In keeping with all this is most of the surgical work of the collection.
We are almost startled by the modern sound of the whole procedure as we
run through the rough note-book κατ' ιητρειον {kat' iêtreion},
_Concerning the Surgery_, or the more elaborate treatise περι ιητρου
{peri iêtrou}, _On the Physician_, where we may read minute directions
for the preparation of the operating-room, and on such points as the
management of light both artificial and natural, scrupulous cleanliness
of the hands, the care and use of the instruments, with the special
precautions needed when they are of iron, the decencies to be observed
during the operation, the general method of bandaging, the placing of
the patient, the use and abuse of splints, and the need for tidiness,
order, and cleanliness. Many of these directions are enlarged upon in
other surgical works of the collection, among which we find especially
full instructions for bandaging and for the diagnosis and treatment of
fractures and dislocations. A very fair representation of such a surgery
as these works describe is to be found on a vase-painting of Attic
origin of the earlier part of the fifth century, and, therefore, a
generation before Hippocrates (see fig. 5). There are also several
beautiful representations on vases of the actual processes of bandaging
(fig. 6).
[Illustration: FIG. 5.
A GREEK CLINIC OF ABOUT 480-470 B. C. From a vase-painting.
In the centre sits a physician holding a lancet and bleeding a patient
from the median vein at the bend of the right elbow into a large open
basin. Above and behind the physician are suspended three cupping
vessels. To the right sits another patient awaiting his turn; his left
arm is bandaged in the region of the biceps. The figure beyond him
smells a flower, perhaps as a preservative against infection. Behind the
physician stands a man leaning on a staff; he is wounded in the left
leg, which is bandaged. By his side stands a dwarfish figure with
disproportionately large head, whose body exhibits deformities typical
of the developmental disease now known as _Achondroplasia_; in addition
to these deformities we note that his body is hairy and the bridge of
his nose sunken; on his back he carries a hare which is almost as tall
as himself. Talking to the dwarf is a man leaning on a long staff, who
has the remains of a bandage round his chest.
See E. Pottier, 'Une Clinique grecque au V^{e} siècle (vase antique du
collection Peztel)', _Fondation Eugène Piot, Monuments et Mémoires_,
xiii. 149, Paris, 1906. (Some of our interpretations differ from those
of M. Pottier.)]
[Illustration: FIG. 6. A kylix from the Berlin Museum of about 490 B. C.
It bears the inscription ΣΟΣΙΑΣ ΕΠΟΙΗΣΕΝ {SOSIAS EPOIÊSEN}, _Sosias
made_ (_me_), and represents Achilles bandaging Patroclus, the names of
the two heroes being written round the margin. The painter is
Euphronios, and the work is regarded as the masterpiece of that great
artist. The left upper arm of Patroclus is injured, and Achilles is
bandaging it with a two-rolled bandage, which he is trying to bring down
to extend over the elbow. The treatment of the hands, a department in
which Euphronios excelled, is particularly fine. Achilles was not a
trained surgeon, and it will be observed, from the position of the two
tails of the bandage, that he will have some difficulty when it comes to
its final fastening!]
Among the surgical procedures of which descriptions are to be found in
the Hippocratic writings are the opening of the chest for the condition
known as _empyema_ (accumulation of pus within the pleura frequently
following pneumonia), and trephining the skull in cases of fracture of
that part--two fundamental operations of modern surgery. Surgical art
has advanced enormously in our own times, yet a text-book containing
much that is useful to this day might be prepared from these surgical
contents of the collection alone.
When we pass to the works on Medicine, in the restricted sense, we enter
into a region more difficult and perhaps even more fascinating. We are
no longer dealing with simple lesions of known origin, but with the
effects of disease and degeneration, of the essential character of which
the Hippocratic writers could in the nature of the case know very
little. Rigidly guarding themselves from any attempt to explain disease
by more immediate and hypothetical causes and thus diverting the
reader's energies in the medically useless direction of vague
speculation--the prevalent mental vice of the Greeks--the best of these
physicians are content if they can put forward generalized conclusions
from actually observed cases. Many of their thoughts have now become
household words, and they have become so, largely as a direct heritage
from these ancient physicians. But it must be remembered that ideas so
familiar to us were with them the result of long and carefully recorded
experience and are like nothing that we encounter in the medicine of
other ancient nations. Such conclusions are best set forth perhaps in
the wonderful book of the _Aphorisms_ from which we may permit ourselves
a few quotations:
'Life is short, and the Art long; the opportunity fleeting;
experiment dangerous, and judgement difficult. Yet we must be
prepared not only to do our duty ourselves, but also patient,
attendants, and external circumstances must co-operate.'[83]
[83] The first lines are the source of the famous lines in Goethe's
_Faust_:
'Ach Gott! die Kunst ist lang
Und kurz ist unser Leben,
Mir wird bei meinem kritischen Bestreben
Doch oft um Kopf und Busen bang.'
