Ἡροφιλος δε εν τω Διαιτητικω και σοφιαν φησιν ανεπιδεικτον και
τεχνην αδηλον και ισχυν αναγωνιστον και πλουτον αχρειον και λογον
αδυνατον, ὑγιειας απουσης.
{Hêrophilos de en tô Diaitêtikô kai sophian phêsin anepideikton kai
technên adêlon kai ischyn anagôniston kai plouton achreion kai logon
adynaton, hygieias apousês.}
Herophilos, a Greek philosopher and physician (_c._ 300 B. C.), has
truly written 'that Science and Art have equally nothing to show, that
Strength is incapable of effort, Wealth useless, and Eloquence powerless
if Health be wanting'.[55] All peoples therefore have had their methods
of treating those departures from health that we call disease, and among
peoples of higher culture such methods have been reduced in most cases
to something resembling a system. In antiquity, as now, a variety of
such systems were in vogue, and those nations who practised the art of
writing from an early date have left considerable records of their
medical methods and doctrines. We may thus form a fairly good idea of
the medical principles of the Mesopotamian, the Egyptian, the Iranian,
the Indian, and the Chinese civilizations. Much in these systems, as in
the medical procedure of more primitive tribes, was based upon some
theory of disease which fitted in with a larger theory of the nature of
evil. Of these theories the commonest was and is the demonic, the view
that regards deviation from the normal state of health as due either to
the attacks of supernatural beings or to their actual entry into the
body of the sufferer. A medical system based on such a view is
susceptible of great elaboration in a higher civilization, but not being
founded on observation is hardly capable of indefinite development, for
a point must ultimately be reached at which the mind recoils from
complex conclusions far remote from observed phenomena. The medicine of
the ancient and settled civilization of such a people as the
Assyro-Babylonians, for instance, of which substantial traces have been
recovered, is hardly, if at all, more effective, though far more
systematized, than that of many a wild and unlettered tribe that may be
observed to-day. Of such medicine as this we may give an account, but we
can hardly write a _history_. We cannot establish those elements of
continuity and of development from which alone history can be
constructed.
[55] The works of Herophilus are lost. This fine passage has been
preserved for us by Sextus Empiricus, a third-century physician, in
his προς τοις μαθηματικους αιτιρρητικοι {pros tois mathêmatikous
aitirrêtikoi}, which is in essence an attack on all positive
philosophy. It is an entertaining fact that we should have to go to
such a work for remains of the greatest anatomist of antiquity. The
passage is in the section directed against ethical writers, xi. 50.
It is the distinction of the Greeks alone among the nations of antiquity
that they practised a system of medicine based not on theory but on
observation accumulated systematically as time went on. The claim can be
made for the Greeks that some at least among them were deflected by no
theory, were deceived by no theurgy, were hampered by no tradition in
their search for the facts of disease and in their attempts at
interpreting its phenomena. Only the Greeks among the ancients could
look on their healers as _physicians_ (= naturalists, φυσις {physis} =
nature), and that word itself stands as a lasting reminder of their
achievement.[56]
[56] The word φυσικος {physikos}, though it passed over into Latin
(Cicero) with the meaning _naturalist_, acquired the connotation of
_sorcerer_ among the later Greek writers. Perhaps the word
_physicianus_ was introduced to make a distinction from the
charm-mongering _physicus_. In later Latin _physicus_ and _medicus_
are almost always interchangeable.
At a certain stage in the history of the Western world--the exact point
in time may be disputed but the event is admitted by all--men turned to
explore the treasures of the ancient wisdom and the whole mass of Greek
medical learning was gradually laid before the student. That mass
contained much dross, material that survived from early as from late
Greek times which was hardly, if at all, superior to the debased
compositions that circulated in the name of medicine in the middle
centuries. But the recovered Greek medical writings also contained some
material of the purest and most scientific type, and that material and
the spirit in which it was written, form the debt of modern medicine to
antiquity.
It is a debt the value of which cannot be exaggerated. The physicians of
the revival of learning, and for long after, doubtless pinned their
faith too much to the written word of their Greek forbears and sought to
imprison the free spirit of Hippocrates and Galen in the rigid wall of
their own rediscovered texts. The great medical pioneers of a somewhat
later age, enraged by this attempt, the real nature of which was largely
hidden from them, not infrequently revolted and rightly revolted against
the bondage to the Greeks in which they had been brought up. Yet it is
sure that these modern discoverers were the true inheritors of the
Greeks. Without Herophilus we should have had no Harvey and the rise of
physiology might have been delayed for centuries; had Galen's works not
survived, Vesalius would never have reconstructed Anatomy, and Surgery
too might have stayed behind with her laggard sister, Medicine; the
Hippocratic collection was the necessary and acknowledged basis for the
work of the greatest of modern clinical observers, Thomas Sydenham, and
the teaching of Hippocrates and of his school is the substantial basis
of instruction in the wards of a modern hospital. In the pages which
follow we propose therefore to review the general character of medical
knowledge in the best Greek period and to consider briefly how much of
that great heritage remained accessible to the earlier modern
physicians. The reader will thus be able to form some estimate of the
degree to which the legacy has been passed on to our own times.
It is evident that among such a group of peoples as the Greeks, varying
in state of civilization, in mental power, in geographical and economic
position and in general outlook, the practice of medicine can have been
by no means uniform. Without any method of centralizing medical
education and standardizing teaching there was a great variety of
doctrines and of practice in vogue among them, and much of this was on a
low level of folk custom. Such lower grade material of Greek origin has
come down to us in abundance, though much of it, curiously enough, from
a later time. But the overwhelming mass of earlier Greek medical
literature sets forth for us a pure scientific effort to observe and to
classify disease, to make generalizations from carefully collected data,
to explain the origin of disease on rational grounds, and to apply
remedies, when possible, on a reasoned basis. We may thus rest fairly
well assured that, despite serious and irreparable losses, we are still
in possession of some of the very finest products of the Greek medical
intellect.
