_Hippocratic Collection_ were taught in the medical schools in a spirit
that was anything but that of Hippocrates. Gradually, however, a better
understanding crept into men’s minds. The spirit of those writings and
their methods and observations came now rightly to be exalted above
the works themselves. The works themselves were wisely dropped from
the medical curriculum. They are no longer used in any medical school.
But if we turn again to contemplate the Hippocratic treatises, we may
recognize in them the modern process of careful record of data and
cautious inference from them--that collation of experience from various
sources obtained by various methods with which we are now so familiar.
We may even see in full force the actual process of case-taking, bed
side instruction and clinical lecture. These methods are practised
much in the way in which we know them, and are set forth with a
conciseness and beauty of language and a loftiness of ethical tone
which have not since been surpassed. To such a collection medical men
must always return. No part of it is more impressive than the so-called
_Hippocratic Oath_.
[Illustration: FIG. 8. A GREEK CLINIC OF ABOUT 400 B.C., when
Hippocrates was in his prime. From a vase painting.
The physician sits in the center. He holds a lancet in his right
hand, seizes the patient’s right arm with his left and is bleeding
him from a vein at the bend of the elbow. The blood falls into a
large basin on the floor. Above the physician’s head are suspended
three cupping vessels, shaped thus:
[Illustration]
To the right sits a patient awaiting his turn to interview the
physician. His left arm is bandaged. Behind this patient stands a
figure smelling a flower as a preventive against infection. Behind the
physician stands a man wounded in the left leg, which is bandaged.
Back to back to this last figure is a dwarf with a disproportionately
large head. His body exhibits deformities typical of the developmental
disease now known as _Achondroplasia_. In addition to his other
deformities, we note that his muscular body is hairy, and that the
bridge of his nose is 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.]
The _Hippocratic Oath_, in its present form, is of very much later date
than Hippocrates. Yet parts of it may be even earlier than he, and
some suggestion of the Oath is, perhaps, to be seen in the contents of
Egyptian papyri of the second millennium B.C. It need hardly be said
that the late date of the _Oath_ by no means removes the interest of
this grand ethical monument. No passage better reflects the spirit of
the Hippocratic physicians. The oath is clearly designed for a youth
entering on his apprenticeship to such a one.
‘I swear by Apollo the healer, invoking all the gods and
goddesses to be my witnesses, that I will fulfil this Oath and
this written Covenant to the best of my ability and judgement.
‘I will look upon him who shall have taught me this Art even as
one of my own parents. I will share my substance with him, and
I will supply his necessities, if he be in need. I will regard
his offspring even as my own brethren, and I will teach them
this Art, if they would learn it, without fee or covenant. I
will impart this Art by precept, by lecture and by every mode
of teaching, not only to my own sons but to the sons of him who
has taught me, and to disciples bound by covenant and oath,
according to the Law of Medicine.
‘The regimen I adopt shall be for the benefit of the patients
according to my ability and judgement, and not for their hurt
or for any wrong. I will give no deadly drug to any, though
it be asked of me, nor will I counsel such, and especially I
will not aid a woman to procure abortion. Whatsoever house I
enter, there will I go for the benefit of the sick, refraining
from all wrongdoing or corruption, and especially from any act
of seduction, of male or female, of bond or free. Whatsoever
things I see or hear concerning the life of men, in my
attendance on the sick or even apart therefrom, which ought not
to be noised abroad, I will keep silence thereon, counting such
things to be as sacred secrets. Pure and holy will I keep my
Life and my Art.
‘If I fulfil this Oath and confound it not, be it mine to enjoy
Life and Art alike, with good repute among all men at all
times. If I transgress and violate my oath, may the reverse be
my lot.’
§ 3. _Hippocratic Practice._
Among the most remarkable features of the _Hippocratic Collection_ is
the feeling of contact with the patient which most of its works convey.
This is naturally a special characteristic of the surgical works. One
treatise, which bears the title _On wounds of the head_, has always
drawn attention as bespeaking especial ingenuity and experience. The
description of trephining is of peculiar interest, because the practice
was known in prehistoric times and is still employed by savage and
semi-civilized peoples. The process recommended for cases of fracture
of the skull and injury to the underlying structures resembles, in
many details, the modern surgical procedure.
‘When it is necessary to trephine a patient, make up your
mind and judge as follows. If you have had charge of the case
from the first, do not trephine the bone down to the membrane
at once, for it is not desirable that the membrane be long
exposed, lest it end by becoming rotten and fungous. There is
also another danger, to wit that you wound the membrane with
the saw during the operation, if you try to remove the bone by
trephining immediately down to the membrane. Therefore, when
the bone is almost sawn through and is already loose, cease
trephining and allow the bone to come away of itself. While
trephining, often remove the instrument and dip it in cold
water. If you do not do this, the trephine, becoming heated by
the circular motion and heating and drying the bone, may burn
it and cause an unduly large piece of the bone round the sawing
to come away.’
