12th Greek Australian Legal and Medical Conference
Samos, Greece 2009

RUFUS of EPHESUS

A Practical Physician in Antiquity

Owen Powell

IN THE FIRST CENTURY of the Christian era there lived, just across the water from where we are now, at Ephesus, a physician named Rufus - Rufus of Ephesus. I have for some time been making a translation of those of his works that have survived in the Greek, and the talk is largely based upon this.

Mind you – an even more influential medical writer of antiquity was undoubtedly Galen of Pergamum, a century later, also in what is now Turkey; and we know quite a lot about him, because he told us a lot – much of it self-congratulatory -about himself. But we know all too little about Rufus, and what we do is from the barest hints in his works; but everything he wrote points to the fact that he must have been a competent and humane doctor - I suspect quite as competent as the Master; indeed, he is one of the very few of en’s predecessors of whom that very critical commentator spoke with respect. That he has not been so influential as Galen is due to several factors – firstly, he produced far less than Galen’s phenomenal output ; and secondly, much that he did produce has been lost, although thanks to the Arab physicians of mediaeval times a good deal less has been lost than might otherwise have been the case.

But above all he was a practitioner rather than a theorist. What he wrote reveals him to have been, for his times, a most competent physician, and for any time a truly humane one.

To my mind the most interesting of all his works, and the one that especially demonstrates his humane approach, is that whose title, literally Medical Questions, I translate in modern terms as The Medical History. But he also wrote on anatomy, osteology, the diseases of the urinary tract and the pulse, as well as a book with the intriguing title of Satyriasis and Spermatorrhoea, which last is of particular interest since it illustrates one aspect of the constant hazards of medical translation; thus, the word used for the second half of the title transliterates as ‘gonorrhoia’ and so has very often has very often been translated as ‘goorrhoea’. But in fact the components of that word – gonos = ‘seed’; rheo = ‘flow’ - indicate that it can better translate as ‘spermatorrhoea’. Which raises a further point - we know that that much of our medical vocabulary originates in the Greek. It would seem that when a word passes from the Greek to the modern tongue it narrows its meaning. So modern epidemic ‘cholera’ has a more restricted meaning than the same word in Greek, which merely indicated diarrhoea.

As well as complete works believed to be by Rufus (one or two are only doubtfully so, it must be admitted) we also have a collection of so-called Fragments – passages of varying size from taken other authors – the equivalent of the modern footnoted attributions - which allegedly expressed Rufus’s views based upon works that have not survived.

But first, I should make some general comments on ancient medical practitioners;

What immediately strikes the reader of the ancient doctor is the emphasis on detailed observation. Since he (it is usually ‘he’) had none of the devices that today reinforce, and indeed even substitute for, pure observation - X-rays and ECGs are obvious examples – and since in any case he was unable to look at the quantitative aspects of a particular feature (such as the rate of the pulse) he was unaware of the diagnostic potential of measurement, and so he naturally concentrated upon the qualitative aspects to the exclusion of the quantitive, and inevitably developed skills in observation which are now to some extent lost to us, or held of less importance.

That is not to say that the outcome of this observation was necessarily of value - frequently it could be quite bizarre, but it is still often sufficient to enable a modern doctor to make a reasonable stab at diagnosis, and occasionally it is truly surprising. Thus Rufus, or some predecessor, first recognised the association of water and guinea worm infestation, as indicated in the following Fragment:

In Egypt I saw an Arab with this disease, and when the worm was about to poke its head outside he experienced pain and became febrile… When I enquired whether the disease was customary among the Arabs, they told me that Arabs fell il in this way and that when foreigners arrived many of them were overcome by the disease on drinking the water. For this is the principal cause…

but the actual details of the life cycle of the parasite had to await technical advances which expanded on the evidence obtained by observation. Surely this demonstrates a remarkable capacity for drawing conclusions from accurate observation supplemented by analytical thought.

Setting aside his inability to measure, however, the ancient physician does often seem to have much in common with his modern successor. This view is supported by the way what has come to be known as The Oath – a set of precepts laid down by Hippocrates, setting out the ethical boundaries to be accepted by any doctor – is the clear antecedent of the twentieth century Declaration of Geneva. But such a view may be illusory, for there is also what seems be an unbridgeable gap between the two periods. Take the following example.

In one Fragment Rufus is said to have recommended a prescription used by the Egyptian doctors one which contained no fewer than fourteen substances of vegetable origin – some of which, in fact, were still present in our modern pharmacopoeia until quite recently. You might well say that polypharmacy was also alive and well in those days, and likely to have as little effect as much that we prescribed fifty or sixty years ago. But there is one major difference; for at the conclusion of that prescription was the following direction….

…when they have mixed it all to smoothness… they make small rounds and burn it as incense to the gods…

Here we have now passéd the boundary of similarity - or is this really any more than an early equivalent of the formal “God Save the Queen” in some situations? How much was the ancient practice merely formulaic, with little genuine meaning? One can only speculate.

And now, at last, I come back to Rufus…

His birth year is of course unknown, but he was professionally active during the second half of the first century of our era, and perhaps a little later; certainly he wrote about a century before Galen. He seems to have received his medical education from a variety of eastern Mediterranean sources, but especially Alexandria – where there was a medical school of note. In spite of the difficulties of travel this peripatetic style of medical education was surprisingly common in antiquity. From internal evidence it also seems likely that at some stage he practiced in Egypt.

