‘Well knew he the olde Esculapyus and Deyscorides, and eek Rufus, Olde Ypocras, Haly and Galyen, Serapion, Razis, and Avycen,…’
Canterbury Tales, General Prologue [lines 429-31]: Geoffrey Chaucer (1342-1400)

The scant remaining writings of Rufus of Ephesus on the brain, melancholia, and many other disorders form an ancient though important part of our neurological heritage.

Although less well known than Hippocrates (c. 460-377 BC), and Galen (c. AD 130-200), Rufus of Ephesus (c. AD 80-150) was acclaimed as one of the great physicians of the ancient Greek era [1]. He studied anatomy, pathology, psychiatry, and a wide range of illnesses, medical and surgical, illustrated here by selected quotations. Many works of the Greek physicians were lost to Western Europe after the 5th century. In the 14th and 15th centuries, however, Western Europeans in Spain started to rediscover and reprint Arab learned tracts and those of Byzantine scholars at the fall of Constantinople in 1453.

Remnants of Rufus’s teachings were preserved in the huge encyclopaedia of Oreibasios of Pergamon (c. AD 320-403), physician to Emperor Julianus. In the four to five centuries between the Alexandrian school and Galen there remain few medical writings. Some survive only in Arabic: Rufus’ influence owed much to these early mediaeval Islamic scholars.

Rufus of Ephesus

Figure 1

Rufus (Figure 1) was born in Ephesus (near modern Selçuk, Turkey), where he probably practiced medicine c. AD 100. Abou-Aly discusses at length the many uncertainties [2] amongst history scholars of his dates, education, and workplaces. During the Ptolemaic Egyptian empire, (c.323 to 30 BC) a major cultural movement developed at Alexandria. Clifford Allbutt reported: His fair anatomy points perhaps to Alexandria, or possibly (nearby) Smyrna, as his school [3].

Little is known about his life [4]. The principal Greek biographical authority is the 10th century Byzantine encyclopaedic Suda lexicon that tells us he lived with the physician Criton in the reign of the Emperor Trajan (98-117 CE) [5]. However, less certain sources suggest he lived earlier. This uncertainty [6] mirrors the sparseness of biographical information.

Galen, Oreibasios, Aetius, and Paul of Aegina, the compilers of later medical encyclopaedias, often cited him extensively. After the ninth century the Arabic world revived his work, especially his studies of melancholy. Medieval Scholars were less aware of Rufus, though citations occur in the Latin translation of the Kitab al-Hāwī (the All-embracing Book) of Rhazes. Goupyl in Paris in 1554 edited his Greek treatises with a Latin translation but the more modern scholarship of Charles Daremberg and Emile Ruelle, (Paris, 1879), made available his extant writings [7]. Brock also gave a translation from the Greek in 1929 [8].

He followed Hippocrates in maintaining the imbalance in the four humours – blood, green bile, phlegm, and black bile: treatment was aimed to restore normal balance. A wise and esteemed physician he made several anatomical and clinical discoveries. Many of his opinions were based on therapeutic responses he observed, in the fashion of the empiricists. As Nutton remarked, ‘What is most striking about Rufus’s writings as people today have them is that theoretical discussion and argument are almost entirely absent.’ [1]

Texts

Figure 2

Some of his works have been lost and can be appraised only from citations and comments. The Arabic sources [9], Ibn al-Nadim, Ibn abi Usaibia and Hajji Khalifa, provided similar lists of Rufus’s works [10,11].
The first modern edition of Rufus’ works was the Daremberg Ruelle’s edition in 1879 [7]. Accounts of over 40 titles [2] include:
On Melancholy, two treatises
On the Names of the Parts of the Human Body (Onomastikon)*
On Diseases accompanied by hydrophobia
Treatise on the icterus and bile (#)
Treatise on Gout, syn. podagra (∞)
Treatise on the diminution of flesh
The book of diet, two treatises
Treatise on the Bladder and Kidneys* (Figure 2)
On the interrogation of the patient (#)
On Satyriasis and Gonorrhoea*
Quaestiones medicinales *
Treatise on epilepsy
Treatise on memory
Treatise on vertigo.
*The only writings preserved in Greek, # in Arabic, ∞ in Latin. All others are fragments quoted by later authors.

Rufus had many medical interests. In his texts, he commended the Hippocratic corpus (450-350 BC). He dissected apes, monkeys, pigs, and other animals. He described the decussation of the optic nerves and the lentil-like capsule of the lens. He regarded the nerves as originating from the brain, and distinguished between nerves of motion and of sensation. He described the oviduct of the sheep and rightly held that life was possible without the spleen. He is remembered as the first to describe bubonic plague, and for his description of the methods of arresting haemorrhage. His work On gout was translated into Latin in the sixth century, but remained unknown till modern times [12].