There is ample evidence that the Greeks inherited, in common with many
other peoples of Mediterranean and Asiatic origin, a whole system of
magical or at least non-rational pharmacy and medicine from a remoter
ancestry. Striking parallels can be drawn between these folk elements
among the Greeks and the medical systems of the early Romans, as well as
with the medicine of the Indian Vedas, of the ancient Egyptians, and of
the earliest European barbarian writings. It is thus reasonable to
suppose that these elements, when they appear in later Greek writings,
represent more primitive folk elements working up, under the influence
of social disintegration and consequent mental deterioration, through
the upper strata of the literate Greek world. But with these elements,
intensely interesting to the anthropologist, the psychologist, the
ethnologist, and to the historian of religion, we are not here greatly
concerned. Important as they are, they constitute no part of the special
claim of the Greek people to distinction, but rather aid us in uniting
the Greek mentality with that of other kindred peoples. Here we shall
rather discuss the course of Greek scientific medicine proper, the type
of medical doctrine and practice, capable of development in the proper
sense of the word, that forms the basis of our modern system. We are
concerned, in fact, with the earliest evolutionary medicine.
We need hardly discuss the first origins of Greek Medicine. The material
is scanty and the conclusions somewhat doubtful and perhaps premature,
for the discovery of a considerable fragment of the historical work of
Menon, a pupil of Aristotle, containing a description of the views of
some of the precursors of the Hippocratic school, renews a hope that
more extended investigation may yield further information as to the
sources and nature of the earliest Greek medical writings.[57] The study
of Mesopotamian star-lore has linked it up with early Greek astronomical
science. The efforts of cuneiform scholars have not, however, been
equally successful for medicine, and on the whole the general tendency
of modern research is to give less weight to Mesopotamian and more to
Egyptian sources than had previously been admitted; thus very recently
an Egyptian medical papyrus of about 1700 B. C. has been described which
bears a distinct resemblance to some of the Hippocratic treatises.[58] A
number of drugs, too, habitually used by the Greeks, such as
_Andropogon_, _Cardamoms_, and _Sesame orientalis_, are of Indian
origin. There are also the Minoan cultures to be considered, and though
our knowledge is not yet sufficient to speak of the heritage that Greek
medicine may or may not have derived from that source, it seems not
improbable that Greek hygiene may here owe a debt.[59] Omitting,
therefore, this early epoch, we pass direct to the later period,
between the sixth and fourth centuries, from which documents have
actually come down to us.
[57] This fragment has been published in vol. iii, part 1, of the
_Supplementum Aristotelicum_ by H. Diels as _Anonymi Londinensis ex
Aristotelis Iatricis Menonis et Aliis Medicis Eclogae_, Berlin,
1893. See also H. Bekh and F. Spät, _Anonymus Londinensis, Auszuge
eines Unbekannten aus Aristoteles-Menons Handbuch der Medizin_,
Berlin, 1896.
[58] As we go to press there appears a preliminary account of the
very remarkable Edwin Smith papyrus, see J. H. Breasted in _Recueil
d'études egyptologiques dédiées à la mémoire de Champollion_, Paris
1922, and _New York Historical Society Bulletin_, 1922.
[59] It is tempting, also, to connect the Asclepian snake cult with
the prominence of the serpent in Minoan religion.
The earliest medical school of which we have definite information is
that of Cnidus, a Lacedaemonian colony in Asiatic Doris. Its origin may
perhaps reach back to the seventh century B. C. We have actual records
that the teachers of Cnidus were accustomed to collect systematically
the phenomena of disease, of which they had produced a very complex
classification, and we probably possess also several of their actual
works. The physicians of Cos, their only contemporary critics whose
writings have survived, considered that the Cnidian physicians paid too
much attention to the actual sensations of the patient and to the
physical signs of the disease. The most important of the Cnidian
doctrines were drawn up in a series of _Sentences_ or Aphorisms, and
these, it appears, inculcated a treatment along Egyptian lines of the
symptom or at most the disease, rather than the patient, a statement
borne out by the contents of the gynaecological works of probable
Cnidian origin included in the so-called 'Hippocratic Collection'. A few
names of Cnidian physicians have, moreover, come down to us with titles
of their works, and a later statement that they practised anatomy. There
can be little doubt too that the Cnidian school drew also on Persian and
Indian Medicine.
The origin of the school of the neighbouring island of Cos was a little
later than that of Cnidus and probably dates from the sixth century B.
C. Of the Coan school, or at least of the general tendencies that it
represented, we have a magnificent and copious literary monument in the
Corpus Hippocraticum, a collection which was probably put together in
the early part of the third century B. C. by a commission of Alexandrian
scholars at the order of the book-loving Ptolemy Soter (reigned 323-285
B. C.). The elements of which this collection is composed are of varying
dates from the sixth to the fourth century B. C., and of varying value
and origin, but they mainly represent the point of view of physicians
of the eastern part of the Greek world in the fifth and fourth
centuries.
The most obvious feature, the outstanding element that at once strikes
the modern observer in these 'Coan' writings, is the enormous emphasis
laid on the actual course of disease. 'It appears to me a most excellent
thing', so opens one of the greatest of the Hippocratic works, 'for a
physician to cultivate _pronoia_.[60] Foreknowing and foretelling in the
presence of the sick the past, present, and future (of their symptoms)
and explaining all that the patients are neglecting, he would be
believed to understand their condition, so that men would have
confidence to entrust themselves to his care.... Thus he would win just
respect and be a good physician. By an earlier forecast in each case he
would be more able to tend those aright who have a chance of surviving,
and by foreseeing and stating who will die, and who will survive, he
will escape blame....'[61]
[60] This word _pronoia_, as Galen explains (εις το Ἱπποκρατους
προγνωστικον {eis to Hippokratous prognôstikon}, K. xviii, B. p.
