrate the anatomy own country in the eighteenth century? of the brain, even as Charles the First On the evidence the case is not looked on when Harvey demonstrated proved and there seems no more rea- the circulation of the blood. Under the first two Ptolemies the dition which was sound so far as it went school of medicine reached the zenith lasted until the rise of the Alexandrian of its fame and though it lasted for cen- school and then, some time in the third turies we are not able to record any century b .c ., probably after the death discoveries to equal those made by He- of Herophilus and Erasistratus, there rophilus and Erasistratus. One is dis- was a break-away and there arose the appointed to find that the successors sect called “Empirics.” did not follow faithfully in the foot- Man seems to have an inborn bent steps of their masters. Fresh discoveries for taking sides and the formation of are not recorded, the school of anatomy this sect split the profession for some languished and fell into decay so that centuries, every physician ranging him- when visited by Galen about a .d . 150 self under one or other of these two he only found two skeletons. Why this parties. The harm done to the advance- happened we do not know and can only ment of medicine was incalculable. guess that either the men were not good The rendering of the word “empiric” enough, that the organisation for study is difficult to give on account of the failed or that the medical profession hint of quackery it carries today. There became tainted with the general ex- is no English word that gives the exact travagance and dissipation which char- meaning so we must rely on a literal acterised the court life. Instead of con- translation of the word (from trial) and tinued progress we find that there arose an explanation. No taint of the charla- dissension and a bitter sectarian strife. tan was implied in those days. The The origin of the split is obscure and “Empirics” professed to gain their as it is dry work raking among the ashes knowledge from the light of experience of dead controversies, only the broad only, in contradistinction to the “Dog- outlines will be given here. matists” who laid most stress on the powers of reasoning. The arguments by The Dog mat ist s and the Empir ics which these two sects supported their It appears that after the death of Hip- opinions have been set out very fairly pocrates, his son Thessalus and his son- by Celsus and can be read in the trans- in-law, Polybus, and their followers lation by W. G. Spencer (Loeb Trans- described themselves as “Dogmatists” lation, Vol. 1). Clifford Allbutt has deriving their name from “dogma” written at length in his inimitable style meaning a philosophical tenet or opin- on this phase of medicine and his com- ion. At that time the name carried no ments are worth quoting:8 stigma of rigidity or narrow-minded- ness such as it does today. The Dog- It has been the trial of Medicine, that matists were the orthodox practitioners, while as compared on the one hand with the followers of the Hippocratic the no less complex but far more acces- method, who held that it was necessary sible phenomena of law and politics, and on the other with the far less complex to be acquainted with the elements or phenomena of the physical sciences, it has principles of which the body is com- stood and stands still, in respect of the dif- posed and its natural actions and dif- ficulty and inaccessibility of its knowl- ferent functions. Though they did not edge, at a great disadvantage; yet in no deny the necessity of experiments, they unnatural impatience with these peren- said that these experiments could never nial bafflings and obscurities, the moan of be made without reasoning.9 This tra- suffering man and woman and the poign- ant misery of their children have ever favoured Medicine, he is scarcely less driven us into action, however blind, how- celebrated than his father in his patron- ever premature. Remedies, orthodox, em- age of literature and science and his pirical or quackish, one way or another, passion for garnering books. He was for- remedies by whatsoever means have al- tunate in attracting to his court the ways been imperiously demanded by us. most celebrated and versatile man of And as nowadays the modern physician the times, whom he put at the head of cannot wait for pharmacology which seems to him and not unnaturally, to be the tor- the library. This was Eratosthenes, the toise behind the hare of empirical practice, man who made the first attempt to so after a like manner we may imagine the measure the earth and whose work impatience of the Alexandrian physicians, added lustre to the science side of the sick of the pursuit of anatomy. . . . Such Museum. then in the middle of the third century During the next hundred years there b .c . was the ground on which in spite of is little noteworthy to tell about Medi- its