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Dentist s Guide to Medical Conditions and Complications
1st Edition Kanchan Ganda Digital Instant Download
Author(s): Kanchan Ganda
ISBN(s): 9780813809267, 0813806615
Edition: 1
File Details: PDF, 4.32 MB
Year: 2008
Language: english
Dentist’s Guide
to Medical Conditions
and Complications
Dentist’s Guide to
Medical Conditions
and Complications

Kanchan M. Ganda, M.D.

A John Wiley & Sons, Inc., Publication

Edition first published 2008
© 2008 Wiley-Blackwell

Blackwell Munksgaard, formerly an imprint of Blackwell Publishing was acquired by John Wiley &
Sons in February 2007. Blackwell’s publishing programme has been merged with Wiley’s global
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Disclaimer
The contents of this work are intended to further general scientific research, understanding, and
discussion only and are not intended and should not be relied upon as recommending or promoting
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and the author make no representations or warranties with respect to the accuracy or completeness of
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Library of Congress Cataloguing-in-Publication Data

Ganda, Kanchan M.
Dentist’s guide to medical conditions and complications / by Kanchan M. Ganda.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8138-0926-7 (alk. paper)
1. Chronically ill—Dental care. 2. Sick—Dental care. 3. Oral manifestations of general
diseases. I. Title.
[DNLM: 1. Stomatognathic Diseases—complications. 2. Dental Care—standards. 3. Medical
History Taking. 4. Pharmaceutical Preparations,
Dental—administration & dosage. 5. Pharmaceutical Preparations,
Dental—contraindications. 6. Stomatognathic Diseases—diagnosis. WU 140 G195d 2008]
RK55.S53G36 2008
617.6’026—dc22
2008007433

A catalogue record for this book is available from the U.S. Library of Congress.

Set in 9.5 on 12 pt Palatino by SNP Best-set Typesetter Ltd., Hong Kong

Printed in Singapore by Markono Print Media Pte Ltd

1 2008
 Dedication

This book is dedicated to all my students, past and present; to my late parents, Amrit
Devi and Roop Krishan Dewan; and to my family for all their encouragement and
loving support.

v
 Contents

Acknowledgments xii

Introduction: Integration of Medicine in Dentistry xiii

Section I: Patient Assessment 3

1. Routine History-Taking and Physical Examination 5
2. History and Physical Assessment of the Medically
Compromised Dental Patient (MCP) 25

Section II: Pharmacology 31

3. Prescription Writing, DEA Schedules, and FDA
Pregnancy Drug Categories 33
4. Local Anesthetics Commonly Used in Dentistry: Assessment,
Analysis and Associated Dental Management Guidelines 40
5. Analgesics Commonly Used in Dentistry: Assessment,
Analysis, and Associated Dental Management Guidelines 48
6. Odontogenic Infections and Antibiotics Commonly Used
in Dentistry: Assessment, Analysis, and Associated Dental
Management Guidelines 63
7. Antifungals Commonly Used in Dentistry: Assessment,
Analysis, and Associated Dental Management Guidelines 83
8. Antivirals Commonly Used in Dentistry: Assessment,
Analysis, and Associated Dental Management Guidelines 87

Section III: Acute Care and Stress Management 91

9. Management of Medical Emergencies in the Dental Setting:
Assessment, Analysis, and Associated Dental Management
Guidelines 93

vii
viii Contents

10. Oral and Parenteral Conscious Sedation for Dentistry: Assessment,

Analysis, and Associated Dental Management Guidelines 110

Section IV: Hematopoietic System 125

11. Complete Blood Count (CBC): Assessment, Analysis, and Dental
Management Guidelines 127
12. Red Blood Cells (RBCs) Associated Disorder: Anemia:
Assessment, Analysis, and Associated Dental
Management Guidelines 134
13. Red Blood Cells Associated Disorder: Polycythemia: Assessment,
Analysis, and Associated Dental Management Guidelines 144
14. Red Blood Cells Associated Disorder: Hemochromatosis:
Assessment, Analysis, and Associated Dental
Management Guidelines 146

Section V: Hemostasis and Associated Bleeding Disorders 149

15. Primary and Secondary Hemostasis: Normal Mechanism,
Disease States, and Coagulation Tests: Assessment,
Analysis, and Associated Dental Management Guidelines 151
16. Platelet Disorders: Thrombocytopenia, Platelet Dysfunction, and
Thrombocytosis: Assessment, Analysis, and Associated Dental
Management Guidelines 155
17. Von Willebrand’s Disease: Assessment, Analysis, and Associated
Dental Management Guidelines 159
18. Coagulation Disorders: Common Clotting Factor Deficiency
Disease States, Associated Systemic and/or Local Hemostasis
Adjuncts, and Dental Management Guidelines 162
19. Anticoagulants Warfarin (Coumadin), Standard Heparin,
and Low Molecular Weight Heparin (LMWH): Assessment,
Analysis, and Associated Dental Management Guidelines 169

Section VI: Cardiology 175

20. Rheumatic fever (RF): Assessment, Analysis, and Associated
Dental Management Guidelines 177
21. Infective Endocarditis and Current Premedication Prophylaxis
Guidelines 181
22. Hypertension and Target Organ Disease States: Assessment,
Analysis, and Associated Dental Management Guidelines 189
23. Cerebral Circulation Diseases TIAs and CVAs: Assessment,
Analysis, and Associated Dental Management Guidelines 195
 Contents ix

24. Coronary Circulation Diseases, Classic Angina and

Myocardial Infarction: Assessment, Analysis, and Associated
Dental Management Guidelines 197
25. Congestive Heart Failure (CHF): Assessment, Analysis, and
Associated Dental Management Guidelines 202
26. Cardiac Arrhythmias: Assessment, Analysis, and Associated
Dental Management Guidelines 204
27. Peripheral Circulation Disease 206
28. Renal Function Tests, Renal Disease, and Dialysis:
Assessment, Analysis, and Associated Dental
Management Guidelines 207