10), is not used in the philosophic sense, as when we ask whether
the universe was made by chance or by _pronoia_, nor is it used
quite in the modern sense of _prognosis_, though it includes that
too. _Pronoia_ in Hippocrates means knowing things about a patient
before you are told them. See E. T. Withington, 'Some Greek medical
terms with reference to Luke and Liddell and Scott,' _Proceedings of
the Royal Society of Medicine_ (_Section of the History of
Medicine_), xiii, p. 124, London, 1920.
[61] _Prognostics_ 1.
Just as the Cnidians by dividing up diseases according to symptoms
over-emphasized diagnosis and over-elaborated treatment, so the Coans
laid very great force on prognosis and adopted therefore a largely
expectant attitude towards diseases. Both Cnidian and Coan physicians
were held together by a common bond which was, historically if not
actually, related to temple worship. Physicians leagued together in the
name of a god, as were the Asclepiadae, might escape, and did escape,
the baser theurgic elements of temple medicine. Of these they were as
devoid as a modern Catholic physician might be expected to be free from
the absurdities of Lourdes. But the extreme cult of prognosis among the
Coans may not improbably be traced back to the medical lore of the
temple soothsayers whose divine omens were replaced by indications of a
physical nature in the patient himself.[62] We are tempted too to link
it with that process of astronomical and astrological prognosis
practised in the Mesopotamian civilizations from which Ionia imitated
and derived so much. Religion had thus the same relation to medicine
that it would have with a modern 'religious' medical man as suggesting
the motive and determining the general direction of his practice though
without influence on the details and method.
[62] There is a discussion of the relation of the Asclepiadae to
temple practice in an article by E. T. Withington, 'The Asclepiadae
and the Priest of Asclepius,' in _Studies in the History and Method
of Science_, edited by Charles Singer, vol. ii, Oxford, 1921.
During the development of the Coan medical school along these lines in
the sixth and fifth centuries, there was going on a most remarkable
movement at the very other extreme of the Greek world. Into the course
and general importance of Sicilian philosophy it is not our place to
enter, but that extraordinary movement was not without its repercussion
on medical theory and practice. Very important in this direction was
Empedocles of Agrigentum (_c._ 500-_c._ 430 B. C.). His view that the
blood is the seat of the 'innate heat', εμφυτον θερμον {emphyton
thermon}, he took from folk belief--'the blood is the life'--and this
innate heat he closely identified with soul. More profitable was his
doctrine that breathing takes place not only through what are now known
as the respiratory passages but also through the pores of the skin. His
teaching led to a belief in the heart as the centre of the vascular
system and the chief organ of the 'pneuma' which was distributed by the
blood vessels. This pneuma was equivalent to both soul and life, but it
was something more. It was identified with air and breath, and the
pneuma could be seen to rise as shimmering steam from the shed blood of
the sacrificial victim--for was not the blood its natural home? There
was a pneuma, too, that interpenetrated the universe around us and gave
it those qualities of life that it was felt to possess. Anaximenes (_c._
610-_c._ 545 B. C.), an Ionian predecessor of Empedocles, may be said to
have defined for us these functions of the pneuma; ὁιον ἡ ψυχη ἡ ἡμετερα
αηρ ουσα συγκρατει ἡμας, ὁλον τον κοσμον πνευμα και αηρ περιεχει {hoion
hê psychê hê hêmetera aêr ousa synkratei hêmas, holon ton kosmon pneuma
kai aêr periechei}, 'As our soul, being air, sustains us, so pneuma and
air pervade the whole universe';[63] but it is the speculation of
Empedocles himself that came to be regarded as the basis of the
Pneumatic School in Medicine which had later very important
developments.
[63] The works of Anaximenes are lost. This phrase of his, however,
is preserved by the later writer Aetios.
Another early member of the Western school who made important
contributions to medical doctrine--in which relation alone we need
consider him--was Pythagoras of Samos (_c._ 580-_c._490 B. C.). For him
number, as the purest conception, formed the basis of philosophy. Unity
was the symbol of perfection and corresponded to God Himself. The
material universe was represented by 2, and was divided by the number
12, whence we have 3 worlds and 4 spheres. These in turn, according at
least to the later Pythagoreans, give rise to the four elements, earth,
air, fire, and water--a primary doctrine of medicine and of science
derived perhaps from ancient Egypt and surviving for more than two
millennia. The Pythagoreans taught, too, of the existence of an animal
soul, an emanation of the soul of the universe. In all this we may
distinguish the germ of that doctrine of the relation of man and
universe, microcosm and macrocosm, which, suppressed as irrelevant in
the Hippocratic works, reappears in the Platonic and especially in the
Neoplatonic writings, and forms a very important dogma in later
medicine.
A pupil of Pythagoras and an older contemporary of Empedocles was
Alcmaeon of Croton (_c._ 500 B. C.), who began to construct a positive
basis for medical science by the practice of dissection of animals, and
discovered the optic nerves and the Eustachian tubes. He even extended
his researches to Embryology, describing the head of the foetus as the
first part to be developed--a justifiable deduction from appearances.
Alcmaeon introduced also the doctrine that health depends on harmony,
disease on discord of the elements within the body. Curiosity as to the
distribution of the vessels was excited by Empedocles and Alcmaeon and
led to further dissection, and Alcmaeon's pupils Acron (_c._ 480 B. C.)
and Pausanias (_c._ 480 B. C.), and the later Philistion of Lokri,[64]
the contemporary of Plato, all made anatomical investigations.
[64] For the work of these physicians see especially M. Wellmann,
_Fragmentsammlung der griechischen Aerzte_, Bd. I, Berlin, 1901.