scientific spirit, or perhaps engendered cine. The records, such as they are, con- by it, empiricism and medical infidelity tain little but a list of names. Those sprang up and gyrating in the void of posi- who are interested may consult Suse- tive knowledge, would and did give rise mihl (Geschichte der Grieschischen to endless and weary disputes. Litteratur der Alexandriner zeit) which The name of the man who figures as contains the most complete list of names the founder of the sect of Empirics is yet published. Serapion of Alexandria. Little is known Mention however may be made of of him beyond the fact that Celsus one Andreas of Carystus, the physician stated that he declared that the reason- to Ptolemy Philopater. He was killed ing method was in no way pertinent to while on attendance on that king Medicine and that he based his methods shortly before the battle of Raphia entirely on practice and experience.9 (b .c . 217) by a man who entered the He also wrote against Hippocrates with royal tent to murder the king. It is this much vehemence (Galen) but none of Andreas also who is reputed to have his works are now extant. uttered the scurrilous story that Hip- On the whole one may say that the pocrates set fire to the library of Cnidos, Empirics recruited their ranks from a story we cannot believe. He is also said followers of Erasistratus, while the ad- to have written the first treatise on hy- herents of the Hippocratic method and drophobia as well as other works all of of Herophilus remained “Dogmatists.” which have perished. If he did write Thus in these two parties we can still these books, and there seems no reason trace the rivalry which existed between for doubt, here is evidence that all the the schools of Cos and Cnidos, for He- time steady though unrecorded work rophilus was a Coan and Erasistratus was going on and the sum of human a Cnidian and one appreciates also the knowledge was gradually being added perennial quarrel, not yet defunct, be- to. tween the practical man and the man of The next big event to record is the science. misfortune which befell the members Ptolemy Philadelphus died in b .c . of the Museum in the reign of the sev- 246 and was succeeded by his son enth Ptolemy, (b .c . 145-116.) Ptolemy (111) Euergetes. Though there This king was an ugly and evil king. is no record that this king specially So fat was he that he earned the nick- name of “Physcon” or “Potbelly” from Rome, being the first person to make the Alexandrians. And he was evil in medicine a distinct profession in that that he was the author of bloody perse- city.12 He was received with respect, cutions, banishments, and confiscations. and a “taberna” or surgery was bought So bad was he that many of the mem- for him at the public expense. His prac- bers of the Museum and scholars fled tice was largely surgical, and he was the country. It may well be that this called “vulnarius” on account of his dispersal led to the foundation of specialty, though later his reputation schools and a revival of learning in vari- for cutting and cauterizing earned him ous parts of the Greek lands. At any rate the title of “butcher,” and Pliny fol- about this time we hear of the existence lows up his record with a diatribe of two other medical schools which ob- against all doctors. viously owed their origin to that of The attraction of Rome did not grow Alexandria. One was established at less and as time went on she became a Mens Carus near Laodicea in Asia serious rival in the field of practice Minor. This is mentioned by Strabo as though she never had a medical school existing in his time (c. b .c . 64-A.D. 19) to equal that of Alexandria. and he describes it as “a large He- Cleopatra was the last of the Ptole- rophilan school under the direction of mies and at her death Egypt became a Zeuxis, and afterwards of Alexander province of Rome. But the school went Philaletus.” Strabo also refers to an- on and the Museum continued to func- other medical school saying, “in the tion in much the same manner as of time of our ancestors there was at old, only now it was Caesar who nomi- Smyrna a school of the disciples of nated the President instead of the King. Erasistratus under the conduct of Hi- The school of medicine also maintained cesius. At present there is nothing of its prestige, for when Galen visited the kind.”10 Alexandria about 150 a .d . he was able Hicesius was a physician of renown to declare it still the principal centre for he was called by Pliny “a physician of medical studies. of no small authority” (N.H.H. xxvn- Of the progress of medicine in the 14) and he was evidently beloved by the last two hundred years before Christ people of Smyrna for they struck a coin, we have little information, and if it had which is still extant, in his honour.11 not been for Celsus we should know Unfortunately beyond this, nothing still less. The work of Celsus is