In this one memorable paragraph, so condensed in the original as to be
almost untranslatable, he who 'first separated medicine from philosophy'
puts aside at once all speculative interest while in the actual presence
of the sick. His whole energy is concentrated on the case in hand with
that peculiar attitude, at once impersonal and intensely personal, that
has since been the mark of the physician, and that has made of Medicine
both a science and an art.
'For extreme diseases, extreme methods of cure.'[84]
'The aged endure fasting most easily; next adults; next young
persons, and least of all children, and especially such as are the
most lively.'
'Growing bodies have the most innate heat; they therefore require
the most nourishment, and if they have it not they waste. In the
aged there is little heat, and therefore they require little fuel,
for it would be extinguished by much. Similarly fevers in the aged
are not so acute, because their bodies are cold.'
'In disease sleep that is laborious is a deadly symptom; but if
sleep relieves it is not deadly.'
'Sleep that puts an end to delirium is a good symptom.'
'If a convalescent eats well, but does not put on flesh, it is a
bad symptom.'
'Food or drink which is a little less good but more palatable is to
be preferred to such that is better but less palatable.'
'The old have generally fewer complaints than young; but those
chronic diseases which do befall them generally never leave them.'
[84] The extreme of treatment refers in the original to the extreme
restriction of diet, ες ακριβειην {es akribeiên}, but the meaning of
the Aphorism has always been taken as more generalized.
Here we have a group of observations, some of which have become
literally household words, nor is it difficult to understand how such
sayings have passed from professional into lay keeping. This magnificent
book of _Aphorisms_ was very early translated into Latin, probably
before and certainly not later than the sixth century of the Christian
era, and thus became accessible throughout the West. Manuscripts of this
Latin version, dating from the ninth and tenth centuries of our era,
have survived in the actual places in which they were written, at Monte
Cassino in Southern Italy and at Einsiedeln in Switzerland, and in 991
the book of _Aphorisms_ was well known and closely studied at the
Cathedral school of Chartres. From France the _Aphorisms_ reached
England, and they are mentioned in documents of the tenth or eleventh
century. By now, too, the book had been translated into Syriac and later
into Arabic and Hebrew, so that in the true mediaeval period it was
known both East and West, and in the vernacular as well as the classical
tongues. From the oriental dialects several further translations were
again made into Latin. An enormous number of manuscripts of the work
have survived in almost every Western dialect, and these show on the
whole that the text has been surprisingly little tampered with. In the
middle of the thirteenth century some of the better-known Aphorisms were
absorbed into a very popular Latin poem that went forth in the name of
the medical school of Salerno, though with a false ascription to a yet
earlier date. The Salernitan poem, being itself translated into every
European vernacular, further helped to bring Hippocrates into every
home.
But by no means all the Aphorisms are of a kind that could well become
absorbed into folk medicine. It is only those concerning frequently
recurring states to which this fate could befall. The book contains also
a number of notes on rare conditions seldom seen or noted save by
medical men. Such are the following very acute observations:
'Spasm supervening on a wound is fatal.'
'Those seized with tetanus die within four days, or if they survive
so long they recover.'
'A convulsion, or hiccup, supervening on a copious discharge of
blood is bad.'
'If after severe and grave wounds no swelling appears, it is very
serious.'
These four sentences all concern wounds. The first two refer to the
disease _tetanus_, which is very liable to supervene on wounds fouled
with earth, especially in hot and moist localities. The disease is
characterized by a series of painful muscular contractions which in the
more severe and fatal form may become a continuous spasm, a type that is
referred to in the first sentence. It is true of tetanus that the later
the onset after the wound is sustained the better the chance of
recovery. This is brought out by the second sentence. The third and
fourth sentences record untoward symptoms following a severe wound, now
well recognized and watched for by every surgeon. There were, of course,
innumerable illustrations of the truth of these Aphorisms in extensive
wounds, especially those involving crushed limbs, in the late war.
'Phthisis occurs most commonly between the ages of eighteen and
thirty-five.'
'Diarrhœa supervening on phthisis is mortal.'
The period given by the _Aphorisms_ for the maximum frequency of onset
of the disease is closely borne out by modern observations. The second
Aphorism is equally valid; continued diarrhœa is a very frequent
antecedent of the fatal event in chronic phthisis, and post-mortem
examination has shown that secondary involvement of the bowel is an
exceedingly common condition in this disease.
No less remarkable is the following saying: 'In jaundice it is a grave
matter if the liver becomes indurated.' Jaundice is a common and
comparatively trivial symptom following or accompanying a large variety
of diseases. In and by itself it is of little importance and almost
always disappears spontaneously. There is a small group of pathological
conditions, however, in which this is not the case. The commonest and
most important of these are the fatal affections of cirrhosis and cancer
of the liver in which that organ may be felt to be enlarged and
hardened. If therefore the liver can be so felt in a case of jaundice,
it is, as the Aphorism says, of gravest import. Representations of such
cases have actually come down to us from Greek times. Thus on a monument
erected at Athens to the memory of a physician who died in the second
century of the Christian era we may see the process of clinical
examination (fig. 7). The physician is palpating the liver of a dwarfish
figure whose swollen belly, wasted limbs, and anxious look tell of some
such condition as that described in the Aphorism. The ridge caused by
the enlarged liver can even be detected on the statue.