The views of Empedocles, and especially his doctrine that regarded the
heart as the main site of the pneuma, though rejected by the Coan school
as a whole, were not without influence on Ionia. Diogenes of Apollonia,
the philosopher of pneumatism, a late fifth-century writer who must have
been contemporary with Hippocrates the Great, himself made an
investigation of the blood vessels; and the influence of the same school
may be traced in a little work περι καρδιης {peri kardiês}, _On the
heart_, which is the best anatomical treatise of the Hippocratic
Collection. This work describes the aorta and the pulmonary artery as
well as the three valves at the root of each of the great vessels, and
it speaks of experiments to test their validity. It treats of the
pericardium and of the pericardial fluid and perhaps of the musculi
papillares, and contrasts the thickness of the walls of right and left
ventricles. The author considers that the left ventricle is empty of
blood--as indeed it is after death--and is the source of the innate heat
and of the absolute intelligence. These views fit in with the doctrines
of Empedocles, so that we may perhaps even venture to regard this work
as a surviving document of the Sicilian school. It is interesting to
observe that we have here the first hint of human dissection, for the
author tells us that the hearts of animals may be compared to that of
man. The distinction of having been the first to write on human anatomy,
as such, belongs however, probably to a later writer, Diocles, son of
Archidamus of Carystus, who lived in the fourth century B. C.[65]
[65] Galen, περι ανατομικων εγχειρησεων {peri anatomikôn
encheirêseôn}, _On anatomical preparations_, § 1, K. II, p. 282.
We may now turn to the Hippocratic Corpus as a whole. This collection
consists of about 60 or 70 separate works, written at various periods
and in various states of preservation. At best only a very small
proportion of them can be attributed to Hippocrates, but the discussion
of the general question of the 'genuineness' of the works is now
admitted to be futile, for it is certain that we have no criteria
whatever to determine whether or no a particular work be from the pen of
the Father of Medicine, and the most we can ever say of such a treatise
is that it appears to be of his school and in his spirit. Yet among the
great gifts of this collection to our time and to all time are two which
stand out above all others, the picture of a man, and the picture of a
method.
The man is Hippocrates himself. Of the actual details of his life we
know next to nothing. His period of greatest activity falls about 400 B.
C. He seems to have led a wandering life. Born of a long line of
physicians in the island of Cos, he exerted his activities in Thrace,
Abdera, Delos, the Propontis (Cyzicus), Thasos, Thessaly (notably at
Larissa and Meliboea), Athens, and elsewhere, dying at Larissa in
extreme old age about the year 377 B. C. He had many pupils, among whom
were his two sons Thessalus and Dracon, who also undertook journeys, his
son-in-law Polybus, of whose works a fragment has been preserved for us
by Aristotle,[66] together with three other Coans bearing the names
Apollonius, Dexippus, and Praxagoras. This is practically all we know
of him with certainty. But though this glimpse is very dim and distant,
yet we cannot exaggerate the influence on the course of medicine and the
value for physicians of all time of the traditional picture that was
early formed of him and that may indeed well be drawn again from the
works bearing his name. In beauty and dignity that figure is beyond
praise. Perhaps gaining in stateliness what he loses in clearness,
Hippocrates will ever remain the type of the perfect physician. Learned,
observant, humane, with a profound reverence for the claims of his
patients, but an overmastering desire that his experience shall benefit
others, orderly and calm, disturbed only by anxiety to record his
knowledge for the use of his brother physicians and for the relief of
suffering, grave, thoughtful and reticent, pure of mind and master of
his passions, this is no overdrawn picture of the Father of Medicine as
he appeared to his contemporaries and successors. It is a figure of
character and virtue which has had an ethical value to medical men of
all ages comparable only to the influence exerted on their followers by
the founders of the great religions. If one needed a maxim to place upon
the statue of Hippocrates, none could be found better than that from the
book Παραγγελιαι {Parangeliai}, _Precepts_:
ην γαρ παρη φιλανθρωπιη παρεστι και φιλοτεχνιη
{ên gar parê philanthrôpiê paresti kai philotechniê}
'Where the love of man is, there also is love of the Art.'[67]
[66] _Historia animalium_, iii. 3, where it is ascribed to Polybus.
The same passage is, however, repeated twice in the Hippocratic
writings, viz. in the περι φυσιος ανθρωπου {peri physios anthrôpou},
_On the nature of man_, Littré, vi. 58, and in the περι οστεων
φυσιος {peri osteôn physios}, _On the nature of bones_, Littré, ix.
174.
[67] Παραγγελιαι {Parangeliai}, § 6.
The numerous busts of him which have reached our time are no portraits.
But the best of them are something much better and more helpful to us
than any portrait. They are idealized representations of the kind of man
a physician should be and was in the eyes of the best and wisest of the
Greeks.[68]
[68] See Fig. 1.
[Illustration: Fig. 1. HIPPOCRATES
British Museum, second or third century B. C.]
[Illustration: Fig. 2. ASCLEPIUS
British Museum, fourth century B. C.]
The method of the Hippocratic writers is that known to-day as the
'inductive'. Without the vast scientific heritage that is in our own
hands, with only a comparatively small number of observations drawn from
the Coan and neighbouring schools, surrounded by all manner of bizarre
oriental religions in which no adequate relation of cause and effect was
recognized, and above all constantly urged by the exuberant genius
for speculation of that Greek people in the midst of whom they lived and
whose intellectual temptations they shared, they remain nevertheless,
for the most part, patient observers of fact, sceptical of the
marvellous and the unverifiable, hesitating to theorize beyond the data,
yet eager always to generalize from actual experience; calm, faithful,
effective servants of the sick. There is almost no type of mental
activity known to us that was not exhibited by the Greeks and cannot be
paralleled from their writings; but careful and constant return to
verification from experience, expressed in a record of actual
observations--the habitual method adopted in modern scientific
departments--is rare among them except in these early medical authors.