He accurately described the guinea worm, Dracunculus medinensis (medina worm, serpent worm, or dragon worm), often misquoted as filarial worms (Filarioidea). With prescience he believed the cause of gout was an accumulation of poisons in the body. In one treatise, his keen powers of observation were applied to an epidemic of the plague in recording its environmental causes, symptoms, and treatment [13].

Rufus often deferred to his predecessors but he did re-examine and sometimes corrected their claims. Dissection of human corpses was banned in his time, which frustrated him since the first Ptolemies had briefly legalised dissection for Herophilus and Erasistratus.

The Brain

Questions about the location of the soul (Aristotle’s ‘cardiocentric’ or Herophilus’s ‘encephalaocentric’) were recurring arguments in Roman and Greek anatomy. Although Rufus explained the brain in a fashion similar to Herophilus and Erasistratus, he perceptively recognised that the brain, spinal cord, and nerves were composed of the same substance, whilst he distinguished them as separate anatomical entities. His dissections disclosed:

The brain is located inside the skull; it is covered by meninges; one denser and more resistant, is attached to the bone [dura mater]; the other, thinner but also resistant, stretches over the brain [pia mater]. The upper surface of the brain is called varicose [convoluted]… the extension from the base is the parencephalon [cerebellum]; the cavities of the brain have been designated hollows [ventricles]. The membrane which lines the ventricles is called the choroid membrane. Herophilus also calls it the choroid meninges. The processes springing from the brain are the sensory and motor nerves with the help of which we are able to feel and to move voluntarily and which are responsible for all activities of the body. There are also nerves which issue from the spinal marrow; one may designate indifferently all of the marrow which descends through the vertebrae either as dorsal or spinal. (p. 13) [14]

And:

The marrow [spinal cord] arises from the brain and escapes through the hole of the cranium at the occiput [foramen magnum] and descends as far as the base of the spine through all vertebrae; it is not a special substance but an extension from the brain; it is called the marrow of the back. Nervous channels [nerves], which are distributed to sense, arise and emerge from the brain: for example, to the ear, to the nose, and to other sensory parts. One of these processes comes off in front from the base of the brain, is divided into two branches [optic nerves], and inclines towards each of the eyes in the part called the basin or cavity of vision, in the form of a fossa, and which is found on each side of the nose. [14]

In a fragment preserved by Oreibasios he commended inducing fever to treat convulsions, epilepsy, asthma (orthopnoea), melancholia, certain skin diseases, tetanus, and women in labour with convulsions [15]. (p. 547)

Nerves

Rufus showed that the nerves proceed from the brain. He divided them into those of sensibility and those of motion that were named: aisthêtika [sensation] and prohairetika [purposeful choice/motor] (De nominatione Partium hominis p. 36). However he credited Herophilus and Erasistratus with discovery of the nerves, noting that they first distinguished motor from sensory nerves:

‘Nerve (neuron) is a simple solid body, the cause of voluntary motion, but difficult to perceive in dissection… According to Erasistratus there are two kinds of nerves, sensory and motor nerves; the beginnings of the sensory nerves, which are hollow, you find in the meninges [sc. Of the brain], and those of the motor nerves in the cerebrum (enkephalos) and in the cerebellum (parenkephalis). According to Herophilus, on the other hand, the neura that make voluntary [motion] possible have their origin in the cerebrum (enkephalos) and the spinal marrow, and some grow from bone to bone, others from muscle to muscle, and some also bind together the joints.’ (De anatomia partium hominis. (pp. 71-5, 184-5.) [7]

He recorded that Herophilus was unclear in differentiating nerves from ligaments and tendons.

Although the details of the brain’s circulation were vague and remained so until Willis’s studies (Cerebri Anatome, I664), Rufus mentions the carotid (καρωτίδες) vessels [16]. ‘The ancients,’ he says, (De nominatione Partium hominis p. 42) ‘called the arteries of the neck καρωτίδες because they believed, that, when they were pressed hard, the animal became sleepy and lost its voice; but in our age, it has been discovered that this accident does not proceed from pressing upon these arteries, but upon the nerves contiguous to them.’

Medical treatises

On Melancholy

In this detailed and praised work, Rufus described the consequences of an excess of bile as ‘melancholy humour.’ [17] Melancholy reflected black bile as a cause for bad digestion and for madness. Worse in autumn, he noted that intense intellectual activity precipitated symptoms. Typical sadness, anxiety, fear, suspicion, and the misery of depression contrasted with periods of joy with quick powerful movements; and if unrelieved the patient might die. Galen praised his knowledge of the Hippocratic corpus, and thought his treatise On Melancholy [6,17], the best work on the subject before his own (sic).

