The Legacy of Greece Part 12

[66] _Historia animalium_, iii. 3, where it is ascribed to Polybus.

The same pa.s.sage is, however, repeated twice in the Hippocratic writings, viz. in the pe?? f?s??? a????p?? {peri physios anthropou}, _On the nature of man_, Littre, vi. 58, and in the pe?? ?ste??

f?s??? {peri osteon physios}, _On the nature of bones_, Littre, ix.

174.

[67] ?a?a??e??a? {Parangeliai}, -- 6.

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.[68]

[68] See Fig. 1.

[Ill.u.s.tration: Fig. 1. HIPPOCRATES British Museum, second or third century B. C.]

[Ill.u.s.tration: Fig. 2. ASCLEPIUS British Museum, fourth century B. C.]

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 ill.u.s.trated than by the words of the so-called 'Hippocratic oath'. That doc.u.ment, though of late date in its present form, throws a flood of light on the ethics of Greek medicine.

'I swear by Apollo the physician and Asclepius and Hygieia and Panacea, invoking all the G.o.ds and G.o.ddesses to be my witnesses, that I will fulfil this Oath and this written covenant to the best of my power and of my judgment.

'I will look upon him who shall have taught me this art even as on mine own parents; I will share with him my substance, and supply his necessities if he be in need; I will regard his offspring even as my own brethren, and will teach them this art, if they desire to learn it, without fee or covenant. I will impart it by precept, by lecture and by all other manner of teaching, not only to my own sons but also to the sons of him who has taught me, and to disciples bound by covenant and oath according to the law of the physicians, but to none other.

'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 ma.n.u.script of the Hippocratic text, dating from the tenth century, this magnificent pa.s.sage 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 pe?? f?s??? pa?d??? {peri physios paidiou}.

There is evidence, however, that the author of this work was not a medical pract.i.tioner.

[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 pa.s.sage from the _Airs, Waters, and Places_ tells us that the Scythians attribute a certain physical disability to a G.o.d, '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 ill.u.s.tration of the habitual att.i.tude 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 pa.s.sed 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] Kuhlewein, i. 79, regards this as an interpolated pa.s.sage.

[73] Littre, ii. 112; Kuhlewein, i. 79. The texts vary: Kuhlewein 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] ?e?? te???? {Peri technes}, -- 3.

[75] ?e?? ???s?? a' {Peri nouson 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 pa.s.ses 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.

Pa.s.sages 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 n.o.blest period the artist betrays no evidence of a.s.sistance derived from anatomization. Such evidence is not found until we come to sculpture of Alexandrian date, when the somewhat strained att.i.tudes 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 pe?? a????? {peri arthron}, _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 pe?? t?p?? t?? ?ata a????p?? {peri topon ton kata anthropon}, _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 a.s.sume 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 const.i.tuents. 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_, ???s?? f?se??

??t??? {nouson physeis ietroi}, 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 a.s.sist 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 att.i.tude 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 ill.u.s.trate 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 circ.u.mstances. 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 pa.s.sed 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 s.p.a.ced, and again hurried. _Seventeenth day_, after stimulation of the bowels she pa.s.sed 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 G.o.d 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 G.o.d came from Epidaurus and fastened her head on to her neck.

Then he cut open her belly, and st.i.tched it up again. So she was cured.'

'A man had an abdominal abscess. He saw a vision, and thought that the G.o.d 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 st.i.tched 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 d.i.c.kins), _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).