The spirit of their practice cannot be better illustrated than by the
words of the so-called 'Hippocratic oath'. That document, though of late
date in its present form, throws a flood of light on the ethics of Greek
medicine.
'I swear by Apollo the physician and Asclepius and Hygieia and
Panacea, invoking all the gods and goddesses to be my witnesses,
that I will fulfil this Oath and this written covenant to the best
of my power and of my judgment.
'I will look upon him who shall have taught me this art even as on
mine own parents; I will share with him my substance, and supply
his necessities if he be in need; I will regard his offspring even
as my own brethren, and will teach them this art, if they desire to
learn it, without fee or covenant. I will impart it by precept, by
lecture and by all other manner of teaching, not only to my own
sons but also to the sons of him who has taught me, and to
disciples bound by covenant and oath according to the law of the
physicians, but to none other.
'The regimen I adopt shall be for the benefit of the patients to
the best of my power and judgment, not for their injury or for any
wrongful purpose. I will not give a deadly drug to any one, though
it be asked of me, nor will I lead the way in such counsel; and
likewise I will not give a woman a pessary to procure abortion. But
I will keep my life and my art in purity and holiness. Whatsoever
house I enter, I will enter for the benefit of the sick, refraining
from all voluntary wrongdoing and corruption, especially seduction
of male or female, bond or free. Whatsoever things I see or hear
concerning the life of men, in my attendance on the sick or even
apart from my attendance, which ought not to be blabbed abroad, I
will keep silence on them, counting such things to be as religious
secrets.
'If I fulfil this oath and confound it not, be it mine to enjoy
life and art alike, with good repute among all men for all time to
come; but may the contrary befall me if I transgress and violate my
oath.'[69]
[69] Translation by Professor Arthur Platt.
Respected equally throughout the ages by Arab, Jew, and Christian, the
oath remains the watchword of the profession of medicine.[70] The
ethical value of such a declaration could not escape the attention even
of a Byzantine formalist, and it is interesting to observe that in our
oldest Greek manuscript of the Hippocratic text, dating from the tenth
century, this magnificent passage is headed by the words 'from the oath
of Hippocrates according as it may be sworn by a Christian.'[71]
[70] It must, however, be admitted that in the Hippocratic
collection are breaches of the oath, e. g. in the induction of
abortion related in περι φυσιος παιδιου {peri physios paidiou}.
There is evidence, however, that the author of this work was not a
medical practitioner.
[71] Rome Urbinas 64, fo. 116.
When we examine the Hippocratic corpus more closely, we discern that not
only are the treatises by many hands, but there is not even a uniform
opinion and doctrine running through them. This is well brought out by
some of the more famous of the phrases of this remarkable collection.
Thus a well-known passage from the _Airs, Waters, and Places_ tells us
that the Scythians attribute a certain physical disability to a god,
'but it appears to me', says the author, 'that these affections are just
as much divine as are all others and that no disease is either more
divine or more human than another, but that all are equally divine, for
each of them has its own nature, and none of them arise without a
natural cause.' But, on the other hand, the author of the great work on
_Prognostics_ advises us that when the physician is called in he must
seek to ascertain the nature of the affections that he is treating, and
especially 'if there be anything divine in the disease, and to learn a
foreknowledge of this also.'[72] We may note too that this sentence
almost immediately precedes what is perhaps the most famous of all the
Hippocratic sentences, the description of what has since been termed the
_Hippocratic facies_. This wonderful description of the signs of death
may be given as an illustration of the habitual attitude of the
Hippocratic school towards prognosis and of the very careful way in
which they noted details:
'He [the physician] should observe thus in acute diseases: first,
the countenance of the patient, if it be like to those who are in
health, _and especially if it be like itself, for this would be the
best_; but the more unlike to this, the worse it is; such would be
these: _sharp nose, hollow eyes, collapsed temples; ears cold,
contracted, and their lobes turned out; skin about the forehead
rough, distended, and parched; the colour of the whole face
greenish or dusky_. If the countenance be so at the beginning of
the disease, and if this cannot be accounted for from the other
symptoms, inquiry must be made whether he has passed a sleepless
night; whether his bowels have been very loose; or whether he is
suffering from hunger; and if any of these be admitted the danger
may be reckoned as less; and it may be judged in the course of a
day and night if the appearance of the countenance proceed from
these. But if none of these be said to exist, and the symptoms do
not subside in that time, be it known for certain that death is at
hand.'[73]
[72] Kühlewein, i. 79, regards this as an interpolated passage.
[73] Littré, ii. 112; Kühlewein, i. 79. The texts vary: Kühlewein is
followed except in the last sentence.
Again, in the work _On the Art_ [_of Medicine_] we read: 'I hold it to
be physicianly to abstain from treating those who are overwhelmed by
disease',[74] a prudent if inhumane procedure among a people who might
regard the doctor's powers as partaking of the nature of magic, and
perhaps a wise course to follow at this day in some places not very far
from Cos. Yet in the book _On Diseases_ we are advised even in the
presence of an incurable disease 'to give relief with such treatment as
is possible'.[75]
[74] Περι τεχνης {Peri technês}, § 3.
[75] Περι νουσων α' {Peri nousôn a'}, § 6.
Furthermore, works by authors of the Hippocratic school stand sometimes
in a position of direct controversy with each other. Thus in the
treatise _On the Heart_ an experiment is set forth which is held to
prove that a part at least of imbibed fluid passes into the cavity of
the lung and thence to the parts of the body, a popular error in
antiquity which recurs in Plato's _Timaeus_. This view, however, is
specifically held to be fallacious by the author of the work _On
Diseases_, who is supported by a polemical section in the surviving
Menon fragment.