[Illustration: Fig. 7. ATHENIAN FUNERARY MONUMENT
Second century A. D. British Museum
Inscription reads: 'Jason, also called Dekmos, the Acharnian, a
physician', followed by his genealogy. By side of patient stands a
cupping vessel.]
'We must attend to the appearances of the eyes in sleep as presented
from below; for if a portion of the white be seen between the closing
eyelids, and if this be not connected with diarrhœa or severe purging,
it is a very bad and mortal symptom.' In this, the last Aphorism which
we shall quote, we see the Hippocratic physician actually making his
observations. Now during sleep the eyeball is turned upward, so that if
the eye be then opened and examined only the white is seen. In the later
stages of all wasting and chronic diseases the eyelids tend not to be
closed during sleep. Such patients, as is well known, often die with the
eyes open and sometimes exhibiting only the whites.
But the Hippocratic physician was not content to make only passive
observation; he also took active measures to elicit the 'physical
signs'. In modern times a large, perhaps the chief, task of the student
of medicine is to acquire a knowledge of these so-called physical signs
of disease, the tradition of which has been gradually rebuilt during the
last three centuries. Among the most important measures in which he
learns to acquire facility is that of auscultation. This useful process
has come specially into vogue since the invention of the stethoscope in
1819 by Laennec, who derived valuable hints for it from the Hippocratic
writings. Auscultation is several times mentioned and described by the
Hippocratic physicians, who used the direct method of listening and not
the mediate method devised by Laennec. There are, however, certain cases
in which the modern physician still finds the older non-instrumental
Hippocratic method superior. In the Hippocratic work περι νουσων {peri
nousôn}, _On diseases_, we read of a case with fluid in the pleura that
'you will place the patient on a seat which does not move, an assistant
will hold him by the shoulders, and you will shake him, applying the ear
to the chest, so as to recognize on which side the sign occurs'. This
sign is still used by physicians and is known as _Hippocratic
succussion_. In another passage in the same work the symptoms of
pleurisy are described and 'a creak like that of leather may be heard'.
This is the well known _pleuritic rub_ which the physician is accustomed
to seek in such cases, and of which the creak of leather is an excellent
representation.
Such quotations give an insight into the general method and attitude of
the Hippocratics. Of an art such as medicine, which even in those times
had a long and rational tradition behind it, it is impossible to give
more than the merest glimpse in such a review as this. The actual
practice is far too complex to set down briefly. This is especially the
case with the ancient teaching as regards epidemic disease at which we
must cursorily glance. The Hippocratic physicians and indeed all
antiquity were as yet ignorant of the nature, and were but dimly aware
of the existence, of infection.[85] For them acute disease was something
imposed on the patient from outside, but how it reached him from outside
and what it was that thus reached him they were still admittedly
ignorant. In this dilemma they turned to prolonged observation and noted
as a result of repeated experience that epidemic diseases in their world
had characteristic seasonal and regional distributions. One country was
not quite like another, nor was one season like another nor even one
year like another. By a series of carefully collated observations as to
how regions, seasons, and years differed from each other, they succeeded
in laying the basis of a rational study of epidemiology which gave rise
to the notion of an 'epidemic constitution' of the different years, a
conception which was very fertile and stimulating to the great
clinicians of the seventeenth and eighteenth centuries and is by no
means without value even for the modern epidemiologist. The work of the
modern fathers of epidemiology was consciously based on Hippocrates.
[85] The ancients knew almost nothing of infection _as applied
specifically_ to disease. All early peoples--including Greeks and
Romans--believed in the transmission of qualities from object to
object. Thus purity and impurity and good and bad luck were
infections, and diseases were held to be infections in that sense.
But there is little evidence in the belief of the special
infectivity of _disease as such_ in antiquity. Some few diseases
are, however, unequivocally referred to as infectious in a limited
number of passages, e. g. ophthalmia, scabies, and phthisis in the
περι διαφορας πυρετων {peri diaphoras pyretôn}, _On the differentiae
of fevers_, K. vii, p. 279. The references to infection in antiquity
are detailed by C. and D. Singer, 'The scientific position of
Girolamo Fracastoro', _Annals of Medical History_, vol. i, New York,
1917.
Before parting with the Hippocratic physician a word must be said as to
his therapeutic means. His general armoury may be described as
resembling that of the modern physician of about two generations ago.