prob- more is known of him or of the school ably representative of the best Alex- which disappeared. andrian practice13 and he shows that in In spite of the persecutions of the fields of anatomy and surgery there Ptolemy Physcon the school survived had been a substantial advance since though it never regained the lustre it the time of Hippocrates. From him we enjoyed under the early kings. Another are able to learn the names of some of reason, however, may account for the the surgeons who worked in Alexan- decline, namely, the growing attraction dria. He mentions especially the influ- of Rome, which the Greek physicians ence of Philoxenus, who wrote a careful were beginning to find a lucrative field and comprehensive work in three vol- for practice. umes, which like so many others are Already, about 220 b .c . Archagathus, lost and we cannot judge its value. We a Peloponnesian had emigrated to do know something of three other men he mentions: Gorgias, Heron, and So- There was one Andromachus of Crete, stratus. All these contributed to the for instance, said to have been a pupil knowledge of umbilical hernia. They of Alexandria who invented a famous knew that this condition was caused compound medicine and antidote sometimes by protrusion of the bowel, known as “Theriaca Andromachi” sometimes by omentum and sometimes which contained no less than seventy- by both. They knew how the hernia five ingredients. By its daily use the could be reduced and they did some taker was supposed to be fortified sort of operation for its cure. against innumerable ills, except the Urinary diseases and vesical calculus nauseous draught itself. were common in Egypt so we are not Of the succeeding centuries there is surprised to learn that surgery of this little noteworthy to record. region was advanced. The catheter had John of Alexandria, Paul of Aegina already been introduced by Erasistratus and Palladius, the last representatives and the operation for removal of a vesi- of this famous school were erudite com- cal calculus was already being done in mentators of the past but cannot be re- the third century b .c . An operation had even been devised by Ammonius garded as discoverers of new truths or for breaking up a stone which was too inventors of new methods. big to extract. For this he gained the In 640 a .d . Alexandria was taken by name of “Lithotomist.” The details of the Arabs and the town destroyed. And the operation may be read in Celsus’ so after a life of 900 years the famous “De Medicina.”14 school came to an end. Another surgeon who deserves men- tion is Apollonius of Cyprus, who Looking back over the centuries one studied medicine at Alexandria under sees what an important place the School Zopyrus. He is the oldest commentator of Alexandria occupies in the history on Hippocrates, whose works are still of medical education. For the first time extant. In his book are preserved some systematic anatomy was practised and of the writings of another Alexandrian for the first time there was a school to surgeon, Hegetor, who made a careful which students from all parts of the study of the methods of reducing dis- world could go for instruction. It suf- locations of the hip and gives the first fered through all its life from a serious description of the ligamentum teres.13 deficit. There was no sort of examina- These instances and others that could tion, or diploma for practice, though it be mentioned, such as methods of den- was considered as a sign of distinction tal extraction and an operation for re- to have studied there. The result was moval of tonsils, show beyond all doubt that quacks and badly educated men that the practice of surgery in Egypt could practise with insufficient knowl- reached a high level, far higher indeed edge. than that of the Middle Ages. The great glory of the school lies in Another branch of practice which the fact that it preserved to the world had grown enormously was the collec- the culture of Greece and sent students tion and use of herbs and drugs. Much into all parts of the civilised world, was written on this subject, though a where they in their turn established great deal seems to us now ridiculous. centres of medical education. Ref ere nce s 1. Strabo . Bohn Ed., Vol. 3, p. 229. Rome, 1921, pp. 156-7. 2. Diogenes Laertiu s . Bohn Ed., p. 200. 9. Celsus . De Medicina. Prooemium. Loeb 3. Smith . Dictionary of Greek and Roman Ed. Geography. 10. Strabo . Bohn Ed., Book xn. c. vm. 4. Proc. R. S. M. Hist. Med., Vol. 18, 1925; 11. Mead . Dissert, de Nummis quibusdam a Vol. 20, 1927. Smyrnacei in Medicorum honorem per- 5. Tertulli an . De Anima. cussis. London, 1724. 6. Celsus . Prooemium. Loeb Ed., Vol. 1. 12. Pliny . N. H. xxix . 6. 7. Bevan . A History of Egypt under the 13. Singe r . Legacy of Greece. Ptolemaic Dynasty, p. 56. 14. Cels us . De Medicina. Loeb Ed., Vol. 3, 8. Allb utt , Clif ford . Greek Medicine in P- 439-