Section VII: Pulmonary Diseases 213

29. Pulmonary Function Tests and Sedation with
Pulmonary Diseases: Assessment, Analysis, and Associated
Dental Management Guidelines 215
30. Upper Airway Disease: Assessment, Analysis, and Associated
Dental Management Guidelines 218
31. Asthma and Airway Emergencies: Assessment,
Analysis, and Associated Dental Management Guidelines 220
32. Chronic Bronchitis: Assessment, Analysis, and Associated
Dental Management Guidelines 226
33. Emphysema: Assessment, Analysis, and Associated
Dental Management Guidelines 227
34. Chronic Obstructive Pulmonary Disease (COPD):
Assessment, Analysis, and Associated Dental
Management Guidelines 228
35. Obstructive Sleep Apnea (OSA): Assessment, Analysis, and
Associated Dental Management Guidelines 232
36. Tuberculosis: Assessment, Analysis, and Associated
Dental Management Guidelines 233

Section VIII: Clinical Pharmacology 239

37. Prescribed and Nonprescribed/Over-the-Counter Medications:
Assessment, Analysis, and Associated Dental Management
Guidelines 241

Section IX: Endocrinology 245

38. Diabetes: Type 1 and Type 2 Diabetes: Assessment, Analysis, and
Associated Dental Management Guidelines 247
x Contents

39. Thyroid Gland Dysfunctions, Hyperthyroidism and

Hypothyroidism: Assessment, Analysis, and Associated
Dental Management Guidelines 257
40. Adrenal Gland Cortex and Medulla Disease States:
Assessment, Analysis, and Associated Dental
Management Guidelines 261
41. Parathyroid Dysfunction Disease States: Assessment,
Analysis, and Associated Dental Management Guidelines 268
42. Pituitary Gland Dysfunction: Acromegaly 272

Section X: Seizure Disorders 273

43. Classic Seizures, Petit Mal and Grand Mal Epilepsy:
Assessment, Analysis, and Associated Dental
Management Guidelines 275

Section XI: Gastrointestinal Conditions/Diseases 283

44. Gastrointestinal Disease States and Associated Oral
Cavity Lesions: Assessment, Analysis, and Associated Dental
Management Guidelines 285

Section XII: Hepatology 299

45. Liver Function Tests (LFTs), Hepatitis, and Cirrhosis:
Assessment, Analysis, and Associated
Dental Management Guidelines 301

Section XIII: Postexposure Prevention and Prophylaxis 325

46. Needle-Stick Exposure Protocol and Associated
Management Prophylaxis in the Dental Setting 327

Section XIV: Infectious Diseases 331

47. Human Immunodeficiency Virus (HIV) and Sexually
Transmitted Diseases (STDs): Assessment, Analysis, and
Associated Dental Management Guidelines 333

Section XV: Oral Lesions and Dentistry 349

48. Therapeutic Management of Oral Lesions in the Immune-
Competent and the Immune-Compromised Patient in the
Dental Setting 351

Section XVI: The Female Patient: Pregnancy, Lactation, and

Contraception 371
49. Pregnancy and Lactation: Assessment and Associated Dental
Management Guidelines 373
 Contents xi

Section XVII: Rheumatology: Diseases of the Joints, Bones,

and Muscles 385
50. Classic Rheumatic Diseases: Assessment of Disease
States and Associated Dental Management Guidelines 387

Section XVIII: Oncology: Head and Neck Cancers, Leukemias,

Lymphomas, and Multiple Myeloma 413
51. Head and Neck Cancers and Associated
Dental Management Guidelines 415

Section XIX: Psychiatry 447

52. Psychiatric Conditions: Assessment of Disease States
and Associated Dental Management Guidelines 449

Section XX: Transplants 465

53. Organ Transplants, Immunosuppressive Drugs, and
Associated Dental Management Guidelines 467

Section XXI: Common Laboratory Tests 473

54. Comprehensive Metabolic Panel (CMP) and Common
Hematological Tests 475

Appendix: Suggested Reading 479

Index 502
 Acknowledgments

I wish to sincerely thank Dr. Bruce J. Baum, D.M.D., Ph.D., Chief, Gene Therapy and
Therapeutics Branch, National Institute of Dental and Craniofacial Research, Bethesda,
Maryland, who was instrumental in mentoring and motivating me to publish my work.
Dr. Baum’s vision for dentistry and the confidence that my work would make a differ-
ence is very humbling.
Thanks to my Dean at Tufts University School of Dental Medicine, Dr. Lonnie Norris,
D.M.D, M.P.H., and our Dean of Curriculum, Dr. Nancy Arbree, D.D.S., M.S., for making
a reality of my vision of integrating medicine into the dental curriculum and experienc-
ing the outcome over the years. I was given the flexibility to create a medicine curricu-
lum for our students and integrate this education through all the four years of dental
curriculum. My sincere thanks to Dr. Noshir Mehta, D.M.D, M.S., Chair, Department of
General Dentistry, Tufts University School of Dental Medicine, and to Dr. Catherine
Hayes, D.M.D., D.M.Sc., Chair, Department of Public Health and Community Services,
Tufts University School of Dental Medicine, for their support and critiquing of my
work.
To all the past and present medicine course speakers and rotation directors, special-
ists in their respective fields of medicine, this unique dental education would have been
incomplete without your active participation, dedication, and support. I wish to
acknowledge and thank you all for your efforts and endless support.
I also would like to thank Patricia DiAngelis, Heidi S. Birnbaum, Lily Parsi, Amanda
Jones, and Daniel M. Callahan for their unflagging support and help with the project.
I’d like to thank my son-in-law, Akshat Tewary, Esq., for his help with my book con-
tract, my daughter Kiran for providing her not-so-computer-savvy mother with round-
the-clock technical support, and my daughter Anjali and husband Om, both physicians,
for the numerous discussions offering their insights about patient care.
Last but not least, I wish to thank all my students, who have been my constant source
of inspiration. I could never have experienced the joy of teaching without their active
participation and endurance in the learning of medicine!

