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.’[120]
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 ἐγκοίμησις, _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.[121] 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.
[120] 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).
[121] 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.[122] 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[123] (see Figs. 3, 4).
[122] 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.
[123] This famous manuscript is known as Laurentian, Plutarch 74, 7,
and its figures have been reproduced by H. Schöne, _Apollonius von
Kitium_, Leipzig, 1896.
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 notebook κατ’ ἰητρεῖον,
_Concerning the Surgery_, or the more elaborate treatise περὶ ἰητροῦ,
_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 Ionic origin which is of the fifth century and therefore about
contemporary with Hippocrates himself (see fig. 5). There are also
several beautiful representations on vases of the actual processes of
bandaging (fig. 6).
[Illustration: From MS. of APOLLONIUS OF KITIUM, of Ninth Century
Copied from a pre-Christian original
Fig. 3.
REDUCING DISLOCATED SHOULDER]
[Illustration: Fig. 4.
REDUCING DISLOCATED JAW]
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:
[Illustration: FIG. 5. A GREEK CLINIC OF ABOUT 400 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 Vᵉ 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: ΣΟΣΙΑΣ ΕΠΟΙΗΣΕΝ
FIG. 6. A kylix from the Berlin Museum of about
490 B. C. It bears the inscription ΣΟΣΙΑΣ ΕΠΟΙΗΣΕΝ,
_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!
]
‘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.’[124]
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.’[125]
[124] 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.’
[125] The extreme of treatment refers in the original to the extreme
restriction of diet, ἐς ἀκριβείην, but the meaning of the Aphorism has
always been taken as more generalized.
‘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.’
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.
‘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 περὶ νούσων, _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.[126] 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.