Passages like these have convinced all students that we have to deal in
this collection with a variety of works written at different dates by
different authors and under different conditions, a state that may be
well understood when we reflect that among the Greeks medicine was a
progressive study for a far longer period of time than has yet been the
case in the Western world. An account of such a collection can therefore
only be given in the most general fashion. The system or systems of
medicine that we shall thus attempt to describe was in vogue up to the
Alexandrian period, that is, to the beginning of the third century B. C.
Anatomy and physiology, the basis of our modern system, was still a very
weak point in the knowledge of the pre-Alexandrians. The surface form of
the body was intimately studied in connexion especially with fractures,
but there is no evidence in the literature of the period of any closer
acquaintance with human anatomical structure.[76] The same fact is well
borne out by Greek Art, for in its noblest period the artist betrays no
evidence of assistance derived from anatomization. Such evidence is not
found until we come to sculpture of Alexandrian date, when the somewhat
strained attitudes and exaggerated musculature of certain works of the
school of Pergamon suggest that the artist derived hints, if not direct
information, from anatomists who, we know, were active at that time. It
is not improbable, however, that separate bones, if not complete
skeletons, were commonly studied earlier, for the surgical works of the
Hippocratic collection, and especially those on fractures and
dislocations, give evidence of a knowledge of the relations of bones to
each other and of their natural position in the body which could not be
obtained, or only obtained with greatest difficulty, without this aid.
[76] A reference to dissection in the περι αρθρων {peri arthrôn},
_On the joints_, § 1, appears to the present writer to be of
Alexandrian date.
There are in the Hippocratic works a certain number of comparisons
between human and animal structures that would have been made possible
by surgical operations and occasional accidents. The view has been put
forward that some anatomical knowledge was derived through the practice
of augury from the entrails of sacrificial animals. It appears, however,
improbable that a system so scientific and so little related to temple
practice would have had much to learn from these sources, and, moreover,
since we know that animals were actually dissected as early as the time
of Alcmaeon it would be unnecessary to invoke the aid of the priests.
The unknown author of the περι τοπων των κατα ανθρωπον {peri topôn tôn
kata anthrôpon}, _On the sites of_ [_diseases_] _in man_, a work written
about 400 B. C., declares indeed that 'physical structure is the basis
of medicine', but the formal treatises on anatomy that we possess from
Hippocratic times give the general anatomical standard of the corpus,
and it is a very disappointing one. The tract _On Anatomy_, though
probably of much later date (perhaps _c._ 330 B. C.), is inferior even
to the treatise _On the Heart_ (perhaps of about 400 B. C.).
Physiology and Pathology are almost as much in the background as anatomy
in the Hippocratic collection. As a formal discipline and part of
medical education we find no trace of these studies among the
pre-Alexandrian physicians. But the meagreness of the number of
ascertained facts did not prevent much speculation among a people eager
to seek the causes of things. Of that speculation we learn much from the
fragments of contemporary medical writers and philosophers, from the
medical works of the Alexandrian period, and to some extent from the
Hippocratic writings themselves. But the wiser and more sober among the
writers of the Hippocratic corpus were bent on something other than the
causes of things. Their pre-occupation was primarily with the suffering
patient, and the best of them therefore excluded--and we may assume
consciously--all but the rarest references to such speculation.
The general state of health of the body was considered by the
Hippocratists to depend on the distribution of the four elements, earth,
air, fire, and water, whose mixture (_crasis_) and cardinal properties,
dryness, warmth, coldness, and moistness, form the body and its
constituents. To these correspond the cardinal fluids, blood, phlegm,
yellow bile and black bile. The fundamental condition of life is the
_innate heat_, the abdication of which is death. This innate heat is
greatest in youth when most fuel is therefore required, but gradually
declines with age. Another necessity for the support of life is the
_pneuma_ which circulates in the vessels. All this may seem fanciful
enough, but we may remember that the first half of the nineteenth
century had waned before the doctrine of the humours which had then
lasted for at least twenty-two centuries became obsolete, and perhaps it
still survives in certain modern scientific developments. Moreover, the
finest and most characteristic of the Hippocratic works either do not
mention or but casually refer to these theories which are not essential
to their main pre-occupation. Their task of observation of symptoms, of
the separation of the essentials from the accidents of disease, and of
generalization from experience could go on unaffected by any view of the
nature of man and of the world. Even treatment, which must almost of
necessity be based on _some_ theory of causation, was little deflected
by a view of elements and humours on which it was impossible to act
directly, while therapeutics was further safeguarded from such influence
by the doctrine of _Nature as the healer of diseases_, νουσων φυσεις
ιητροι {nousôn physeis iêtroi}, the _vis medicatrix naturae_ of the
later Latin writers and of the present day.
Diseases are to be cured, in the Hippocratic view, by restoring the
disturbed harmony in the relation of the elements and humours. These, in
fact, tend naturally to an equilibrium and in most cases if left to
themselves will be brought to this state by the natural tendency to
recovery. The process is known as _pepsis_ or, to give it the Latin
form, _coctio_, and the turning-point at which the effects of this
process exhibit themselves is the _crisis_, a term which, together with
some of its original content, has still a place in medicine. Such a
turning-point does in fact occur in many diseases, especially those of a
zymotic character, on certain special days, though undue emphasis was
laid by the Greek physicians upon the exact numerical character of the
event. It was no unimportant duty of the physician to assist nature by
bringing his remedies to bear at the critical times. If the crisis is
wanting, or if the remedies are applied at the wrong moment, the disease
may become incurable. But diseases were only immediately or proximately
caused by disturbances in the balance or harmony of the humours. This
was a mere hypothesis, as the Hippocratists themselves well knew. There
were other more remote causes which came into the actual purview of the
physician, conditions which he could and did study. Such conditions
were, for instance, injudicious modes of life, exposure to climatic
changes, advancing age, and the like. Many of these could be directly
corrected. But for those that could not there were various therapeutic
measures at hand.