Kanchan Ganda, M.D.

xii
 Introduction: Integration of
Medicine in Dentistry

Dental care today holds many challenges for the dental practitioner. Patients live longer,
often retaining their own dentition, have one or more medical conditions, and routinely
take several medications.
Along with excellence in dentistry, the practicing dentist has the dual task of staying
updated with the current concepts of medicine and pharmacology and should rightfully
be called the “Physician of the Oral Cavity.”
The integration of medicine in the dental curriculum has become a necessity, and
this integration must begin with the freshman class for the students to gain maximum
benefit and for the change to also gain credibility. The integration of medicine is best
achieved when done in a case-based or problem-based format and correlated with the
basic sciences, pharmacology, general pathology, oral pathology, and dentistry. There
needs to be a true commitment and constant reenforcement of the integration in all the
didactic and clinical courses.
The integration of medicine, pharmacology, and medically compromised patient care
is best achieved when done in a pyramidal process, through the four years of dental
education.
The foundation should instill a basic knowledge of:
1. Standard and medically compromised patient history taking and physical
examination
2. Symptoms and signs of highest-priority illnesses along with the common laboratory
tests evaluating those disease states
3. Anesthetics, analgesics, and antibiotics used in dentistry
4. Prescription writing
“Normal” patient assessment, when stressed in the first year, prepares students to better
understand the changes prompted by disease states during the second year of their
education, when didactic and clinical knowledge of highest-priority illnesses, associated
diagnostic laboratory tests, and the vast pharmacopia used for the care of those diseases
is added on. Case-based scenarios should be used to solidify this information.
The progressive learning up to the end of the second year prepares the student to
“care” for the patient “on paper”. With the start of the clinical years, the student is pre-
pared to apply this knowledge toward “actual” patient care during the third and fourth
years of education.

xiii
xiv Introduction

During the third year the student should participate in medical and surgical clinical
rotations in a hospitalized setting and complete a Hospital Clerkship Program where
the student is exposed to head-and-neck cancer care, emergency medicine, critical care,
anesthesia, hematology, oncology, transplants, cardiothoracic surgery, etc. This will
widen the student’s knowledge, broaden clinical perception, and further enhance the
link between medicine and dentistry.
During the clinical years, the students should complete faculty-reviewed medical
consults for all their medically compromised patients, prior to dentistry. This patient-
by-patient health status review will help correctly translate their didactic patient-care
knowledge in the clinical setting.
The text is a compilation of materials needed for the integration of medicine in den-
tistry. It is a book all dental students and dental practitioners will appreciate both as a
read and chairside.
The text provides information on epidemiology; physiology; pathophysiology; labo-
ratory tests evaluation; associated pharmacology; dental alerts; and suggested devia-
tions in the use of anesthetics, analgesics, and antibiotics for each disease state
discussed.
The student will greatly benefit from the sections detailing history taking and physi-
cal examination; clinical and applied pharmacology of dental anesthetics, analgesics,
and antibiotics; stress management; and management of medical emergencies in the
dental setting.
Dentist’s Guide
to Medical Conditions
and Complications
 I
Patient Assessment
 Routine History-Taking and
Physical Examination
1
GENERAL OVERVIEW
Patient Interview Introduction
The primary job of the dental student starting clinical work is to learn to conduct a
patient workup thoroughly and efficiently. The heart of every patient workup is a set
pattern in sequential order of data collection and analysis.

Patient Workup Sequential Pattern

The sequential pattern of patient workup consists of the following:
1. History and physical examination
2. Laboratory data collection and analysis
3. Diagnostic and therapeutic plan formulation
The first step, the patient interview or the history, is probably the single most impor-
tant task in the diagnostic patient workup because of its importance in diagnosis and
in the development of a good doctor-patient relationship. The provider should have a
professional manner that will put the patient at ease. During the interview, always listen
carefully to the patient. Use interrogation sparingly or later, to aid a communicating
patient or to restrict the rare patient who has a tendency to ramble!

Patient Interview Practical Points

Keep your appearance neat and clean. This will help gain your patient’s trust. Always
introduce yourself when meeting a patient and refer to the patient as “Mr. John Doe”
or “Miss Jane Doe.” Do not use first names during the initial encounter. Exchange a few
brief pleasantries because this will help both you and the patient feel comfortable and
at ease with each other.
Always have a friendly and sincere interest in your patient’s problem(s). Always be
courteous, respectful, and confidential and show a continued interest while you are with
the patient.

5
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different content
 3. In the third place, Nature is matter. On the theoretical side
Stoicism agrees with Epicureanism only at one point,—both were
materialistic. The materialism of both these New Schools got a
disproportionate prominence because it had to be defended against
the attacks of the Academy and the Lyceum. The materialism of the
Epicureans was a mere adoption of a theory; the materialism of the
Stoics was only one aspect of its supplementary basis. Nevertheless,
to the Stoic matter alone is real, because it alone acts and is acted
upon. Everything is matter,—nature-objects, God and the soul, and
even the qualities, forces, and relations between material bodies.
The Stoics regarded the presence and interchange of the qualities of
things as the appearance and intermingling of bodies in these
things.

There can be no doubt about the materialism of the Stoic

teaching, although both material and spiritual attributes are ascribed
to God in a way that is startling. The Heracleitan conception of fire
as the primary substance is the Stoic conception of God. God is fire,
air, ether, and most commonly the atmospheric currents which
pervade all things. But God is also the World-soul, the World-mind,
the Cosmic-reason, the universal Law, Nature, Destiny, Providence.
He is a perfect, happy, and kind Being. In single statements these
aspects are often combined and God is described as the Fiery
Reason of the world, the Mind in matter, the reasonable Air-currents.
The Stoic equation is Nature ＝ Matter ＝ Fire ＝ Reason ＝ Fate ＝
Providence ＝ God.

The Stoics followed Heracleitus also in their conception of the

development of the present world from the cosmic fire. “In all points
of detail their views on what we call physical science are
contemptible. They contained not one iota of scientific thinking.” 36
They followed Aristotle, however, in their description of the elements
and their teleological arrangements.

The primitive substance changes by its own inner rational law

into force and matter. Force is the World-soul, the pneuma or warm
breath, which pervades all things. Matter is the World-body, and is
water and earth. In cosmic periods the primitive fire is destined to
re-absorb the world of variety into itself and then consume it in a
universal catastrophe.

