Chapter IV: Part 4

Just as the Cnidians by dividing up diseases according to symptoms over-emphasized diagnosis and over-elaborated treatment, so the Coans laid very great force on prognosis and adopted therefore a largely expectant attitude towards diseases. Both Cnidian and Coan physicians were held together by a common bond which was, historically if not actually, related to temple worship. Physicians leagued together in the name of a god, as were the Asclepiadae, might escape, and did escape, the baser theurgic elements of temple medicine. Of these they were as devoid as a modern Catholic physician might be expected to be free from the absurdities of Lourdes. But the extreme cult of prognosis among the Coans may not improbably be traced back to the medical lore of the temple soothsayers whose divine omens were replaced by indications of a physical nature in the patient himself.[105] We are tempted too to link it with that process of astronomical and astrological prognosis practised in the Mesopotamian civilizations from which Ionia imitated and derived so much. Religion had thus the same relation to medicine that it would have with a modern ‘religious’ medical man as suggesting the motive and determining the general direction of his practice though without influence on the details and method.

[105] There is a discussion of the relation of the Asclepiadae to temple practice in an article by E. T. Withington, ‘The Asclepiadae and the Priest of Asclepius,’ in _Studies in the History and Method of Science_, edited by Charles Singer, vol. ii, Oxford, 1921.

During the development of the Coan medical school along these lines in the sixth and fifth centuries, there was going on a most remarkable movement at the very other extreme of the Greek world. Into the course and general importance of Sicilian philosophy it is not our place to enter, but that extraordinary movement was not without its repercussion on medical theory and practice. Very important in this direction was Empedocles of Agrigentum (_c._ 500-_c._ 430 B. C.). His view that the blood is the seat of the ‘innate heat’, ἔμφυτον θερμόν, he took from folk belief—‘the blood is the life’—and this innate heat he closely identified with soul. More profitable was his doctrine that breathing takes place not only through what are now known as the respiratory passages but also through the pores of the skin. His teaching led to a belief in the heart as the centre of the vascular system and the chief organ of the ‘pneuma’ which was distributed by the blood vessels. This pneuma was equivalent to both soul and life, but it was something more. It was identified with air and breath, and the pneuma could be seen to rise as shimmering steam from the shed blood of the sacrificial victim—for was not the blood its natural home? There was a pneuma, too, that interpenetrated the universe around us and gave it those qualities of life that it was felt to possess. Anaximenes (_c._ 610-_c._ 545 B. C.), an Ionian predecessor of Empedocles, may be said to have defined for us these functions of the pneuma; οῖον ἡ ψυχὴ ἡ ἡμετέρα ἀὴρ οῧσα συγκρατεί ἡμᾶς, ὅλον τὸν κόσμον πνεῦμα καὶ ἀὴρ περιέχει ‘As our soul, being air, sustains us, so pneuma and air pervade the whole universe’;[106] but it is the speculation of Empedocles himself that came to be regarded as the basis of the Pneumatic School in Medicine which had later very important developments.

[106] The works of Anaximenes are lost. This phrase of his, however, is preserved by the later writer Aetios.

Another early member of the Western school who made important contributions to medical doctrine—in which relation alone we need consider him—was Pythagoras of Samos (_c._ 580-_c._ 490 B. C.). For him number, as the purest conception, formed the basis of philosophy. Unity was the symbol of perfection and corresponded to God Himself. The material universe was represented by 2, and was divided by the number 12, whence we have 3 worlds and 4 spheres. These in turn, according at least to the later Pythagoreans, give rise to the four elements, earth, air, fire, and water—a primary doctrine of medicine and of science derived perhaps from ancient Egypt and surviving for more than two millennia. The Pythagoreans taught, too, of the existence of an animal soul, an emanation of the soul of the universe. In all this we may distinguish the germ of that doctrine of the relation of man and universe, microcosm and macrocosm, which, suppressed as irrelevant in the Hippocratic works, reappears in the Platonic and especially in the Neoplatonic writings, and forms a very important dogma in later medicine.

A pupil of Pythagoras and an older contemporary of Empedocles was Alcmaeon of Croton (_c._ 500 B. C.), who began to construct a positive basis for medical science by the practice of dissection of animals, and discovered the optic nerves and the Eustachian tubes. He even extended his researches to Embryology, describing the head of the foetus as the first part to be developed—a justifiable deduction from appearances. Alcmaeon introduced also the doctrine that health depends on harmony, disease on discord of the elements within the body. Curiosity as to the distribution of the vessels was excited by Empedocles and Alcmaeon and led to further dissection, and Alcmaeon’s pupils Acron (_c._ 480 B. C.) and Pausanias (_c._ 480 B. C.), and the later Philistion of Lokri,[107] the contemporary of Plato, all made anatomical investigations.

[107] For the work of these physicians see especially M. Wellmann, _Fragmentsammlung der griechischen Aerzte_, Bd. I, Berlin, 1901.

The views of Empedocles, and especially his doctrine that regarded the heart as the main site of the pneuma, though rejected by the Coan school as a whole, were not without influence on Ionia. Diogenes of Apollonia, the philosopher of pneumatism, a late fifth century writer who must have been contemporary with Hippocrates the Great, himself made an investigation of the blood vessels; and the influence of the same school may be traced in a little work περὶ καρδίης, _On the heart_, which is the best anatomical treatise of the Hippocratic Collection. This work describes the aorta and the pulmonary artery as well as the three valves at the root of each of the great vessels, and it speaks of experiments to test their validity. It treats of the pericardium and of the pericardial fluid and perhaps of the musculi papillares, and contrasts the thickness of the walls of right and left ventricles. The author considers that the left ventricle is empty of blood—as indeed it is after death—and is the source of the innate heat and of the absolute intelligence. These views fit in with the doctrines of Empedocles, so that we may perhaps even venture to regard this work as a surviving document of the Sicilian school. It is interesting to observe that we have here the first hint of human dissection, for the author tells us that the hearts of animals may be compared to that of man. The distinction of having been the first to write on human anatomy, as such, belongs however, probably to a later writer, Diocles, son of Archidamus of Carystus, who lived in the fourth century B. C.[108]

[108] Galen, περὶ ἀνατομικῶν ἐγχειρήσεων, _On anatomical preparations_, § 1, K. II, p. 282.

We may now turn to the Hippocratic Corpus as a whole. This collection consists of about 60 or 70 separate works, written at various periods and in various states of preservation. At best only a very small proportion of them can be attributed to Hippocrates, but the discussion of the general question of the ‘genuineness’ of the works is now admitted to be futile, for it is certain that we have no criteria whatever to determine whether or no a particular work be from the pen of the Father of Medicine, and the most we can ever say of such a treatise is that it appears to be of his school and in his spirit. Yet among the great gifts of this collection to our time and to all time are two which stand out above all others, the picture of a man, and the picture of a method.

The man is Hippocrates himself. Of the actual details of his life we 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.

British Museum, second or third century B. C.]

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.’

‘A man had an abdominal abscess. He saw a vision, and
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).

Copied from a pre-Christian original

Fig. 3.

REDUCING DISLOCATED SHOULDER]

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:

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.)
]

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.