During those two generations we have, it is true, added to our list of
effective remedies but, on the other hand, there has been by common
consent a return to the Hippocratic simplicity of treatment. After rest
and quiet the central factor in treatment was Dietetics. This science
regarded the age--'Old persons use less nutriment than young'; the
season--'In winter abundant nourishment is wholesome, in summer a more
frugal diet'; the bodily condition--'Lean persons should take little
food, but this little should be fat, fat persons on the other hand
should take much food, but it should be lean'. Respect was also paid to
the digestibility of different foods--'white meat is more easily
digestible than dark'--and to their preparation. Water, barley water,
and lime water were recommended as drinks. The dietetic principles of
the Hippocratics, especially in connexion with fevers, are substantially
those of the present day, and it may be said that the general medical
tendency of the last generation in these matters has been an even closer
approximation to the Hippocratic. 'The more we nourish unhealthy bodies
the more we injure them'; 'The sick upon whom fever seizes with the
greatest severity from the very outset, must at once subject themselves
to a rigid diet'; 'Complete abstinence often acts well, if the strength
of the patient can in any way sustain it'; yet 'We should examine the
strength of the sick, to see whether they be in condition to maintain
this spare diet to the crisis of the disease'. 'In the application of
these rules we must always be mindful of the strength of the patient and
of the course of each particular disease, as well as of the constitution
and ordinary mode of life in each disease.'
Besides diet the Hippocratic physician had at his disposal a
considerable variety of other remedies. Baths, inunctions, clysters,
warm and cold suffusions, massage and gymnastic, as well as gentler
exercise are among them. He probably employed cupping and bleeding
rather too freely, and we have several representations of the
instruments used for these operations (fig. 8). He was no great user of
drugs and seldom names them except, we may note, in the works on the
treatment of women, which are probably of Cnidian origin and whence the
greater part of the 300 constituents of the Hippocratic pharmacopœia are
derived. Thus his list of drugs is small but several known to him are
still used by us.
The work of these men may be summed up by saying that without
dissection, without any experimental physiology or pathology, and
without any instrumental aid they pushed the knowledge of the course and
origin of disease as far as it is conceivable that men in such
circumstances could push it. This was done as a process of pure
scientific induction. Their surgery, though hardly based on anatomy, was
grounded on the most carefully recorded experience. In therapeutics they
allowed themselves neither to be deceived by false hopes nor led aside
by vain traditions. Yet in diagnosis, prognosis, surgery and
therapeutics alike they were in many departments unsurpassed until the
nineteenth century, and to some of their methods we have reverted in the
twentieth. Persisting throughout the ages as a more or less definite
tradition, which attained clearer form during and after the sixteenth
century, Hippocratic methods have formed the basis of all departments of
modern advance.
But the history of Greek medicine did not end with the Hippocratic
collection; in many respects it may indeed be held only to begin there;
yet we never get again a glimpse of so high an ethical and professional
standard as that which these works convey. From Alexandrian times
onwards, too, the history of Greek medicine becomes largely a history of
various schools of medical thought, each of which has only a partial
view of the course and nature of medical knowledge. The unravelling of
the course and teachings of these sects has long been a pre-occupation
of professed medical historians, but the general reader can hardly take
an interest in differences between the Dogmatists, Empirics, and
Methodists whose doctrines are as dead as themselves. In this later
Alexandrian and Hellenistic age the Greek intellect is no less active
than before, but there is a change in the taste of the material. A
general decay of the spirit is reflected in the medical as in the
literary products of the time, and we never again feel that elevation of
a beautiful and calmly righteous presence that breathes through the
Hippocratic collection and gives it a peculiar aroma.
We shall pass over the general course of later Greek medicine with great
rapidity. A definite medical school was established at Alexandria and
others perhaps at Pergamon and elsewhere. Athens, after the death of
Aristotle and his pupils, passes entirely into the background and is of
no importance so far as medicine is concerned. At Alexandria, where a
great medical library was collected, anatomy began to be studied and two
men whose discoveries were of primary importance for the history of that
subject, Erasistratus and Herophilus, early practised there. With
anatomy as a basis medical education could become much more systematic.
It is a very great misfortune that the works of these two eminent men
have disappeared. Of Herophilus fragments have survived embedded in the
works of Galen (A. D. 130-201), Caelius Aurelianus (fifth century), and
others. These fragments have been the subject of one of the earliest,
most laborious, and most successful attempts made in modern times to
reconstruct the lost work of an ancient author.[86] For Erasistratus our
chief source of information are two polemical treatises directed against
him by Galen. Recently, too, a little more information concerning the
works of both men has become available from the Menon papyrus.
[86] K. F. H. Marx, _Herophilus, ein Beitrag zur Geschichte der
Medizin_, Karlsruhe, 1838.
It has been found possible to reconstruct especially a treatise on
anatomy by Herophilus with a considerable show of probability. He opened
by giving general directions for the process of dissection and followed
with detailed descriptions of the various systems, nervous, vascular,
glandular, digestive, generative, and osseous. There was a separate
section on the liver, a small part of which has survived. It is of his
account of the nervous system that we have perhaps the best record, and
it is evident that he has advanced far beyond the Hippocratic position.