The most important feature in the Stoic materialism is the

conception of pneuma, or the force into which the original substance
is differentiated. This is the World-soul. Nature is thus conceived as
dynamical. The Stoic word for the World-soul is translated by various
expressions, as “creative reason,” “generative powers,” “formative
fire-mind.” It penetrates all things and dominates all as their active
principle. Through it the universe is one, not a plurality of parts. The
pneuma is the life of the universe. Its motion is spontaneous; its
development is teleological. The pneuma is an extraordinarily
condensed conception, containing as it does suggestions from
Heracleitus’ Logos, Anaxagoras’ Nous, Democritus’ fire-atoms, and
Aristotle’s Energeia.

The human being has a constitution analogous to the universe.

Man is the microcosm and the universe the macrocosm. The soul of
man is the pneuma which holds his body together, and it is an
emanation from the divine pneuma. Mental states—thought and
emotions—are air currents. Virtue is the tension of the atmospheric
substance of the soul. The material, yet divine, pneuma constitutes
man’s reason, causes his activities, is seated in his breast. Since the
pneuma is a body, it disconnects itself from the human corpse at
death, has a limited immortality, and returns to the cosmic pneuma
at the conflagration of the world.

The Conceptions of Nature and Personality supplement

each other. Thus fundamentally the personality is identical with the
cosmos—it is reason. To turn the matter about, by reason or
“nature” the Stoic means two things that are essentially one. He
means the reason of man, or the reason of the world; to “live
according to nature” is to live according to the nature of man or
according to the nature of the world. The life of the Wise Man as a
harmony with physical nature is a harmony with itself as well. The
antithesis to “nature” or “reason” is sensuous nature. What we
speak of as the natural impulses were not “natural” at all in the Stoic
teaching.

“Nature” as universal is the creative cosmic power acting for

ends. Coördination with this constitutes morality. It is a willing
obedience to eternal necessity. The “fool” acts according to his
sensations and impulses, and therefore against “nature.” But the
Wise Man, by withdrawing within himself, is his own independent
master because he is acting universally. “Nature” is the life-unity of
the human soul with the world reason. True individual morality is
therefore universal morality, complete humanity, universal rationality.
To obey “nature” is to develop the essential germ in one’s self.

Thus these two points of view were obtained of life-unity: a

universe rationally guiding in all its changes; the human individual
epitomizing this universe in himself as a rule for his conduct amid his
vicissitudes.

The Stoic and Society. Men are divided into two classes,—the
entirely wise and virtuous, or the entirely foolish and vicious. There
is no middle ground. If a man possesses a sound reason, he has all
the virtues; if he lacks this reason, he lacks all. There are only a few
Sages; the mass of men are fools. The Stoics were continually
lamenting with Pharisaical pessimism the great baseness of men.
From their sublime height they looked upon the Wise Man as
incapable of sin, upon the fool as incapable of virtue. In thus
denying the ordinary distinctions between good and evil, they were
dangerous in politics. Their political perspective was not reliable. In
general, they did not enter the politics of the democracies where
they lived. They were, however, often the advisers of tyrants, and
often assisted in removing them (as in the case of Julius Cæsar).
The Stoic School of Musonius Rufus made a splendid Puritan protest
against Nero and Domitian, and finally his disciples and friends
controlled the empire for a century (second century A. D.). 37 The
Stoic regarded his Wise Man as attaining the same independence
that the Epicurean claimed for his Wise Man. He is lord and king. He
is inferior to no other rational being, not even to Zeus himself.

The Stoic differs from the Epicurean in his attitude toward the
political state. The two Schools agree that the sufficient Wise Man
needs the state but little. The Epicurean teaches that society is not
natural and not inherent in human nature. The Stoic, however,
maintained that society is a divine institution, which gives way only
occasionally to man’s individual perfecting. Since man and the
cosmic reason are identical, all men are essentially identical. When
men therefore lead a life of reason, they lead a social life. This realm
of reason includes not Romans alone, but all men, gods, and slaves.
But the political government is only secondary, for the Stoic’s ideal is
a universal empire. The Stoic’s interest in practical politics was as
weak as his ideal of a rational society was transcendent. His teaching
of justice and love for man was, however, a forecasting of the
coming religious emancipation.

There are two antagonistic tendencies running through Stoicism.

The first is to seek society with its virtues,—justice, love of men,
sociability or cosmopolitanism. The second dispenses with society to
gain an inner freedom. Yet these two tendencies often coincide.

They may be presented as follows:—

To seek society. To dispense with society.

Exaltation of inner freedom
1. Exaltation of justice and love.
and happiness.
2. World citizenship. The Wise Man.
Relations and degrees of Absolute virtue and absolute
3.
virtue. vice.
Virtue depends somewhat on
4. Knowledge alone is virtue.
conditions.
 Individual should submit to
5. Individual should make fate.
fate.

Duty and Responsibility. The Stoic’s identity of human and

cosmic reason elevated the law of human conduct into a strict,
universal law of duty. It embodies, on the one hand, the Cynic’s
protest against external law, and on the other the construction of
the inner moral law. The backbone of Stoicism is sense of
responsibility. The Stoics brought out as never before the contrast
between what is and what ought to be. They were the most
outspoken doctrinaires of antiquity, and formed a school of character
building in stubbornness. As time went on they substituted human
nature for cosmic nature, and then accentuated human nature as
conscience. The individual could then define the right for himself,
and this sort of individualism was developed with so much skill that
it admitted great laxity of morals. Duty commands some things and
forbids others, but there are left a great mass of activities that are
ethically indifferent. These indifferent matters offered opportunity for
these men of conscience to perform what in the eyes of others were
crimes (for example, Brutus). Baseness is only what is
unconditionally forbidden.

