Chapter XI: Book I: of the Metrica calculates the areas of triangles, (4)

'The regimen I adopt shall be for the benefit of the patients to
the best of my power and judgment, not for their injury or for any
wrongful purpose. I will not give a deadly drug to any one, though
it be asked of me, nor will I lead the way in such counsel; and
likewise I will not give a woman a pessary to procure abortion. But
I will keep my life and my art in purity and holiness. Whatsoever
house I enter, I will enter for the benefit of the sick, refraining
from all voluntary wrongdoing and corruption, especially seduction
of male or female, bond or free. Whatsoever things I see or hear
concerning the life of men, in my attendance on the sick or even
apart from my attendance, which ought not to be blabbed abroad, I
will keep silence on them, counting such things to be as religious
secrets.

'If I fulfil this oath and confound it not, be it mine to enjoy
life and art alike, with good repute among all men for all time to
come; but may the contrary befall me if I transgress and violate my
oath.'[69]

[69] Translation by Professor Arthur Platt.

Respected equally throughout the ages by Arab, Jew, and Christian, the oath remains the watchword of the profession of medicine.[70] 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.'[71]

[70] It must, however, be admitted that in the Hippocratic
collection are breaches of the oath, e. g. in the induction of
abortion related in περι φυσιος παιδιου {peri physios paidiou}.
There is evidence, however, that the author of this work was not a
medical practitioner.

[71] 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.'[72] 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:

'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.'[73]

[72] Kühlewein, i. 79, regards this as an interpolated passage.

[73] Littré, ii. 112; Kühlewein, i. 79. The texts vary: Kühlewein is
followed except in the last sentence.

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',[74] 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'.[75]

[74] Περι τεχνης {Peri technês}, § 3.

[75] Περι νουσων α' {Peri nousôn a'}, § 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.[76] 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.

[76] A reference to dissection in the περι αρθρων {peri arthrôn},
_On the joints_, § 1, appears to 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 περι τοπων των κατα ανθρωπον {peri topôn tôn kata anthrôpon}, _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_, νουσων φυσεις ιητροι {nousôn physeis iêtroi}, 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.[77] 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 shows 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.'

[77] 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.[78] 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'.

[78] 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 Asclepius 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.'[79]

[79] 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).

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 εγκοιμησις {enkoimêsis}, _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.[80] 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.

[80] 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.[81] 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[82] (see Figs. 3, 4).

[81] 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.

[82] This famous manuscript is known as Laurentian, Plutarch 74, 7,
and its figures have been reproduced by H. Schöne, _Apollonius von
Kitium_, Leipzig, 1896.

Fig. 3 REDUCING DISLOCATED SHOULDER

Fig. 4 REDUCING DISLOCATED JAW]

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 note-book κατ' ιητρειον {kat' iêtreion}, _Concerning the Surgery_, or the more elaborate treatise περι ιητρου {peri iêtrou}, _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 Attic origin of the earlier part of the fifth century, and, therefore, a generation before Hippocrates (see fig. 5). There are also several beautiful representations on vases of the actual processes of bandaging (fig. 6).

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 V^{e} 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.)]

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:

'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.'[83]

[83] 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.'

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.'[84]

'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.'

[84] The extreme of treatment refers in the original to the extreme
restriction of diet, ες ακριβειην {es akribeiên}, but the meaning of
the Aphorism has always been taken as more generalized.

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.

Inscription reads: 'Jason, also called Dekmos, the Acharnian, a physician', followed by his genealogy. By side of patient stands a cupping vessel.]

'We must attend to the appearances of the eyes in sleep as presented from below; for if a portion of the white be seen between the closing eyelids, and if this be not connected with diarrhœa or severe purging, it is a very bad and mortal symptom.' In this, the last Aphorism which we shall quote, we see the Hippocratic physician actually making his observations. Now during sleep the eyeball is turned upward, so that if the eye be then opened and examined only the white is seen. In the later stages of all wasting and chronic diseases the eyelids tend not to be closed during sleep. Such patients, as is well known, often die with the eyes open and sometimes exhibiting only the whites.

But the Hippocratic physician was not content to make only passive observation; he also took active measures to elicit the 'physical signs'. In modern times a large, perhaps the chief, task of the student of medicine is to acquire a knowledge of these so-called physical signs of disease, the tradition of which has been gradually rebuilt during the last three centuries. Among the most important measures in which he learns to acquire facility is that of auscultation. This useful process has come specially into vogue since the invention of the stethoscope in 1819 by Laennec, who derived valuable hints for it from the Hippocratic writings. Auscultation is several times mentioned and described by the Hippocratic physicians, who used the direct method of listening and not the mediate method devised by Laennec. There are, however, certain cases in which the modern physician still finds the older non-instrumental Hippocratic method superior. In the Hippocratic work περι νουσων {peri nousôn}, _On diseases_, we read of a case with fluid in the pleura that 'you will place the patient on a seat which does not move, an assistant will hold him by the shoulders, and you will shake him, applying the ear to the chest, so as to recognize on which side the sign occurs'. This sign is still used by physicians and is known as _Hippocratic succussion_. In another passage in the same work the symptoms of pleurisy are described and 'a creak like that of leather may be heard'. This is the well known _pleuritic rub_ which the physician is accustomed to seek in such cases, and of which the creak of leather is an excellent representation.

Such quotations give an insight into the general method and attitude of the Hippocratics. Of an art such as medicine, which even in those times had a long and rational tradition behind it, it is impossible to give more than the merest glimpse in such a review as this. The actual practice is far too complex to set down briefly. This is especially the case with the ancient teaching as regards epidemic disease at which we must cursorily glance. The Hippocratic physicians and indeed all antiquity were as yet ignorant of the nature, and were but dimly aware of the existence, of infection.[85] For them acute disease was something imposed on the patient from outside, but how it reached him from outside and what it was that thus reached him they were still admittedly ignorant. In this dilemma they turned to prolonged observation and noted as a result of repeated experience that epidemic diseases in their world had characteristic seasonal and regional distributions. One country was not quite like another, nor was one season like another nor even one year like another. By a series of carefully collated observations as to how regions, seasons, and years differed from each other, they succeeded in laying the basis of a rational study of epidemiology which gave rise to the notion of an 'epidemic constitution' of the different years, a conception which was very fertile and stimulating to the great clinicians of the seventeenth and eighteenth centuries and is by no means without value even for the modern epidemiologist. The work of the modern fathers of epidemiology was consciously based on Hippocrates.

[85] The ancients knew almost nothing of infection _as applied
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
περι διαφορας πυρετων {peri diaphoras pyretôn}, _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.

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.[86] 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.

[86] 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 (καλαμος ὡ γραφομεν {kalamos hô graphomen}), because it seemed to him, as Galen tells us, to resemble the pens then in use in Alexandria.[87] We still use, too, his term _duodenum_ (δωδεκαδακτυλος εκφυσις {dôdekadaktylos ekphysis} = twelve-finger extension), for as Galen assures us, Herophilus 'so named the first part of the intestine before it is rolled into folds'.[88] 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.

[87] Galen, περι ανατομικων εγχειρησεων {peri anatomikôn
encheirêseôn}, _On anatomical preparations_, ix. 5 (last sentence).

[88] Galen, περι φλεβων και αρτηριων ανατομης {peri phlebôn kai
artêriôn anatomês}, _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.'[89] 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.[90]

[89] 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.

[90] 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 περι αιτιων {peri aitiôn}, _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'.[91] 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.

[91] This is the only passage of Hegetor's writing that has
survived. It has been preserved in the work of Apollonius of Citium.