That human bodies are and normally remain in a state of health, and that
on the whole they tend to recover from disease, is an attitude so
familiar to us to-day that we scarcely need to be reminded of it. We
live some twenty-three centuries later than Hippocrates; for some
sixteen of those centuries the civilized world thought that to retain
health periodical bleedings and potions were necessary; for the last
century or two we have been gradually returning on the Hippocratic
position!
The chief glory of the Hippocratic collection regarded from the clinical
point of view is perhaps the actual description of cases. A number of
these--forty-two in all--have survived.[77] They are not only unique as
a collection for nearly 2,000 years, but they are still to this day
models of what succinct clinical records should be, clear and short,
without a superfluous word, yet with all that is most essential, and
exhibiting merely a desire to record the most important facts without
the least attempt to prejudge the case. They illustrate to the full the
Greek genius for seizing on the essential. The writer shows not the
least wish to exalt his own skill. He seeks merely to put the data
before the reader for his guidance under like circumstances. It is a
reflex of the spirit of full honesty in which these men lived and worked
that the great majority of the cases are recorded to have died. Two of
this remarkable little collection may be given:
'The woman with quinsy, who lodged with Aristion: her complaint
began in the tongue; voice inarticulate; tongue red and parched.
_First day_, shivered, then became heated. _Third day_, rigor,
acute fever; reddish and hard swelling on both sides of neck and
chest; extremities cold and livid; respiration elevated; drink
returned by the nose; she could not swallow; alvine and urinary
discharges suppressed. _Fourth day_, all symptoms exacerbated.
_Fifth day_, she died.'
[77] They are to be found as an Appendix to Books I and III of the
_Epidemics_ and embedded in Book III.
We probably have here to do with a case of diphtheria. The quinsy, the
paralysis of the palate leading to return of the food through the nose,
and the difficulty with speech and swallowing are typical results of
this affection which was here complicated by a spread of the septic
processes into the neck and chest, a not uncommon sequela of the
disease. The rapid onset of the conditions is rather unusual, but may be
explained if we regard the case as a mild and unnoticed diphtheria,
subsequently complicated by paralysis and by secondary septic infection,
for which reasons she came under observation.
'In Thasos, the wife of Delearces who lodged on the plain, through
sorrow was seized with an acute and shivering fever. From first to
last she always wrapped herself up in her bedclothes; kept silent,
fumbled, picked, bored and gathered hairs [from the clothes];
tears, and again laughter; no sleep; bowels irritable, but passed
nothing; when urged drank a little; urine thin and scanty; to the
touch the fever was slight; coldness of the extremities. _Ninth
day_, talked much incoherently, and again sank into silence.
_Fourteenth day_, breathing rare, large, and spaced, and again
hurried. _Seventeenth day_, after stimulation of the bowels she
passed even drinks, nor could retain anything; totally insensible;
skin parched and tense. _Twentieth day_, much talk, and again
became composed, then voiceless; respiration hurried. _Twenty-first
day_, died. Her respiration throughout was rare and large; she was
totally insensible; always wrapped up in her bedclothes; throughout
either much talk, or complete silence.'
This second case is in part a description of low muttering delirium, a
common end of continued fevers such as, for instance, typhoid. The
description closely resembles the condition known now in medicine as the
'typhoid state'. Incidentally the case contains a reference to a type of
breathing common among the dying. The respiration becomes deep and slow,
as it sinks gradually into quietude and becomes rarer and rarer until it
seems to cease altogether, and then it gradually becomes more rapid and
so on alternately. This type of breathing is known to physicians as
'Cheyne-Stokes' respiration in commemoration of two distinguished Irish
physicians of the last century who brought it to the attention of
medical men.[78] Recently it has been partially explained on a
physiological basis. We may note that there is another and even better
pen-picture of Cheyne-Stokes respiration in the Hippocratic collection.
It is in the famous case of 'Philescos who lived by the wall and who
took to his bed on the first day of acute fever'. About the middle of
the sixth day he died and the physician notes that 'the respiration
throughout was _like that of a person recollecting himself_ and was
large and rare'. Cheyne-Stokes breathing is admirably described as 'that
of a person recollecting himself'.
[78] John Cheyne (1777-1836) described this type of respiration in
the _Dublin Hospital Reports_, 1818, ii, p. 216. An extreme case of
this condition had been described by Cheyne's namesake George Cheyne
(1671-1743) as the famous 'Case of the Hon. Col. Townshend' in his
_English Malady_, London, 1733. William Stokes (1804-78) published
his account of Cheyne-Stokes breathing in the _Dublin Quarterly
Journal of the Medical Sciences_, 1846, ii, p. 73.
Such records as these may be contrasted with certain others that have
come down from Greek antiquity. We may instance two steles discovered at
Epidaurus in 1885, bearing accounts of forty-four temple cures. The
following two are fair samples of the cures there described:
'_Aristagora of Troizen._ She had tape-worm, and while she slept in
the Temple of Asclepius at Troizen, she saw a vision. She thought
that, as the god was not present, but was away in Epidaurus, his
sons cut off her head, but were unable to put it back again. Then
they sent a messenger to Asclepius asking him to come to Troizen.
Meanwhile day came, and the priest actually saw her head cut off
from the body. The next night Aristagora had a dream. She thought
the god came from Epidaurus and fastened her head on to her neck.
Then he cut open her belly, and stitched it up again. So she was
cured.'