Yet it must not be supposed that the Stoics generally employed

the indifferent as an excuse for moral license. On the contrary, the
concept of life as a struggle originated with the Stoics, and from
them it passed into the common consciousness of man. There was
before them (1) the struggle with environment dominated by a false
evaluation, (2) the struggle with effete civilization, (3) the struggle
particularly with one’s self. The Stoic hero of inner courage and
greatness of soul rises above his fellows, not because he gains
dominion over the world, but because in indifference to it he isolates
himself. He exists in premeditation of doing rather than in the actual
doing in which his power would be spent. Still, in the absolute
contrast between the good and the evil, in making life a disjunctive,
an “Either—Or,” duty got a definite and distinct meaning. Duty,
according to the Stoics’ conception, had not so much the nature of
an imperative as of what is suitable,—an act adapted to nature, a
consistent and justifiable act. In a manner unknown to antiquity the
ethical nature of conduct was thus universalized in the new
conceptions of philanthropy, of the universality of God and man, in
the tendency to suppress slavery and care for the poor and sick.
Nevertheless, as a moral force Stoicism accepted the world as it
found the world, and did not attempt to make it over.

The Problem of Evil and the Problem of Freedom. On the

questions of moral freedom and evil, the Stoics suffered severe
attacks from the Academy and the Epicureans. Alone among the
Schools of antiquity the Stoics preached the doctrine of Fate. The
demands of ethical responsibility, however, required that the
individual should determine his own conduct. To suit these demands
the Stoic did not modify his fundamental conception of Nature, but
he tried to justify his position on the ground that the individual
expressed the law of nature. His argument may be stated thus: Man
is like God; Man is one with God; Man is free. It was also stated on
psychological grounds. Man can have one of two attitudes toward
the world-law: (1) his performance may be through blind
compulsion; (2) his performance may be through an intelligent
understanding of the law, in which case he is free. The occurrence of
his act is fateful, but it makes great difference to the man whether
the occurrence is in spite of him or with his intelligent acquiescence.
The occurrence is not an evil in itself; for physical evils are no evils,
and things that appear to be moral evils are (1) subservient to the
good; (2) merely relative to good; or (3) show that God’s ways are
not our ways. My will is mine though necessary; my will is mine
though it be law. The soul is free when it fulfills its own destiny. God
works through man’s will. Outer circumstances are only accessory
causes, but the main cause is the assent of the will. At the same
time the Stoics did not shrink from the logic of their own fatalism.
Chrysippus said that only on the basis of determinism could correct
judgments of the future be made. Only on this ground could the
gods foreknow. Only the necessary can be known.
 The Modifications of the Stoic Doctrine after the First
Period. The inherent difficulties in the Stoic doctrine and the attacks
upon it gave rise to later concession that only further complicated it.
(1) The moral ideal was lowered to make a set of rules for the
mediocre man, and thereby the Stoics became the originators of the
dangerous doctrine of a twofold morals.

(2) By admitting any supposition instead of strict scientific

deduction into their theory they introduced probabilism. An absolute
personality! An absolute Nature! In order to make either practical
the Stoics had to modify both. In the course of time, when new
leaders represented the School, there came compromises according
to practical exigencies. The teaching of the Wise Man was
superseded by instruction how to become wise. The moral idealism
was not renounced but the idea of progress was introduced.

(3) The doctrine of Goods was modified. From out the Goods,
esteemed as indifferent, there appear Goods as desirable. Yet these
were never thought to be Goods in themselves, but were only
adapted to further the Good in itself. Such were, for example, the
physical Good of health, enjoyment of the senses, etc. On the side
of its ideals Stoicism thus was brought into touch with practical life.

(4) A distinction was made concerning those who were not Wise
Men. It was recognized that all “fools” are not the same distance
from virtue. There are then recognized progressive men,—men who
are improving. Apathy is thus modified by a state of progress. Even
the Wise Man has in common with others the affections of his
senses, such as pain. The Stoic ethical aristocracy became more
humane. Nevertheless, the Stoic never yielded this point, viz., that
there is no gradual growth in virtue. Virtue is not attained through a
transition. It is a sudden turning about.

(5) During the empire Stoicism became merely a moral

philosophy, but even in this form it was an impressive presentation
of the noblest convictions of antiquity. It prepared moral feeling for
Christianity. The more Stoicism became mere moralizing, the more
the Cynic element in it dominated it. In the first and second
centuries Cynicism was revived by wandering, garbed preachers,
who went about affecting beggary and teaching morals.
 CHAPTER XII

SKEPTICISM AND
ECLECTICISM
The Appearances of Philosophic Skepticism. We have now
traced the history of the positive and dogmatic aspect of the
Hellenic-Roman Period through its Ethical Division and far into the
Religious Division of the Period. The influence of the ethical
movement did not disappear until at least two centuries after the
beginning of this era, and the Schools themselves did not disappear
until they were abolished by Justinian in 529 A. D. But the Ethical
Period may be said to close at the beginning of this era, and even a
century and a half before that—about 150 B. C.—its positive and
dogmatic character had been lost. Eclecticism appeared in the
Schools, and the last one hundred and fifty years of the Ethical
Period was in character transitional and eclectic. This was caused by
the growth and power of Skepticism, which we have already pointed
out as the undercurrent of the entire period. Skepticism was the
fundamental frame of mind of the eight hundred years of this time.
It was the negative side of the period in contrast with the Schools.
Philosophic Skepticism appeared contemporaneously with the rise of
the New Schools at the very beginning of the Period, and the
controversy between the Schools and Skepticism reached its height
about 150 B. C. What was the result? Did philosophy turn, as in the
Age of Pericles, back to greater triumphs in speculation? No; the
world was no longer virile and no longer possessed the creative
impulse. On account of the attacks of Skepticism upon the Schools,
philosophy dissolved itself first into eclecticism, and then later by the
introduction of new elements from the East was superseded by
religion. In the philosophical sense, religion and eclecticism are both
skeptical—both have doubts of the ability of the reason to reach
truth. Eclecticism shows its Skepticism by doubting any one
dogmatic scheme, and therefore it constructs a compromise of all;
religion crowns faith in place of reason.

Philosophic Skepticism in these times did not appear except with

reference to the doctrines of the Schools. It arose as merely
polemical and antagonistic to the Schools’ teaching. While the
Skepticism of antiquity busied itself with the problem of knowledge,
it was superficial compared with modern Skepticism. Ancient
Skepticism did not doubt that the object of knowledge existed; it did
not doubt that the object of knowledge is external and even
material. It assumed that things exist which, to the modern Skeptic,
is the problem at issue.