[Illustration: FIG. 9. INSTRUMENTS USED BY GREEK SURGEONS.
_a_ Simplest form of trephine. It has central pin and serrated edge.
The point is held against the skull and the staff twirled between
the hands. (Cf. Fig. 112.) It could also be rotated by a crosspiece
and thong, as in Fig. 22. _b_ Case of scalpels from a bas-relief in
the temple of Aesculapius on the Acropolis at Athens. _c_ Trephining
instrument of type still in use. The carpenter’s ‘center bit’ was known
in antiquity, and was probably adapted to the trephine. _a_ and _c_
represent sixteenth-century instruments of ancient type. No ancient
trephines of Greek origin are known, though a specimen has come down to
us from Mesopotamia, see Fig. 3.
]
So much for a normal case which comes to the physician’s hands directly
after the accident. But in less fortunate cases he is not called in so
early, and the wound suppurates before he can bring his Art to bear
upon it. In such a case he is advised:
‘Saw the bone immediately to the membrane with a serrated
trephine (Fig. 9, _a_ and _c_), frequently removing the
trephine and testing with the probe all round along the track,
for the bone is sawn through much more quickly if it is already
suppurating and penetrated by the pus. The bone, however, often
happens to be thin in places. Therefore be on your guard not to
apply the trephine at random, but fix it in the bone where it
appears thickest, frequently making an examination and trying
to raise the bone by moving it. And after removing it, continue
such treatment as may appear advantageous to the wound,
according to circumstances.’
Among the works of the _Hippocratic Collection_ is a lecture note-book
known by the title _Concerning the things in the Surgery_. It is
written in very abbreviated style and consists of mere headings.
Nevertheless, our attention is arrested by its startling modernness,
when we read such a category as this:
‘Operative requisites in the surgery: the patient; the
operator; assistants; instruments; the light, where and how
placed; the patient’s person and apparatus. The operator,
whether seated or standing, should be placed conveniently to
the part being operated upon and to the light. Each of the two
kinds of light, ordinary or artificial, may be used in two
ways, direct or oblique.’
Or again, such details as:
‘The nails [of the operator] neither to exceed nor come short
of the finger-tips. Practise using the finger-ends. Practise
all operations with each hand and with both together, your
object being to attain ability, speed, painlessness, elegance
and readiness. Let those who look after the patient present the
part for operation as you want it, and hold fast the rest of
the body so as to be all steady, keeping silence and obeying
their superior.’
Are we not here reminded of an up-to-date operator and operating
theater?
In the _Hippocratic Collection_ the physician attends cases of every
type, and does not refuse to do his best for a case because the use
of an instrument is demanded. He is thus no ‘specialist’. But the
mass of his practice lay with cases to which instrumental treatment
was inapplicable. In cases in which surgical intervention was not
justified the Hippocratic physician adopted for the most part what is
called an ‘expectant’ line of treatment. Realizing that, in general,
the tendency of the body is to recover, he contented himself with
‘waiting on Nature’. This does not by any means imply that he was
helpless, for much could be done by nursing, regimen and diet to aid
the patient in that conflict which he alone must fight out. For the
conduct of that great battle wise and useful directions are recorded.
But believing in _the healing power of Nature_--the famous phrase is
used in the Hippocratic writings--the physician was none too eager to
administer drugs. In the state of knowledge of the day this reluctance
was well-judged. Nevertheless the Hippocratic drugs, though neither
numerous nor complex, were some of them very efficient, and their
judicious if reluctant use at the right juncture saved many a life.
_The Aphorisms_ is the most famous book with which the name of
Hippocrates is associated, and is as likely as any of the Collection
to be by Hippocrates himself. It consists of a series of very brief
generalizations. Many of these have been confirmed by the clinical
experience of later ages. Some have passed into medical commonplaces,
others have become popular proverbs. The style of the work suggests an
aged physician reflecting on the experience of a lifetime. Among modern
medical writings its closest analogue is perhaps the _Commentaries_ of
the great English physician, William Heberden the elder (1710-1801),
which was commenced by him after the age of seventy, occupied the last
twenty years of his life, contained a summary of the whole of his
vast experience, and was published by his son after his death. If the
_Aphorisms_ is similarly a work of the old age of Hippocrates it may be
dated about 380 B.C. A few extracts give a good idea of the nature of
the book.