We cannot be sure of the target audience for his works. On one instance, when he is demonstrating surface anatomy upon some unfortunate individual (quite possibly a slave) one has a strong feeling that he is teaching students – or in any case is playing some educational role, but that is about all that can be said in this context.

One do no more than guess the order in which these works appeared, so that my treatment of them must necessarily be somewhat arbitrary; one may appear suited to an Intoduction for students; another is more clearly directed at the practising doctor; but it would be hazardous to assume that we are reading a planned series of lectures. So I shall impose my own view on the group, dealing with the books in some (hopefully) rational order, at the same time saving what I think is the best for the last. The majority were first edited and published, with a facing French translation, by Daremberg and Ruelle, in 1879, but individual editions, with or without translation, have appeared from time to time since then. I used, in addition to Daremberg, more modern editions of Medical History-taking and Diseases of the Urinary Tract.

But let me now deal with the various books, more or less in turn…

First, there is a group of three anatomically-oriented works:

The Names of the Parts of Man

The Anatomy of the Parts of Man

On Bones

The first commences with a statement of the importance of anatomy…I quote…

What did you learn first in playing the kithera? To pluck and name each chord… In the same way in teaching other skills they start from the names …the smith learns the name of iron...

…and among the more prestigious skills…what did you learn first in geometry…the point, the line, the plane…?

And if you apply this to Medicine, he goes on…

First, what you must call each part of the body…next, those other names that might follow on from the word…

which, I take it, means in modern terms another name such as ‘appendicitis’ following on from ‘appendix’. He continues

first I shall try to teach you how you must name the internal parts, having dissected some animal which most closely resembles man…In former times they used to give more genuine instruction on such matters on man…

The last sentence refers to the fact that in the time of Rufus human dissection was frowned upon, although earlier it had been customary in Alexandria when the great teacher Herophilus held sway there. In default, Rufus and others fell back upon animals, typically the pig, whose anatomy was believed more closely than other species to resemble that of man. Another subject was the ape, which reminds me to point out that ‘dissection’ in practice often meant ‘vivisection’. It is said that one early vivisector indicated a preference for the pig over the ape, because he found the expression on the ape’s face too disturbing!

There would really be no point in examining the actual content of these works, except to say that they demonstrate a sound knowledge of gross anatomy, but suffer from the occasional defect due to differences between the species. But in one case particularly, the anatomy of the eye, Rufus has handled that difficult subject by means of most detailed dissection of the material.

One soon comes to realise that much of his anatomical work, especially that dealing with the Names of the Parts, is more than a purely descriptive, anatomy. More often than not he embellishes the description of the part with an account of its function in the body – in other words, he is part of the way to discussing the physiology, as well as the anatomy.

In his book On the Pulses, however, he goes all the way, to produce what is effectively a physiology text. Here I should mention out a potential source of confusion in this work. In Greek the words ‘systole’ and ‘diastole’ mean, respectively, ‘contraction’ and ‘dilatation’ – which fits nicely with accounts of heart action. But when Rufus applies it to the action of the pulse we would find that the measure of the blood pressure at the conclusion of cardiac ‘systole’ is the same as the measure of the blood pressure at the conclusion of pulse ‘diastole’; which is confusing, to say the least. That aside, I think that we might without exaggeration asserrt that his description of the characteristcs of the single pulse beat may well have been the first detailed look at what we now call the pulse wave, until Sir James Mackenzie’s polygraph almost two millennia later. With Rufus, as with ourselves, ‘pulse’ can refer to a single beat or to a succession of beats, depending upon the context.

When it comes to his views on clinical medicine – diagnosis and therapeutics – we have two works, On the Diseases of the Kidneys and Bladder, and the one I mentioned earlier – Satyriasis and Spermatorrhoea. The latter has reached us in somewhat corrupt form (for example, one would dearly love to know what followed ‘there was a certain man in whom the penis used to quiver…’!) but the former work gives a sufficiently detailed account of his views on renal tract pathology and therapeutics to allow comparison with today’s views. It is of interest that surgical intervention to remove calculi was available although he advised its avoidance where possible. As one might expect, there is much in The Fragments to interest us. A good deal lies in fantasyland, but there is still much that ties quite happily to today.

However, and finally, it is in The Medical History that ‘then’ and ‘now’ most closely meet. Let me quote a few actual examples…

…it is necessary to ask the patient questions from which one might more precisely distinguish some of the features of the illness…

… But if you ask one thing and he replies to another, and if he becomes forgetful while speaking…or switches from his former manner to the opposite… all this indicates a confusional state. But deafness…is also indicated in some such way…

…One should also question someone else on behalf of a child or a very old man…

…Is the present incident some illness that is customary with the patient, and if it is not, whether it has occured before…

…For we are not all by nature after the same fashion, but differ greatly from each other in one way or another… one should also learn from the patient how he is affected in regard to each drink or food, and if he has obvious experience of a particular drug one should not neglect this..

I think there is no need to go further. You may agree that in this work he speaks in the very much same way as we might to today’s student. He also, it seems to me, gives a hint of the humane approach to which I made early reference.

Be that as it may, I hope that in this paper I have introduced you to a doctor from those ancient times who will engender in you as much interest as he did in myself.