We shall look now at the appearances of philosophic Skepticism,

and the effect of this Skepticism upon the Schools in their turning to
eclecticism.

The Three Phases of Philosophic Skepticism. These are

three somewhat loosely connected appearances of Skepticism, and
are determined in their character in large measure by the doctrines
which they attacked.

1. The First Phase of Philosophic Skepticism is called

Pyrrhonism (from about 300 to 230 B. C.). This was a Skepticism
directed against the assumptions of the philosophy of Aristotle. From
the dates above it will be seen to be contemporary with the founding
of the Stoic and Epicurean Schools, at the very beginning of the
period. The two representatives were Pyrrho (365–275 B. C.) of Elis
and his pupil Timon (320–230 B. C.) of Phlius. When Zeno had
begun to teach in the Painted Porch and Epicurus in the Gardens,
when Theophrastus had succeeded his master in the Lyceum and
Polemo led the Academy, the Skeptic Pyrrho began his personal
instruction in the city of Elis. Pyrrho had but little influence. He left
no writings, and his doctrine became known to the ancients through
his pupil, Timon, who was the literary exponent of this Skepticism.
The teaching may be stated in the three following sentences: (1) We
can know nothing of the nature of things, but only of the states of
feeling into which they put us; (2) The only correct attitude of mind
is to withhold all judgment and restrain all action; (3) The result of
this suspense of judgment is ataraxia or imperturbability. The Skeptic
therefore sought the same internal peace for which Stoic and
Epicurean were seeking, but he was skeptical of the Aristotelian
metaphysics as an instrument to gain it. The opposite of any
conclusion being equally plausible, suspense of judgment is the only
peace of mind.

Pyrrhonism reminded the age after Aristotle that the problem of

the certitude of knowledge is fundamental and must be settled
before any philosophy can be constructed. The School was short
lived, and people disposed to be skeptical joined the Academy.

2. The Second Period of Philosophic Skepticism—The

Skepticism of the Academy (280–129 B. C.). The Middle
Academy and its Skepticism was directed particularly against the
Stoic teaching that an “apprehensive presentation” guaranteed its
own truth by the conviction of immediate certainty. The two most
distinguished representatives of this Skeptical period of the Academy
were Arcesilaus (315–241 B. C.) and Carneades (214–129 B. C.).
Carneades must be mentioned particularly as a genius and a
philosopher of great personal influence. “He was the greatest
philosopher of Greece in the four centuries from Chrysippus to
Plotinus; indeed, in ability and depth of thought he surpassed
Chrysippus.” 38 Carneades was the most formidable opponent of the
Stoics. He had listened to the Stoic lecturers, had studied their
writings, and had refuted them on their own grounds in brilliant
lectures of his own.

The Skepticism of the Academy arose somewhat in this way. The

rivalry of the Porch and the Older Academy had grown apace and
had been a battle between two dogmatic Schools. The Academy was
being worsted, its ancient spirit was waning, and it had gradually
deserted speculation for ethics. Under Arcesilaus it was provoked to
new life by the aggressive dogmatism of the Stoics. Speculation,
which it had ignored, it now began to antagonize openly. Arcesilaus,
in directing his attack against the doctrine of “apprehensive
presentation” of the Stoics, came to conclusions but slightly different
from Pyrrho. Carneades laid out for himself a twofold task: (1) to
refute all existing dogmas, and (2) to evolve a theory of probability
as the basis for practical activity. He applied his Skepticism not only
to speculation, like Arcesilaus, but also to ethics and religion. 39

The Academy did not fully adopt Skepticism, but used it as a

weapon against the Stoics. The Platonic tradition was kept alive
within the School, and Skepticism made no advance in the Academy
after Carneades. It did not even continue in the path marked out by
him. In the next generation the Academy became eclectic.

3. The Third Period of Philosophic Skepticism—

Sensationalistic Skepticism (during two centuries or more of the
Christian era). The chief representatives were Ænesidemus of
Cnossus (first century A. D.), Agrippa (about 200 A. D.), and Sextus
Empiricus (about 200 A. D.).

This phase of Skepticism was represented mainly by physicians,

with arguments based upon empirical physiological grounds. When
the Academy passed from Skepticism to eclecticism, Skepticism
became centred in Alexandria. For two centuries before Galen (131–
201 A. D.) great discoveries had been made in medicine, but the
meaning of the discoveries had not been apprehended. There was a
general feeling among physicians of that time that there is no such
thing as scientific certainty; and skeptical arguments were
constructed; based on the empirical discoveries of the scientific circle
of Alexandria. While the arguments of the Academy were mostly
formal attacks against the Stoics, this Skeptical School of physicians
returned to Pyrrhonism, immensely reinforced with scientific
material. It strove in vain to disassociate itself from the Academy, for
it used in one way or another the formal arguments of the Skeptics
of the Academy. In his eight books on Pyrrhonism, Ænesidemus
developed the reasons which induced Pyrrho to call in question the
possibility of knowledge. These are known in philosophy as the ten
“tropes,” or ten ways of justifying doubt. 40 They were badly
arranged by Ænesidemus and reduced to five by Agrippa. 41

The Last Century and a Half of the Ethical Period. (150

B. C.–1 A. D.). Eclecticism.—About 150 B. C. the Ethical Period
became eclectic. After 150 years of passionate controversy the
Schools began to compromise their differences and fuse into one
another. They no longer emphasized their differences, but began to
point to their common ground of unity. This tendency to fusion
applies only to the Lyceum, the Academy, and the Porch. The
Epicurean School was never a party to this eclecticism and always
remained relatively stationary. The fusion occurred only in the
teaching of the Schools and not in their organization. Externally the
Schools remained separate bodies for six hundred years longer. In
the second century Hadrian and the Antonines endowed separate
chairs for them in the University of Athens. They were not abolished
as Schools until 529 A. D., by Justinian. Internally their independent
growth lasted only during the two centuries down to the year 150
B. C. At this time their theoretic mission had been completed. Their
internal history from 100 B. C. to 529 A. D. was one of compromise
and adjustment. The year 150 B. C. is therefore important. At this
time the records of the Schools stop, controversy abates, Stoicism
and Epicureanism are introduced into Rome, and fusion of doctrines
begins.