‘Life is short and Art is long; the Crisis is fleeting,
Experiment risky, Decision difficult. Not only must the
physician be ready to do his duty, but the patient, the
attendants, the external circumstances must conduce to the
cure.’
‘Old persons bear fasting most readily, next adults, and young
people yet less; least of all children, and of these least
again those who are particularly lively.’
‘If in any illness sleep does harm, it is a symptom of deadly
import.’
‘When sleep puts an end to delirium, it is a good sign.’
‘Weariness without cause indicates disease.’
‘If there be a painful affection in any part of the body, and
yet no suffering, there is mental disorder.’
‘To eat heartily after a long illness without putting on flesh
is a bad portent.’
‘Food or drink slightly inferior in itself, but more pleasant,
should be preferred to that better itself, but less pleasant.’
‘The old have fewer illnesses than the young, but if any become
chronic with them they generally carry it with them to the
grave.’
‘Those naturally very fat are more liable to sudden death than
the thin.’
‘The dry seasons are more healthy than the rainy, and attended
by less mortality.’
‘Cold sweats in conjunction with an acute fever indicate death,
but with a milder fever only prolonged sickness.’
‘Convulsions supervening on a wound are deadly.’ (Tetanus, cp.
p. 267.)
‘Those attacked by tetanus either die within four days, or if
they get through these they recover’ (compare pp. 257 and 267).
‘Phthisis comes on mostly from eighteen to thirty-five years of
age.’
‘It is fatal for a woman in pregnancy to be attacked by one of
the acute diseases.’
‘In cases of jaundice, hardening of the liver is a bad sign.’
‘We should observe the appearance of the eyes in sleep. If any
of the white show through the eyelids when closing, this is a
bad sign and very dangerous, unless it be due to diarrhoea or
taking a purgative.’
‘An attack of delirium with laughter is less dangerous than
with despondency.’
‘Apoplexy is commonest between the ages of forty and sixty.’
‘If you give the same nutriment to a patient in a fever and to
a person in health, the patient’s disease is aggravated by what
adds strength to the healthy man.’
The chief clinical achievement of the _Hippocratic Collection_ lies
in the descriptions of actual cases. These descriptions are not only
without parallel during nearly 2,000 years, but they are models of
what succinct clinical records should be. They are clear and short,
they give all the leading features and yet they show no attempt to
prejudge the importance of any particular feature. The records of
these cases illustrate the Greek genius for seizing the essential. The
writer does not betray 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 honesty in which these
men worked that in the great majority of the cases they record death
ensued. Two of these remarkable descriptions 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_, died.’
This was 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 event in 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 reason 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.’
We have here a description of low muttering delirium, a common end of
continued fevers, as, for instance, Typhoid. It resembles the condition
known to physicians 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 slowly 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. In our own time 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_. We read
of one ‘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’.
Immense and, as some may think, overwhelming importance is laid by the
Hippocratic writings upon the art of ‘Prognosis’, that is of predicting
the course which the disease will take. The work to which the title
_Prognostics_ is attached represents a very lofty standard of practice.
We quote from it a description of the signs of death to which the
name of _Hippocratic facies_ has become attached. It is imitated by
Shakespeare in his description of the death of Falstaff in Henry V
(_Act II, Scene 3_).
‘You should observe thus in acute diseases; first the
countenance of the patient, if it be like those of persons
in health, and especially if it be like itself, for this is
best of all. But the opposite are the worst, such as these:
a sharp nose, hollow eyes, collapsed temples; the ears cold,
contracted, and their lobes turned out; the skin about the
forehead rough, stretched and parched; the colour of the face
greenish, dusky, livid or leaden.
‘If the countenance be such at the beginning of the disease,
and if this cannot be accounted for by the symptoms, inquiry
must be made whether the patient has been sleepless, whether
his bowels have been very loose, or whether he has wanted food.
If any of these be confessed, the danger is to be reckoned so
far the less, and it will become obvious in a day and night
whether or no the appearance come of these. But if no such
cause exist and if the symptoms do not subside in this time, be
it known for certain that the end is at hand.’
These glimpses will give some idea of Rational Medicine in the making.
In the fourth century B.C. Medicine emerges as a definite part of the
scientific consciousness. Rational Medicine is now in being.
§ 4. _Aristotle._
During the fourth century B.C. there lived and worked one whose thought
has stamped itself on the whole subsequent course of the biological and
medical sciences, and indeed of all Science.