In the braincase he saw the membranes that cover the brain and
distinguished between the cerebrum and cerebellum. He attained to some
knowledge of the ventricles of the brain, the cranial and spinal nerves,
the nerves of the heart, and the coats of the eye. He distinguished the
blood sinuses of the skull, and the _torcular Herophili_ (winepress of
Herophilus), a sinus described by him, has preserved his name in modern
anatomical nomenclature. He even made out more minute structures, such
as the little depression in the fourth ventricle of the brain, known to
modern anatomists as the _calamus scriptorius_, which still bears the
name which he gave it (καλαμος ὡ γραφομεν {kalamos hô graphomen}),
because it seemed to him, as Galen tells us, to resemble the pens then
in use in Alexandria.[87] We still use, too, his term _duodenum_
(δωδεκαδακτυλος εκφυσις {dôdekadaktylos ekphysis} = twelve-finger
extension), for as Galen assures us, Herophilus 'so named the first part
of the intestine before it is rolled into folds'.[88] The duodenum is a
U-shaped section of the intestine following immediately on the stomach.
Being fixed down behind the abdominal cavity it cannot be further
convoluted, and this accounts for Galen's description of it. It is about
twelve fingers' breadth long in the animals dissected by Herophilus.
[87] Galen, περι ανατομικων εγχειρησεων {peri anatomikôn
encheirêseôn}, _On anatomical preparations_, ix. 5 (last sentence).
[88] Galen, περι φλεβων και αρτηριων ανατομης {peri phlebôn kai
artêriôn anatomês}, _On the anatomy of veins and arteries_, i.
Erasistratus, the slightly younger Alexandrian contemporary of
Herophilus, has the credit of further anatomical discoveries. He
described correctly the action of the epiglottis in preventing the
entrance of food and drink into the windpipe during the act of
swallowing, he saw the lacteal vessels in the mesentery, and pursued
further the anatomy of the brain. He improved on the anatomy of the
heart, and described the auriculo-ventricular valves and their mode of
closure. He distinguished clearly the motor and sensory nerves. He seems
to have adopted a definitely experimental attitude--a very rare thing
among ancient physicians--and a description of an experiment made by him
has recently been recovered. 'If', he says, 'you take an animal, a bird,
for example, and keep it for a time in a jar without giving it food and
then weigh it together with its excreta you will find that there is a
considerable loss of weight.'[89] The experiment is a simple one, but it
was about nineteen hundred years before a modern professor, Sanctorio
Santorio (1561-1636), thought of repeating it.[90]
[89] The quotation is from chapter xxxiii, line 44 of the _Anonymus
Londinensis_. H. Diels, _Anonymus Londinensis_ in the _Supplementum
Aristotelicum_, vol. iii, pars 1, Berlin, 1893.
[90] Sanctorio Santorio, _Oratio in archilyceo patavino anno 1612
habita; de medicina statica aphorismi_. Venice, 1614.
The anatomical advances made by the Alexandrian school naturally reacted
on surgical efficiency. The improvement so effected may be gathered, for
instance, from an account of the anatomical relationships in certain
cases of dislocation of the hip given by the Alexandrian surgeon
Hegetor, who lived about 100 B. C. In his book περι αιτιων {peri
aitiôn}, _On causes_ [_of disease_], he asks 'why (certain surgeons) do
not seek another way of reducing a luxation of the hip.... If the joints
of the jaw, shoulder, elbow, knee, finger, &c., can be replaced, the
same, they think, must be true of all parts, nor can they give an
account of why the femur cannot be put back into its place.... They
might have known, however, that from the head of the femur arises a
ligament which is inserted into the socket of the hip bone ... and if
this ligament is once ruptured the thigh bone cannot be retained in
place'.[91] This passage contains the first description of the structure
known to modern anatomists as the _ligamentum teres_, a strong fibrous
band which unites the head of the femur with the socket into which it
fits in the hip bone, like the string that binds the cup and ball of a
child's toy. This ligament is ruptured in certain severe cases of
dislocation of the hip.
[91] This is the only passage of Hegetor's writing that has
survived. It has been preserved in the work of Apollonius of Citium.
After the establishment of the school at Alexandria, medical teaching
rapidly became organized, but throughout the whole course of antiquity
it suffered from the absence of anything in the nature of a state
diploma. Any one could practise, with the result that many quacks,
cranks, and fanatics were to be found among the ranks of the
practitioners who often were or had been slaves. The great Alexandrian
school, however, did much to preserve some sort of professional
standard, and above all its anatomical discipline helped to this end.
Between the founding of the Alexandrian school and Galen we are not rich
in medical writings. Apart from fragments and minor productions, the
works of only five authors have survived from this period of over four
hundred years, namely, Celsus, Dioscorides, Aretaeus of Cappadocia, and
two Ephesian authors bearing the names of Rufus and Soranus.
The work of Celsus of the end of the first century B. C. is a Latin
treatise, probably translated from Greek, and is the surviving medical
volume of a complete cyclopaedia of knowledge. In spite of its
unpromising origin it is an excellent compendium of its subject and
shows a good deal of advance in many respects beyond the Hippocratic
position. The moral tone too is very high, though without the lofty and
detached beauty of Hippocrates. Anatomy has greatly improved, and with
it surgical procedure, and the work is probably representative of the
best Alexandrian practice. The pharmacopœia is more copious, but has not
yet become burdensome. The general line of treatment is sensible and
humane and the language concise and clear. Among other items he
describes dental practice, with the indications for and methods of tooth
extraction, the wiring of teeth, and perhaps a dental mirror. There is
an excellent account of what might be thought to be the modern operation
for removal of the tonsils. Celsus is still commemorated in modern
medicine by the _area Celsi_, a not uncommon disease of the skin. The
_De re medica_ is in fact one of the very best medical text-books that
have come down to us from antiquity. It has had a romantic history.