The Stoic School was the first to incline to eclecticism. Its own
doctrine was a kind of fusion of incoherent parts, and among the
Schools it could most easily welcome new doctrines. About 150
B. C., under the lead of Panætius and Posidonius, it adopted many of
the Platonic and Aristotelian teachings, tempered its own ethical
rigorism, and extended its scientific interests. At the same time the
Peripatetics of the Lyceum united the pantheism of the Stoics to
their own theism. After the death of Carneades in 129 B. C. the
Academy turned from Skepticism back to the Platonic tradition, but it
was a meagre Platonism adulterated with many foreign elements.
For example, Antiochus of Ascalon taught Cicero from the Academy
at Athens in the winter of 79–78 B. C. that Platonism and
Aristotelianism were only different aspects of the same doctrine.

There were two factors that prepared an easy way for the rapid
spread of eclecticism. One was the growing Skepticism that was so
fundamental in Hellenism, and the other was the adoption of
Hellenic culture by the Romans. Eclecticism is, after all, only another
form of Skepticism. Both exhibit the spirit of undecided conviction.
Neither has regard for the bonds of tradition, for both regard the
individual superior to every tradition or system. Eclecticism, indeed,
attempts to reconcile differing systems; but in doing this it casts a
doubt upon the infallibility of them all only to a lesser degree than
Skepticism. The spread of eclecticism was therefore only an
extension from Greece of the skeptical spirit upon the world, and the
Roman world gave a glad welcome to such a spirit. The Roman
character was naturally eclectic. After his first aversion the Roman
was hospitable to all philosophies and religions. In his practical way,
undisturbed by philosophical hair-splittings, he selected from the
different systems what was suited to his practical needs. Eclecticism
found fertile ground in Roman civilization.
 In the Schools after the year 150 B. C. there appear many
notable names—notable not because they contributed to the
theoretic advance of philosophy, but for some other reason. In the
Stoic School were Panætius, Posidonius, and Boëthus; and later
Seneca, Epictetus, and Marcus Aurelius. Among the Academicians
are Philo of Larissa and Antiochus; among the Peripatetics of the
same century is Andronicus; and among the eclectic Platonists
Plutarch is especially to be named; these were all eclectics. The only
one in this group of eclectics whom we shall have time for a passing
examination of is Cicero.

M. Tullius Cicero (106–43 B. C.) listened to Greek philosophy in

all the Schools in Athens and Rhodes. He read a good deal of Greek
literature, so that he had much philosophical material at his
command. He did not show much discretion in his selection of his
material, but he displayed a good deal of tact in using what the
Roman people would receive. The Greek mind spoke to the Roman
through Cicero’s voice almost as though the Roman were speaking
for himself. It must be admitted that Cicero’s acquaintance with
Greek philosophy was on the whole superficial, yet he was able to
express certain aspects of Greek philosophy with clearness for
contemporary Latin readers and for many generations succeeding
them. He prided himself in his ability to discuss both sides of a
question without himself arriving at a decision—after the manner of
the Middle Academy, of which he inscribed himself as a member. His
books appeared in rather rapid succession.

Cicero does not therefore owe his prominence as a philosopher

so much to his own profound independence of thought as to his skill
in translating Greek thought to the Roman people. His metaphysics
is an eclecticism that is at bottom a skepticism. In view of the
existing philosophical warfare, he despaired of metaphysical or
absolutely complete knowledge. Yet upon ethical and religious
questions he spoke in no undecided manner, for in these realms he
felt that we have more than merely probable evidence. Since he was
unable to refute Skepticism in a scientific way, he took refuge in the
immediate certainty of consciousness in all matters that pertain to
morals and religion. There are certain ideas common to all men.
These have not so much been taught to all men by nature as they
are inborn in all. They are convictions implanted in us; there is a
common human consciousness from which they are derived, and
they are confirmed by universal opinion. Ethical and religious
consciousness thus rests on immediate certainty. Man has the innate
ideas of duty, immortality, and God. Our belief in God’s existence is
supported by the teleological argument for Providence and divine
government. The high dignity of man rests upon this innate
conviction of freedom and immortality. Cicero shows his eclecticism
by moderating the Stoic doctrine of virtue: virtue in itself is vita
beata, but virtue plus happiness is vita beatissima. Unoriginal and
eclectic as Cicero’s philosophical position may be, it is of great
importance to the student of Roman history.
 CHAPTER XIII

THE RELIGIOUS PERIOD

(100 B. C.–476 A. D.)
The Two Causes of the Rise of Religious Feeling. There
were two causes for the turn of the time from its interest in
individual practical ethics to religion. The first was an inner cause
within the nature of the ethical philosophy of the Schools. The rise of
the religious and the supernatural was the culmination of the
undercurrent of skepticism in the validity of reason, which we found
growing rapidly in the Ethical Period. The more the Schools grew
alike in their teaching, the less were they able to assure their
disciples of any certain insight into virtue and happiness. The Ethical
Period ended in eclecticism, and this was the impeachment of the
authority of each School. The Schools examined their dogmatic
assumptions. The fundamental inner conviction grew stronger that
the intellect of man is self-inconsistent: so inconsistent as to be
undependable; so inconsistent as not to vouchsafe man the virtue
and happiness which the Schools had promised. As Skepticism
became more strongly intrenched, the imperturbable self-certainty of
the Wise Man became shaken, the Ethical Period disappeared, and
the Religious Period was born. Belief in the authority of the
supernatural superseded belief in the authority of the reason.