'A man had an abdominal abscess. He saw a vision, and thought that
the god ordered the slaves who accompanied him to lift him up and
hold him, so that his abdomen could be cut open. The man tried to
get away, but his slaves caught him and bound him. So Asclepius cut
him open, rid him of the abscess, and then stitched him up again,
releasing him from his bonds. Straightway he departed cured, and
the floor of the Abaton was covered with blood.'[79]
[79] The Epidaurian inscriptions are given by M. Fraenkel in the
_Corpus Inscriptionum Graecarum_ IV, 951-6, and are discussed by
Mary Hamilton (Mrs. Guy Dickins), _Incubation_, St. Andrews, 1906,
from whose translation I have quoted. Further inscriptions are given
by Cavvadias in the _Archaiologike Ephemeris_, 1918, p. 155 (issued
1921).
In the records of almost all temple cures, a great number of which have
survived in a wide variety of documents, an essential element is the
process of εγκοιμησις {enkoimêsis}, _incubation_ or temple sleep,
usually in a special sleeping-place or Abaton. The process has a close
parallel in certain modern Greek churches and in places of worship much
further West; there are even traces of it in these islands, and it is
more than probable that the Christian practice is descended by direct
continuity from the pagan.[80] The whole character of the temple
treatment was--and is--of a kind to suggest to the patient that he
should dream of the god, an event which therefore usually takes place.
Such treatment by suggestion is applicable only to certain classes of
disease and is always liable to fall into the hands of fanatics and
impostors. The difficulty that the honest practitioner encounters is
that the sufferer, in the nature of the case, can hardly be brought to
believe that his ailment is what in fact it is, a lesion of the mind. It
is this which gives the miracle-monger his chance.
[80] We are almost told as much in the apocryphal _Gospel of
Nicodemus_, § 1, a work probably composed about the end of the
fourth century.
Examine for a moment the two cases from Epidaurus, which are quite
typical of the series. We observe that the first is described simply as
a case of 'tape-worm' without any justification for the diagnosis. It is
not unfrequent nowadays for thin and anxious patients to state,
similarly without justification, that they suffer from this condition.
They attribute certain common gastric experiences to this cause of which
perhaps they have learned from sensational advertisements, and then they
ask cure for a condition which they themselves have diagnosed, but which
has no existence in fact. Such a case is often appropriately treated by
suggestion. Though the elaborateness of the suggestion in the temple
cure is a little startling, yet it can easily be paralleled from the
legends of the Christian saints. Moreover, we must remember that we are
not here dealing with an account set down by the patient herself, but
with an edificatory inscription put up by the temple officials.
In the second inscription, the man with an abdominal abscess, we have a
much simpler state of affairs. It is evident that an operation was
actually performed by the priest masquerading as Asclepius, while the
patient was held down by the slaves. He is assured that all is a dream
and departs cured with the tell-tale comment 'and the floor of the
Abaton was covered with blood'.
These cases might be multiplied indefinitely without great profit for
our particular theme, for in such matters there is no development, no
evolution, no history. There can be no doubt that a very large part of
Greek practice was on this level, as is a small part of modern medicine,
but it is not a level with which we are here dealing and we shall
therefore pass it by. But a word of caution must be added. Such temple
worship has been compared with modern psycho-analysis. That method, like
all methods, has doubtless been abused at times; but it is in essence,
unlike the temple system, a purely scientific process by which the
ultimate basis of the patient's delusions are laid bare and demonstrated
to him.
There is indeed another side to these Asclepian temples. They gradually
developed along the lines of our health resorts and developed many of
the qualities--lovely and unlovely--that we associate with certain
continental watering places. On the bad side they became gossiping
centres or even something little better than brothels, as we may gather
from the _Mimes_ of Herondas. On the good side they formed a quiet
refuge among beautiful and interesting surroundings where the sick,
exhausted, and convalescent might gain the benefits that accrue from
pure air, fine scenery, and a regular and regulated mode of life. It is
more than probable too that the open air and manner of living benefited
many cases of incipient phthisis.
Returning to the Hippocratic collection, the purely surgical treatises
will be found no less remarkable than those of clinical observation. A
very able surgeon, Francis Adams (1796-1861), who was eminent as a Greek
scholar, gave it as his opinion in the middle of the nineteenth century
that no systematic writer on surgery up to his time had given so good
and so complete an account of certain dislocations, notably of the
hip-joint, as that to be found in the Hippocratic collection. Some types
of injury to the hip, as described in the Hippocratic writings, were
certainly otherwise quite inadequately known until described by Sir
Astley Cooper (1768-1841), himself a peculiarly Hippocratic
character.[81] The verdict of Adams was probably just, though since his
time the surgery of dislocations, aided especially by X-rays, has been
enabled to pass very definitely beyond the Hippocratic position.
Admirable, too, is the Hippocratic description of dislocation of the
shoulder and of the jaw. In dislocation of hip, shoulder, or jaw, as in
most similar lesions, there is considerable deformity produced. The
nature and meaning of this deformity is described with remarkable
exactness by the Hippocratic writer, who also sets forth the resulting
disability. The principles and indeed the very details of treatment in
these cases are, save for the use of an anaesthetic, practically
identical with those of the present day. The processes are unfortunately
not suitable for detailed quotation and description here, but they are
of special interest since a graphic record of them has come down to us.
There exists in the Laurentian Library at Florence a ninth-century Greek
surgical manuscript which contains figures of surgeons reducing the
dislocations in question. There is good reason to suppose that these
miniatures are copied from figures first prepared in pre-Christian times
many centuries earlier, and we may here see the actual processes of
reduction of such fractures, as conducted by a surgeon of the direct
Hippocratic tradition[82] (see Figs. 3, 4).
[81] Astley Paston Cooper, _Treatise on Dislocations and Fractures
of the Joints_, London, 1822, and _Observations on Fractures of the
Neck and the Thighbone_, &c., London, 1823.
[82] This famous manuscript is known as Laurentian, Plutarch 74, 7,
and its figures have been reproduced by H. Schöne, _Apollonius von
Kitium_, Leipzig, 1896.
[Illustration: From MS. of APOLLONIUS OF KITIUM, of Ninth Century
Copied from pre-christian original