Forgotten during the Middle Ages, it was brought to light by the
classical scholar Guarino of Verona (1374-1460) in 1426, and a better
copy was discovered by his friend Lamola in 1427. Another copy was found
by Thomas Parentucelli (1397-1455), afterwards Pope Nicholas V in 1443,
and the text was later studied by Politian (1454-94). Though one of the
latest of the great classical medical texts to be discovered, it was one
of the first to be printed (Florence, 1478), and it ran through very
many early editions and had great influence on the medical renaissance.
[Illustration: Fig. 8. VOTIVE TABLET representing cupping and bleeding
instruments from Temple of Asclepius at Athens. In centre is represented
a folding case containing scalpels of various forms. On either side are
cupping vessels.]
After Celsus comes Dioscorides in the first century A. D. He was a Greek
military surgeon of Cilician origin who served under Nero, and in him
the Greek intellect is obviously beginning to flag. His work is
prodigiously important for the history of botany, yet so far as rational
medicine is concerned he is almost negligible. He begins at the wrong
end, either giving lists of drugs with the symptoms that they are said
to cure or to relieve, or lists of symptoms with a series of named
drugs. Clinical observation and record are wholly absent, and the spirit
of Hippocrates has departed from this elaborate pharmacopœia.
With the second century of the Christian era we terminate the creative
period of Greek medicine. We are provided with the works of four
important writers of this century, of whom three, Rufus of Ephesus,
Soranus of Ephesus, and Aretaeus of Cappadocia, though valuable for
forming a picture of the state of medicine in their day, were without
substantial influence on the course of medicine in later ages.
Rufus of Ephesus, a little junior to Dioscorides, has left us the first
formal work on human anatomy and is of some importance in the history of
comparative anatomy. In medicine he is memorable as the first to have
described bubonic plague, and in surgery for his description of the
methods of arresting haemorrhage and his knowledge of the anatomy of
the eye. A work by him _On gout_ was translated into Latin in the sixth
century, but remained unknown till modern times.
Soranus of Ephesus (A. D. _c._ 90-_c._ 150), an acute writer on
gynaecology, has left a book which illustrates well the anatomy of his
day. It exercised an influence for many centuries to come, and a Latin
abstract of it prepared about the sixth century by one Moschion has come
down to us in an almost contemporary manuscript.[92] It is interesting
as opposing the Hippocratic theory that the male embryo is originated in
the right and the female in the left half of the womb, a fallacy derived
originally from Empedocles and Parmenides, but perpetuated by Latin
translations of the Hippocratic treatises until the seventeenth century.
His work was adorned by figures, and some of these, naturally greatly
altered by copyists, but still not infinitely removed from the facts,
have survived in a manuscript of the ninth century, and give us a
distant idea of the appearance of ancient anatomical drawings.[93] We
may assist our imagination a little further, in forming an idea of what
such diagrams were like, with the help of certain other mediaeval
figures representing the form and distribution of the various anatomical
'systems', veins, arteries, nerves, bones, and muscles which are
probably traceable to an Alexandrian origin.[94]
[92] Leyden Voss 4° 9^{*} of the sixth century is a fragment of this
work.
[93] V. Rose, _Sorani Ephesii vetus translatio Latina cum additis
Graeci textus reliquiis_, Leipzig, 1882; F. Weindler, _Geschichte
der gynäkologisch-anatomischen Abbildung_, Dresden, 1908.
[94] The discovery and attribution of these figures is the work of
K. Sudhoff. A bibliography of his writings on the subject will be
found in a 'Study in Early Renaissance Anatomy' in C. Singer's
_Studies in the History and Method of Science_, vol. i, Oxford,
1917.
Aretaeus of Cappadocia was probably a contemporary of Galen (second half
of the second century A. D.). As a clinical author his reputation stands
high, perhaps too high, his descriptions of pneumonia, empyema,
diabetes, and elephantiasis having especially drawn attention. In
treatment he uses simple remedies, is not affected by polypharmacy, and
suggests many ingenious mechanical devices. It would appear that
Aretaeus is not an independent writer, but mainly a compiler. He relies
largely on Archigenes, a distinguished physician contemporary with
Juvenal, whose works have perished save the fragments preserved in this
manner by Aretaeus and Aetius. Aretaeus was a very popular writer among
the Greeks in all ages, but he was not translated into Latin, and was
unknown in the West until the middle of the sixteenth century.[95] He is
philologically interesting as still using the Ionic dialect.
[95] First Latin edition Venice, 1552; first Greek edition Paris,
1554.