The second cause may be called external, and was the

introduction of many eastern religions into the empire. It has been
common to exaggerate the vices of the Romans of the first Christian
centuries, and to point to the corruption of the times as the cause of
the great rise of religions. 42 No doubt, in the city of Rome and other
large cities the populations were very licentious and corrupt. But this
was not the case with the people in the small municipalities and the
country. The people were united in peace under one government.
There was great commercial prosperity and widespread travel.
Education prospered. The religion of the Romans, however, long
since decadent, had become an object of derision. All faith in it had
been lost, and magicians and romancers had a large patronage. The
inner life of man demanded some external spiritual authority to
satisfy it, and, finding it could not be satisfied in the realm of sense,
turned to the supersensuous. It was an age of universal
superstitions, reported miracles, and the multiplying of myths. In the
realm of the religious emotions everything was in flux. Even the
Greek philosophies—the Stoic, the Platonic, the Cynic, and the neo-
Pythagorean—show it in their emphasis upon renunciation in
practical life. In place of the Grecian love for earthly existence, a
longing for the mysterious was growing into a feverish desire for
strange and mysterious cults. A great religious movement possessed
the nations of the empire, and into Roman civilization of the first
century A. D. there streamed many new religions. From the Orient
came the Mithra, Magna Mater, Star Worship, Isis and Osiris, and
many others. These mingled with the western religions, and their
rivalry was energetic for the possession of men’s spirits. The Roman
people were hospitable to all religions, and Rome became a religious
battleground. With the interest turned from earthly to heavenly
things, salvation from trouble seemed to lie in the supernatural.

The Need of Spiritual Authority. Thus the complacent Ethical

Period gave way to the cry for some authority in morals and science.
Man was no longer confident that he could attain present happiness
or his soul’s salvation by his own strength. He turned for help both
to the religious tradition of the past and to the revelation that might
come to him in the present. The authority in either was practically
the same; for the past was only the crystallization of an ever-present
divine spirit. Yet present and past revelations differ in their
credentials: the present revelation is an immediate illumination of
the spirit; the past is presented in historic records. The Alexandrian
school accepted both forms of revelation as the highest source of
knowledge.

The demand for supernatural authority found expression in many

curious ways. It is notorious that at this time the writings and oral
traditions of the past were greatly interpolated. The philosophers of
the first century thought that they themselves could get a hearing
only by inserting their own doctrines into the writings of Plato,
Aristotle, and other heroes of the past. Thus the neo-Pythagoreans
invented a halo of wisdom for Pythagoras in order to give their own
sect its credentials. The demand for authority culminated in the
attempt to trace the entire civilization of the time to some religious
source. Philo on the one side, and the Gnostics on the other, found
that Greek and Hebrew history have a common religious origin.
Greek thought was found in the Oriental writings. The Greek sages
were placed by the side of the Old Testament heroes. The canon of
the Christians is full of cross-references—the Old Testament giving
historical authority to the New Testament, the New Testament giving
to the Old Testament the support of immediate revelation. There
came into vogue what was called “allegorical interpretation,”
according to which an historical document could be given two
interpretations (or more)—a literal interpretation and a spiritual
interpretation. The documents were supposed to have a body and a
soul. The literal interpretation was of the body of the documents and
suitable for the people; the spiritual interpretation was the more
liberal interpretation of the soul of the document and suitable for
philosophers.
 At the same time a vast number of writings appeared as
historical revelations. It was necessary to separate the true from the
false, but this could not be done by the individual without injuring
the very principle upon which revelation was supposed to rest.
Consequently all knowledge was generally regarded as revelation.
For example, Plutarch and the Stoics divided revelation into three
classes: poetry, law, and philosophy. Although Plutarch disclaimed
open superstitions, he nevertheless accepted as true all sorts of
miracles and prophecies. The later neo-Platonists are also examples
of the great body of those who made no discrimination as to what
revelation is true. The Christian church may be said to have been
alone in making a criticism of the records, and in setting up as
criteria tradition and historically accredited authority. As a result of
its criticism the Christian canon was finally decided upon, and the
Old and New Testaments were accepted as alone inspired. The rivals
of the church—the Alexandrian philosophies, especially neo-
Platonism—had no organization that could decide upon a canon.
They were consequently at a disadvantage, but they felt no need of
an infallible historical authority or of historical criticism. Revelation to
them was any immediate illumination of the individual. The
individual man who comes in contact with the Deity has possession
of the divine truth. Although only few attain the truth, and these
only at rare moments, there is nevertheless no way of determining
what is fictitious and what is true. This difference in the conception
of inspiration between the neo-Platonists and the Christians is
important to note, for it marks an important difference in the two
greatest intellectual movements of the next thousand years. The
church fixed revelation on the basis of historical authority, and this
revelation became the source of the scholasticism of the Middle
Ages; neo-Platonism left the individual man free to get revelation
from any source through his own personal contact with the divine,
and this was the basis of the mysticism of the Middle Ages.

The Rise of the Conception of Spirituality. We have seen

that out of the widespread cry for spiritual help came the demand
for spiritual authority. There is also another result,—the increased
importance in history of the spiritual personality. The men of the
past became heroes, the great men sanctified and surrounded with
myths. Hero worship, ancestor worship, the worship of the genius of
the emperor inaugurated by Augustus, were part of this movement.
Disciples began to have unconditional trust in their masters, and in
neo-Platonism this worship culminated in veneration for the leaders
of the School. This movement appears in the grandest form in
history in the impression of the wonderful personality of Jesus
Christ.

The next step was to regard personality as the revelation of the

divine Logos. Personality is the cosmic reason. Nature and history
are kinds of general revelations, but special revelations require great
personalities—Moses, the prophets, the Greek scientists, and
especially Jesus who was the Messiah, the Son of God. The power
that these personalities exhibit must be a revelation, and not the
working of the human reason, for the human unaided reason deals
only with sensations, and is incapable of gaining divine truth. The
reason needs the divine to illuminate it. The great personalities are
therefore the repositories of powers that make them different from
ordinary men. Their revelations are above, and sometimes opposed
to, the conclusions of ordinary reason. Thus personalities themselves
are divided by religious dualism, and in them the human and divine
are far apart. Moreover, the more great personalities were
apotheosized, the more the common run of humanity was
depreciated. Then distinction was made between great personalities.
At first, when authority was sought everywhere, all great
personalities were supposed to have divine revelation; later, when
the lines were drawn between the Christian and other beliefs, only
the Christian leaders were considered by the Christians to be
instruments of the divine.

This spiritualizing of historical personalities laid the emphasis

more than ever before upon the dualism in all human beings. All
men are ensnared in the world of sense, and they can attain
knowledge of the higher world only through the illumination of their
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