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 disease.
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.
PAUL OF ÆGINA
Another extremely important writer in these early medieval times, whose opportunities for study in medicine and for the practice of it, were afforded him by Christian schools and Christian hospitals, was Paul of Ægina. He was born on the island of Ægina, hence the name Æginetus, by which he is commonly known. There used to be considerable doubt as to just when Paul lived, and dates for his career were placed as widely apart as the fifth and the seventh centuries. We know that he was educated at the University of Alexandria. As that institution was broken up at the time of the capture of the city by the Arabs, he cannot have been there later than during the first half of the seventh century. An Arabian writer, Abul Farag, in "The Story of the Reign of the Emperor Heraclius," who died 641, says that "among the celebrated physicians who flourished at this time was Paulus Æginetus." In his works Paul quotes from Alexander of Tralles, so that there seems to be no doubt now that his life must be placed in the seventh century.
The most important portion of Paul's work for the modern time is contained in his sixth book on surgery. In this his personal observations are especially accumulated. Gurlt has reviewed it at considerable length, devoting altogether nearly thirty pages to it, and it well deserves this lengthy abstract. Paul quotes a great many of the writers on surgery before his time, and then adds the results of his own observation and experience. In it one finds careful detailed descriptions of many operations that are usually supposed to be modern. Very probably the description quoted by Gurlt of the method of treating fishbones that have become caught in the throat will give the best idea of how thoroughly practical Paul is in his directions. He says: "It