Traité sur le Pouls

A treatise on the pulse was published in early Latin editions of Galen but identified as pre-Galenic and attributed by Daremberg to Rufus. The French translation, Traité sur le Pouls in 1845, and in 1879 was included in Daremberg’s edition of the works of Rufus [7]. Rufus considered the heart to be the seat of life, and noticed that the left ventricle was smaller and thicker than the right (De nominatione Partium hominis p. 37). He recognised that the heart was the cause of the pulse, which he defined as the diastole, and systole of the heart – terms which persisted. He also noted like Herophilus the pulmonary blood vessels:

‘to the very large and thick vessel leading from the heart to the lungs; for in the lungs conditions are the opposite of what they are elsewhere; the veins are there powerful and in nature very similar to arteries, while the arteries are weak and bear a close resemblance to veins. (p. 162) [7]

For the layman

Although most of his treatises were addressed to medical colleagues, his manual For the Layman considered many diseases and gave public health advice both for preserving health and treating illness. His advice on public health was aimed especially at travellers, the elderly, and children. We can see his pragmatism when he warned of the risks of buying a slave with a suppurating ear, which might risk serious illness to the slave and financial loss to its buyer. In this work [2], (p.104-6), he accurately described diseases of the eye, the lens, its membrane and the optic chiasm. Ophthalmia was caused by smoke, dust and sun; too much sun caused amblyopia; glaucoma was due to changing colours of the crystalline liquid [vitreous] because of dryness, and clotting of liquid between the carotoides and lens caused cataract.

Quaestiones medicinales [18]

Rufus’s famous treatise, Medical Questions detailed how the doctor should elicit the vital history of the patient. The final section is an extension, not a criticism, of Hippocrates’s views in Airs, Waters, and Places. Rufus argued the importance of local cultures, illnesses and remedies he had found in the areas of his work. He wrote:

‘One must put questions to the patient, for thereby certain aspects of the disease can be better understood, and the treatment rendered more effective. And I place the interrogation of the patient himself first, since in this way you can learn how far his mind is healthy or otherwise; also his physical strength and weakness; and you can get some idea of the disease and the part affected. First we have to ask at what time the illness began; this is most valuable both for treatment and for reckoning the critical days; …The next thing to ask is whether what has now happened is one of the diseases to which the individual is accustomed, or is something which has never happened to him before… it is surely not possible, is it, to find out about these in any way except by asking? … For it is justly believed that everything congenital is harder to cure than what is not. …One must put questions to the patient, for thereby certain aspects of the disease can better be understood, and the treatment rendered more effective.’ [7]

Although history is most important, the ancients relied mainly on physical manifestations for diagnosis perhaps foreshadowing the current neglect of the history in favour of sophisticated imaging techniques.

On the Names of the Parts of the Human Body (onomastikón)

Figure 3

This concise anatomy includes position, shape, and functions – a pioneering method to explain anatomy [19]. Rufus stressed the importance of accurate nomenclature to prevent misunderstanding, observing: ‘the smith, the cobbler, and the carpenter first learn the words for metal, tools and such like. Why should it be any different in more noble arts?’ [7] (p. 133) (Figure 3) In this treatise – he described as a manual for the students of medical art – he relied on demonstration in teaching; visible (outer) parts of the body that he demonstrated on a slave, and invisible (inner) parts shown on a dissected monkey. There follows a chapter describing single parts of the human body which he named in the scheme a capite ad calcem (from head to heel).

Legacy

Rufus was clearly a pragmatist. It is interesting that in his writings theoretical discussion and argument are minimal [1]. His emphasis was on his own treatments, and many of his notions of causation of disease stem from inferences he draws from therapeutic responses. His commitment to the theory of the four humours he justified by the results of his therapies rather than by physiological theory. He realised the importance of the individual patient’s biological variations:

we are not naturally all the same; we differ very greatly from one another. One must put questions to the patient, for thereby certain aspects of the disease can be better understood, and the treatment rendered more effective. (p. 115) [8]

Most medieval European scholars were not familiar with his works. The African Constantine referred to his ideas on melancholy through an Arabic intermediary, and there are quotations of Rufus in the Continens, a Latin translation of the Kitab al-Hāwīī (All-embracing Book) of Rhazes (AD. c. 854-925). But ironically, his more important works took second place to his use of the purgative hiera.

It appears that Galen frequently cited Rufus’s texts, with and without quotation. Galen was younger than Rufus, and his occasional reference to him was complimentary: ‘Rufus is an outstanding physician very familiar with [medical] art.’ [20] However, he did not reveal how much he owed to Rufus.

