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,[109] 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
Παραγγελίαι, _Precepts_:
ἢν γὰρ παρῆ φιλανθρωπίη πάρεστὶ καὶ φιλοτεχνίη
‘Where the love of man is, there also is love of the Art.’[110]
[109] _Historia animalium_, iii. 3, where it is ascribed to Polybus.
The same passage is, however, repeated twice in the Hippocratic
writings, viz. in the περὶ φύσιος ἀνθρώπου, _On the nature of man_,
Littré, vi. 58, and in the περὶ ὀστέων φύσιος, _On the nature of
bones_, Littré, ix. 174.
[110] Παραγγελίαι, § 6.
[Illustration: Fig. 1. HIPPOCRATES
British Museum, second or third century B. C.]
[Illustration: Fig. 2. ASCLEPIUS
British Museum, fourth century B. C.]
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. (See Fig. 1.)
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’:
‘I swear by Apollo the healer, and Asclepius, and Hygieia,
and All-heal (Panacea) and all the gods and goddesses ...
that, according to my ability and judgement, I will keep
this Oath and this stipulation—to reckon him who taught me
this Art as dear to me as those who bore me ... to look upon
his offspring as my own brothers, and to teach them this
Art, if they would learn it, without fee or stipulation. By
precept, lecture, and all other modes of instruction, I will
impart a knowledge of the Art to my own sons, and those of
my teacher, and to disciples bound by a stipulation and
oath according to the Law of Medicine, but to none other.
I will follow that system of regimen which, according to
my ability and judgement, I consider for the benefit of
my patients, and abstain from whatever is deleterious and
mischievous. I will give no deadly medicine to any one
if asked, nor suggest any such counsel; nor will I aid
a woman to produce abortion. With purity and holiness I
will pass my life and practise my Art.... Into whatever
houses I enter, I will go there for the benefit of the
sick, and will abstain from every act of mischief and
corruption; and above all from seduction.... Whatever in
my professional practice—or even not in connexion with
it—I see or hear in the lives of men which ought not to
be spoken of abroad, I will not divulge, deeming that
on such matters we should be silent. While I keep this
Oath unviolated, may it be granted me to enjoy life and
the practice of the Art, always respected among men, but
should I break or violate this Oath, may the reverse be my
lot.’
Respected equally throughout the ages by Arab, Jew, and Christian, the
oath remains the watchword of the profession of medicine.[111] 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.’[112]
[111] It must, however, be admitted that even in the Hippocratic
collection itself are cases of breach of the oath. Such, for instance,
is the induction of abortion related in περὶ φύσιος παιδίον, _On the
nature of the embryo_. There is evidence, however, that the author of
this work was not a medical practitioner.
[112] 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.’[113] 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:
[113] Kühlewein, i. 79, regards this as an interpolated passage.
‘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.’[114]
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’,[115] 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’.[116]
[114] Littré, ii. 112; Kühlewein, i. 79. The texts vary: Kühlewein is
followed except in the last sentence.
[115] Περὶ τέχνες, § 3.
[116] Περὶ νούσων α’, § 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.[117] 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.
[117] A reference to dissection in the περὶ ἄρθρων, _On the joints_, §
1, appears of 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 περὶ τόπων τῶν κατὰ
ἄνθρωπον, _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_, νούσων φύσεις ἰητροί, 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.[118] 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 show’s
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.’
[118] 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.[119] 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’.
[119] 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
Asklepius 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.’