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 περὶ διαφορᾶς πυρετῶν, _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.
[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.]
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.[127] 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.
[127] 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 (κάλαμος ῷ
γράφομεν), because it seemed to him, as Galen tells us, to resemble
the pens then in use in Alexandria.[128] We still use, too, his term
_duodenum_ (δωδεκαδάκτυλος ἔκφυσις = twelve-finger extension), for as
Galen assures us, Herophilus ‘so named the first part of the intestine
before it is rolled into folds‘.[129] 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.
[128] Galen, περὶ ἀνατομικῶν ἐγχειρήσεων, _On anatomical preparations_,
ix. 5 (last sentence).
[129] Galen, περὶ φλεβῶν καὶ ἀρτηριων ανατομῆς, _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.’[130] 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.[131]
[130] 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.
[131] 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 περὶ αἰτιῶν,
_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’.[132] 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.
[132] 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.
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.
[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.]
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.[133] 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.[134] 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.[135]
[133] Leyden Voss 4ᵒ 9^* of the sixth century is a fragment of this
work.
[134] V. Rose, _Sorani Ephesii vetus translatio Latina cum additis
Graeci textus reliquiis_, Leipzig, 1882; F. Weindler, _Geschichte der
gynäkologisch-anatomischen Abbildung_, Dresden, 1908.
[135] 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,
emphysema, 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.[136] He is philologically interesting as still using
the Ionic dialect.
[136] 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;[137] 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.[138] 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.
[137] e. g. περὶ κράσεως καὶ δυνάμεως τῶν ἁπάντων φαρμάκων and the
φάρμακα.
[138] e. g. _De dynamidiis Galeni_, _Secreta Hippocratis_ and many
astrological tracts.