More recently, Manfred Ullmann [9,21] has uncovered new texts, some translated into Arabic that confirm Rufus’s major contributions to Medicine.

We can share Allbutt’s opinion [3] that Rufus was one of the few really independent physicians after the Christian era yet of Hippocratean clinical tradition.

References

  1. Nutton V. ‘Rufus of Ephesus.’ In: Complete Dictionary of Scientific Biography. Edited by Simon Hornblower, Anthony Spawforth. 2008. Encyclopedia.com. 4 Dec. 2012. http://www.encyclopedia.com.
  2. Abou-Aly, Amal Mohamed Abdullah. The medical writings of Rufus of Ephesus. Doctoral thesis, University of London. (1992) http://discovery.ucl.ac.uk/1317541/1/246073.pdf
  3. Allbutt TC. Greek Medicine in Rome, 2nd Fitzpatrick lecture. BMJ 1910;2:1481-9. https://ia601407.us.archive.org/12/items/greekmedicineinr00allbuoft/greekmedicineinr00allbuoft.pdf https://doi.org/10.1136/bmj.2.2602.1481
  4. Edelstein L, Nutton V. Rufus of Ephesus. In Simon Hornblower & Anthony Spawforth (Eds.) The Oxford classical dictionary. NY: Oxford University Press. 2003.
  5. Suda On Line: Byzantine Lexicography. http://www.stoa.org/sol/ accessed 5 December 2012
  6. Nutton V. The medical world of Rufus of Ephesus. In: Pormann P E. Rufus of Ephesus. On Melancholy.2008; Volume 12 pp.139-57
  7. Oeuvres de Rufus d’Ephèse. Collection des médecins grecs et latins. Ed. Charles Daremberg, Ch-Emile Ruelle. Paris: Imprimerie Nationale, 1879. Reprint, Amsterdam: Hakkert, 1963.
  8. Brock AJ. Greek Medicine. Being Extracts Illustrative of Medical Writers from Hippocrates to Galen. London: JM Dent, 1929. Includes a partial translation of Rufus’s Quaestiones medicinales.
  9. Ullmann M. Die arabische Überlieferung der Schriften des Rufus von Ephesus. In: Aufstieg und Niedergang der römischen Welt; Geschichte und Kultur Roms im Spiegel der neueren Forschung. Teil II, Band 37.2. Ed. W. Haase. Berlin, New York: de Gruyter. 1995. pp1293-1349.
  10. Scarborough J. (1993), Roman Medicine to Galen, page 45. Aufstieg und Niedergang der römischen Welt (ANRW). https://doi.org/10.1515/9783110887877-002
  11. Littman RJ. Medicine in Alexandria, 1996; p2703. Aufstieg und Niedergang der römischen Welt (ANRW).
  12. Singer Charles. Greek Biology & Greek Medicine Oxford, At The Clarendon Press 1922. p62, 119-121. https://doi.org/10.5962/bhl.title.88048
  13. Laale HW. Ephesus (Ephesos): An Abbreviated History From Androclus to Constantine XI. West Bow Press 2011). p238.
  14. Clarke E, O’Malley CD. The Human Brain and Spinal Cord: A Historical Study Illustrated by Writings From Antiquity to the Twentieth Century, ed 2. San Francisco: Norman Publishing, 1996. p12-14.
  15. Dictionary of Greek and Roman Antiquities edited William Smith. Boston, [London, printed]: C. Little, and J. Brown, 1870. Reproduced: Ann Arbor, Michigan: University of Michigan Library. 2005; pp. 669-70
  16. Singer C. The strange histories of some anatomical terms. Med Hist 1959;3:1-7.
    https://doi.org/10.1017/S0025727300024200
  17. Pormann PE. Rufus of Ephesus. On Melancholy. Volume 12 of Scripta antiquitatis posterioris ad ethicam religionemque pertinentia. Mohr Siebeck, 2008. p1-5.
  18. Letts M. Rufus of Ephesus and the Patient’s Perspective in Medicine, British Journal for the History of Philosophy 2014; 22:5, 996-1020, DOI: 10.1080/09608788.2014.963504 https://doi.org/10.1080/09608788.2014.963504
  19. Bujalkova M. Rufus of Ephesus and his contribution to the development of anatomical nomenclature. Acta Med Hist Adriat. 2011;9(1):89-100.
  20. Kuhn C G (Ed). Claudii Galen. Opera Omnia To. XVII. Pars 1. De antid. II 2: XIv 119, 1 Leipzig: Cnobloch. 1828. https://archive.org/details/operaomnia00assmgoog
  21. Ullmann M. Krankenjournal.. Wiesbaden, Germany: Harrassowitz, 1978, cited by Nutton ref. 1.