There remains the huge overshadowing figure of Galen. The enormous mass
of the surviving work of this man, the dictator of medicine until the
revival of learning and beyond, tends to throw out of perspective the
whole of Greek medical records. The works of Galen alone form about half
of the mass of surviving Greek medical writings, and occupy, in the
standard edition, twenty-two thick, closely-printed volumes. These cover
every department of medicine, anatomy, physiology, pathology, medical
theory, therapeutics, as well as clinical medicine and surgery. In style
they are verbose and heavy and very frequently polemical. They are
saturated with a teleology which, at times, becomes excessively tedious.
In the anatomical works, masses of teleological explanation dilute the
account of often imperfectly described structures. Yet to this element
we owe the preservation of the mass of Galen's works, for his intensely
teleological point of view appealed to the theological bias both of
Western Christianity and of Eastern Islam. Intolerable as literature,
his works are a valuable treasure house of medical knowledge and
experience, custom, tradition, and history.
As in the case of the Hippocratic corpus, so in the case of the Galenic
corpus we are dealing to some extent with material from various
sources. In the case of Galen, however, we have a good standard of
genuineness, for he has left us a list of his books which can be checked
off against those which we actually possess. The general standpoint of
the Galenic is not unlike that of the Hippocratic writings, but the
noble vision of the lofty-minded, pure-souled physician has utterly
passed away. In his place we have an acute, honest, very contentious
fellow, bristling with energy and of prodigious industry, not unkindly,
but loving strife, a thoroughly 'aggressive' character. He loves truth,
but he loves argument quite as much. The value of his philosophical
writings, of which some have survived, cannot be discussed here, but it
is evident that he is frequently satisfied with purely verbal
explanations. An ingenious physiologist, a born experimenter, an
excellent anatomist and eager to improve, possessing a good knowledge of
the human skeleton and an accurate acquaintance with the internal parts
so far as this can be derived from a most industrious devotion to
dissection of animals, equipped with all the learning of the schools of
Pergamon, Smyrna, and Alexandria, and rich with the experience of a vast
practice at Rome, Galen is essentially an 'efficient' man. He has the
grace to acknowledge constantly and repeatedly his indebtedness to the
Hippocratic writings. Such was the man whose remains, along with the
Hippocratic collection, formed the main medical legacy of Greece to the
Western world.
Some of Galen's works are mere drug lists, little superior to those of
Dioscorides;[96] with the depression of the intelligence that
corresponded with the break up of the Roman Empire, it was these that
were chiefly seized on and distributed in the West. Attractive too to
the debased intellect of the late Roman world were certain spurious,
superstitious, and astrological works that circulated in the name of
Galen and Hippocrates.[97] The Greek medical writers after Galen were
but his imitators and abstractors, but through some of them Galen's
works reached the West at a very early period in the Middle Ages. Such
abstractors who were early translated into Latin were Oribasius
(325-403), Paul of Aegina (625-690), and Alexander of Tralles (525-605).
Of the best and most scientific of Galen's works the Middle Ages knew
little or nothing.
[96] e. g. περι κρασεως και δυναμεως των ἁπαντων φαρμακων {peri
kraseôs kai dynameôs tôn hapantôn pharmakôn} and the φαρμακα
{pharmaka}.
[97] e. g. _De dinamidiis Galeni_, _Secreta Hippocratis_ and many
astrological tracts.
Later Galen and Hippocrates became a little more accessible, not by
translation from the Greek, but by translation from the Arabic of a
Syriac version. The first work to be so rendered was a version of
_Aphorisms_ of Hippocrates which, however, as we have seen, were already
available in Latin dress, together with the Hippocratic _Regimen in
acute diseases_, and certain works of Galen as corruptly interpreted by
Isaac Judaeus. These were rendered from Arabic into Latin by
Constantine, an African adventurer who became a monk at Monte Cassino
and died there in 1087. Constantine was a wretched craftsman with an
imperfect knowledge of both Arabic and Latin. More effective was the
great twelfth-century translator from the Arabic, Gerard of Cremona
(died 1185), who turned many medical works into Latin from Arabic, and
who was followed by a whole host of imitators. Yet more important for
the advance of medicine, however, was the learned revival of the
thirteenth century. In the main that revival was based on translations
from Arabic, but a certain number of works were also rendered direct
from the Greek. During the thirteenth century Aristotle's scientific
works began to be treated in this way, but more important for the course
of medicine were those of Galen, and they had to wait till the following
century. The long treatise of Galen, περι χρειας των εν ανθρωπου σωματι
μοριων {peri chreias tôn en anthrôpou sômati moriôn}, _On the uses of
the bodily parts in man_, was translated from the Greek into Latin by
Nicholas of Reggio in the earlier part of the fourteenth century. This
work, with all its defects, was by far the best account of the human
body then available. Many manuscripts of the Latin version have
survived, and it was translated into several vernaculars, including
English, and profoundly influenced surgery. The rendering into Latin of
this treatise, and its wide distribution, may be regarded as the
starting-point of modern scientific medicine. Its appearance is moreover
a part of the phenomenon of the revived interest in dissection which had
begun to be practised in the Universities in the thirteenth century,[98]
and was a generally accepted discipline in the fourteenth and
fifteenth.[99]
[98] Dissection of animals was practised at Salerno as early as the
eleventh century.