Aristotle (384-322 B.C.) was a provincial Greek and son of a Macedonian
physician. At seventeen he became a pupil of Plato at Athens. After
Plato’s death in 347 Aristotle crossed the Aegean to reside in Asia
Minor. The main part of his biological observations was made during
his stay there. In 342 B.C., at the request of King Philip of Macedon,
Aristotle became tutor to Philip’s son, Alexander the Great. He
remained in Macedon for seven years. About 336, when Alexander departed
for the invasion of Asia, Aristotle returned to Athens, where he taught
for the rest of his life. He died in 322 B.C., a few months after his
pupil Alexander.
Aristotle was the great codifier of ancient Science. On him all
subsequent biological development, including that of modern times,
is surely based. In his wonderful biological works, which are still
read by naturalists, he discusses many problems current to this very
day. He laid the basis of the doctrine of Organic Evolution in his
teaching concerning the _Scala Naturae_ ‘Ladder of Nature’ (Fig. 10).
He developed coherent theories of Generation and Heredity. He founded
Comparative Anatomy and he dissected many animals. He did not, however,
anatomize the human body.
[Illustration: FIG. 10. The _Ladder of Nature_ according to Aristotle.]
Aristotle gave good descriptions of some organs, regarded from the
standpoint of Comparative Anatomy. These descriptions he sometimes
illustrated by drawings,
the first anatomical figures of which we have a record. In some cases
these drawings can be restored with confidence. Thus, he gave an
account of the uterus, the nomenclature of which has been retained in
more or less modified form to our own time (Fig. 11). Among the best
anatomical descriptions given by Aristotle is that of the ruminant
stomach. Perhaps his most extraordinary anatomical feat is his account
of the development of the dogfish _Mustelus laevis_, which he showed
was attached to its mother’s womb in a way very similar to the embryo
of a mammal (Fig. 12). This raised the admiration of the greatest
modern morphologist, Johannes Müller (1807-58, pp. 211-13), and would
in itself be sufficient to establish the claim of Aristotle to a place
in the front rank of observing naturalists. Aristotle gave fairly
accurate descriptions of the branches of the great veins and of
the superficial vessels of the arm of mammals. He realized that the
arteries are usually accompanied by veins. He described the generative
and digestive organs of cephalopod Molluscs, and many other parts of
many other animals.
[Illustration:
FIG. 11. The womb with the names of its parts as given by Aristotle.
These names remain, in various forms, in modern anatomy.
FIG. 12. Embryo dogfish, _Mustelus laevis_, after Johannes Müller. The
little creature is shown attached to the wall of its mother’s womb,
somewhat after the manner of a mammal.
]
Something should be said of the errors of Aristotle. Though an
excellent Naturalist, he was in general much weaker in Physiology.
Thus, he made no proper distinction between arteries and veins. He
failed to trace any adequate relations between the sense organs, the
nerves, and the brain. His refusal to attach great importance to
the brain is remarkable. Primacy he placed with the heart, which he
regarded also as the seat of the intelligence. This was contrary not
only to the medical opinion of his day, but also to the popular view,
voiced, for instance, by Aristophanes in his play _The Clouds_, written
about 400 B.C., where we read of a man who had _concussion of the
brain_. Moreover, Aristotle’s teacher Plato placed the seat of thought
and feeling in the brain. From all we know of Aristotle, it seems
probable that he did not take up this attitude without evidence. It
seems likely that he had experimented on the brain and found it devoid
of sensation. Hence his view, opposed to current belief, that it is
not associated with thought. Aristotle regarded the brain simply as an
agent for cooling the heart, and preventing it from being over-heated.
This cooling process, he considered, was effected by the secretion of
_phlegm_ (_pituita_), an idea still preserved in our anatomical term
the _pituitary body_.
The views of Aristotle have had a vast influence in determining
the direction of medical thought. For more than two thousand years
Aristotelian philosophy, in more or less corrupted form, constituted
the main intellectual food of mankind. Without some knowledge of the
biological verdicts of Aristotle, it is impossible to understand the
course taken by Rational Medicine. The influence of Aristotle is
specially evident in certain basic biological conceptions.
The problem of the nature of Generation is one in which Aristotle
never ceased to take an interest. Among the methods by which he sought
to solve it was embryological investigation. His most important
embryological researches were made upon the chick. His choice was most
fortunate, and the chick has remained, to this day, the classical
subject of embryological research. Aristotle asserts that the first
signs of life in the hen’s egg are noticeable on the third day, the
heart being visible as a palpitating blood-spot. As it develops, two
meandering blood-vessels extend to the surrounding tunics. A little
later, he observes, the body becomes distinguishable, at first very
small and white, the head being clearly distinguished and the eyes very
large (Figs. 46-7, p. 117). To follow the main features of the later
stages was a comparatively easy task.