[99] The sources of the anatomical knowledge of the Middle Ages are
discussed in detail in the following works: R. R. von Töply,
_Studien zur Geschichte der Anatomie im Mittelalter_, Vienna, 1898;
K. Sudhoff, _Tradition und Naturbeobachtung_, Leipzig, 1907; and
also numerous articles in the _Archiv für Geschichte der Medizin und
Naturwissenschaften_; Charles Singer, 'A Study in Early Renaissance
Anatomy', in _Studies in the History and Method of Science_, vol. i,
Oxford, 1917.
Until the end of the fifteenth century progress in anatomy was almost
imperceptible. During the fifteenth century more Galenic and Hippocratic
texts were recovered and gradually turned into Latin, but still without
vitally affecting the course of Anatomy. The actual printing of
collected editions of Hippocrates and Galen came rather late, for the
debased taste of the Renaissance physicians continued to prefer
Dioscorides and the Arabs, of whom numerous editions appeared, so that
medicine made no advance corresponding to the progress of scholarship.
The Hippocratic works were first printed in 1525, and an isolated
edition of the inferior Galen in 1490, but the real advance in Medicine
was not made by direct study of these works. So long as they were
treated in the old scholastic spirit such works were of no more value
than those of the Arabists or others inherited from the Middle Ages.
Even Hippocrates can be spoilt by a commentary, and it was not until the
investigator began actually to compare his own observations with those
of Hippocrates and Galen that the real value of these works became
apparent. The department in which this happened first was Anatomy, and
such revolutionaries as Leonardo da Vinci (1452-1518), who never
published, and Vesalius (1514-1564), whose great work appeared in 1543,
were really basing their work on Galen, though they were much occupied
in proving Galen's errors. Antonio Benivieni (died 1502), an eager
prophet of the new spirit, revived the Hippocratic tradition by actually
collecting notes of a few cases with accompanying records of deaths and
post-mortem findings, among which it is interesting to observe a case of
appendicitis.[100] His example was occasionally followed during the
sixteenth century, as for instance, by the Portuguese Jewish physician
Amatus Lusitanus (1511-_c._ 1562), who printed no fewer than seven
hundred cases; but the real revival of the Hippocratic tradition came in
the next century with Sydenham (1624-1689) and Boerhaave (1668-1738),
who were consciously working on the Hippocratic basis and endeavouring
to extend the Hippocratic experience.
[100] Benivieni's notes were published posthumously. Some of the
spurious Greek works of the Hippocratic collection have also case
notes.
Lastly surgery came to profit by the revival. The greatest of the
sixteenth-century surgeons, the lovable and loving Ambroise Paré
(1510-1590), though he was, as he himself humbly confessed, an ignorant
man knowing neither Latin nor Greek, can be shown to have derived much
from the works of antiquity, which were circulating in translation in
his day and were thus filtering down to the unlearned.
Texts of Hippocrates and of Galen had formed an integral part in the
medical instruction of the universities from their commencement in the
thirteenth century. The first Greek text of the _Aphorisms_ of
Hippocrates appeared in 1532, edited by no less a hand than that of
François Rabelais. With the further recovery of the Greek texts and
preparation of better translations, these became almost the sole mode of
instruction during the fifteenth and sixteenth centuries. The
translators became legion and their competence varied. One highly
skilled translator, however, is of special interest to English readers.
Thomas Linacre (1460?-1524), Physician to Henry VIII, Tutor to the
Princess Mary, founder and first president of the College of
Physicians, a benefactor of both the ancient Universities and one of the
earliest, ablest, most typical, and most exasperating of the English
humanists, spent much energy on this work of translation for which his
abilities peculiarly fitted him. He was responsible for no less than six
important works of Galen, of which one, the _De temperamentis et de
inaequali intemperie_, printed at Cambridge in 1521, was among the
earliest books impressed in that town and is said to be the first
printed in England for which Greek types were used. It has been honoured
by reproduction in facsimile in modern times. Such works as these,
purely literary efforts, had great vogue for a century and more, and
were much in use in the Universities. These humanistic products
sometimes produced, among the advocates of the new scientific method, a
degree of fury which was only rivalled by that of some of the humanists
themselves towards the translators from the Arabic. But these are now
dead fires. As the clinical and scientific methods of teaching gained
ground, textual studies receded in medical education, as Hippocrates and
Galen themselves would have wished them to recede.
The texts of Hippocrates and Galen have now ceased to occupy a place in
any medical curriculum. Yet all who know these writings, know too, not
only that their spirit is still with us, but that the works themselves
form the background of modern practice, and that their very phraseology
is still in use at the bedside. Modern medicine may be truly described
as in essence a creation of the Greeks. To realize the nature of our
medical system, some knowledge of its Greek sources is essential. It
would indeed be a bad day for medicine if ever this debt to the Greeks
were forgotten, and the loss would be at least as much ethical as
intellectual. But there is happily no fear of this, for the figure and
spirit of Hippocrates are more real and living to-day than they have
been since the great collapse of the Greek scientific intellect in the
third and fourth centuries of the Christian era.