???f???? d? ??? t? ??a?t?t??? ?a? s?f?a? f?s?? ??ep?de??t?? ?a? t????? ?d???? ?a? ?s??? ??a????st?? ?a? p???t?? ???e??? ?a? ????? ?d??at??, ???e?a? ?p??s??.

Herophilus, a Greek philosopher and physician (c. 300 b. c.), has truly written ‘that Science and Art have equally nothing to show, that Strength is incapable of effort, Wealth useless, and Eloquence powerless if Health be wanting’.[99] All peoples therefore have had their methods of treating those departures from health that we call disease, and among peoples of higher culture such methods have been reduced in most cases to something resembling a system. In antiquity, as now, a variety of such systems were in vogue, and those nations who practised the art of writing from an early date have left considerable records of their medical methods and doctrines. We may thus form a fairly good idea of the medical principles of the Mesopotamian, the Egyptian, the Iranian, the Indian, and the Chinese civilizations. Much in these systems, as in the medical procedure of more primitive tribes, was based upon some theory of disease which fitted in with a larger theory of the nature of evil. Of these theories the commonest was and is the demonic, the view that regards deviation from the normal state of health as due either to the attacks of supernatural beings or to their actual entry into the body of the sufferer. A medical system based on such a view is susceptible of great elaboration in a higher civilization, but not being founded on observation is hardly capable of indefinite development, for a point must ultimately be reached at which the mind recoils from complex conclusions far remote from observed phenomena. The medicine of the ancient and settled civilization of such a people as the Assyro-Babylonians, for instance, of which substantial traces have been recovered, is hardly, if at all, more effective, though far more systematized, than that of many a wild and unlettered tribe that may be observed to-day. Of such medicine as this we may give an account, but we can hardly write a history. We cannot establish those elements of continuity and of development from which alone history can be constructed.

It is the distinction of the Greeks alone among the nations of antiquity that they practised a system of medicine based not on theory but on observation accumulated systematically as time went on. The claim can be made for the Greeks that some at least among them were deflected by no theory, were deceived by no theurgy, were hampered by no tradition in their search for the facts of disease and in their attempts at interpreting its phenomena. Only the Greeks among the ancients could look on their healers as physicians (= naturalists, f?s?? = nature), and that word itself stands as a lasting reminder of their achievement.[100]

At a certain stage in the history of the Western world—the exact point in time may be disputed but the event is admitted by all—men turned to explore the treasures of the ancient wisdom and the whole mass of Greek medical learning was gradually laid before the student. That mass contained much dross, material that survived from early as from late Greek times which was hardly, if at all, superior to the debased compositions that circulated in the name of medicine in the middle centuries. But the recovered Greek medical writings also contained some material of the purest and most scientific type, and that material and the spirit in which it was written, form the debt of modern medicine to antiquity.

It is a debt the value of which cannot be exaggerated. The physicians of the revival of learning, and for long after, doubtless pinned their faith too much to the written word of their Greek forbears and sought to imprison the free spirit of Hippocrates and Galen in the rigid wall of their own rediscovered texts. The great medical pioneers of a somewhat later age, enraged by this attempt, the real nature of which was largely hidden from them, not infrequently revolted and rightly revolted against the bondage to the Greeks in which they had been brought up. Yet it is sure that these modern discoverers were the true inheritors of the Greeks. Without Herophilus we should have had no Harvey and the rise of physiology might have been delayed for centuries; had Galen’s works not survived, Vesalius would never have reconstructed Anatomy, and Surgery too might have stayed behind with her laggard sister, Medicine; the Hippocratic collection was the necessary and acknowledged basis for the work of the greatest of modern clinical observers, Thomas Sydenham, and the teaching of Hippocrates and of his school is the substantial basis of instruction in the wards of a modern hospital. In the pages which follow we propose therefore to review the general character of medical knowledge in the best Greek period and to consider briefly how much of that great heritage remained accessible to the earlier modern physicians. The reader will thus be able to form some estimate of the degree to which the legacy has been passed on to our own times.

It is evident that among such a group of peoples as the Greeks, varying in state of civilization, in mental power, in geographical and economic position and in general outlook, the practice of medicine can have been by no means uniform. Without any method of centralizing medical education and standardizing teaching there was a great variety of doctrines and of practice in vogue among them, and much of this was on a low level of folk custom. Such lower grade material of Greek origin has come down to us in abundance, though much of it, curiously enough, from a later time. But the overwhelming mass of earlier Greek medical literature sets forth for us a pure scientific effort to observe and to classify disease, to make generalizations from carefully collected data, to explain the origin of disease on rational grounds, and to apply remedies, when possible, on a reasoned basis. We may thus rest fairly well assured that, despite serious and irreparable losses, we are still in possession of some of the very finest products of the Greek medical intellect.

There is ample evidence that the Greeks inherited, in common with many other peoples of Mediterranean and Asiatic origin, a whole system of magical or at least non-rational pharmacy and medicine from a remoter ancestry. Striking parallels can be drawn between these folk elements among the Greeks and the medical systems of the early Romans, as well as with the medicine of the Indian Vedas, of the ancient Egyptians, and of the earliest European barbarian writings. It is thus reasonable to suppose that these elements, when they appear in later Greek writings, represent more primitive folk elements working up, under the influence of social disintegration and consequent mental deterioration, through the upper strata of the literate Greek world. But with these elements, intensely interesting to the anthropologist, the psychologist, the ethnologist, and to the historian of religion, we are not here greatly concerned. Important as they are, they constitute no part of the special claim of the Greek people to distinction, but rather aid us in uniting the Greek mentality with that of other kindred peoples. Here we shall rather discuss the course of Greek scientific medicine proper, the type of medical doctrine and practice, capable of development in the proper sense of the word, that forms the basis of our modern system. We are concerned, in fact, with the earliest evolutionary medicine.

We need hardly discuss the first origins of Greek Medicine. The material is scanty and the conclusions somewhat doubtful and perhaps premature, for the discovery of a considerable fragment of the historical work of Menon, a pupil of Aristotle, containing a description of the views of some of the precursors of the Hippocratic school, renews a hope that more extended investigation may yield further information as to the sources and nature of the earliest Greek medical writings.[101] The study of Mesopotamian star-lore has linked it up with early Greek astronomical science. The efforts of cuneiform scholars have not, however, been equally successful for medicine, and on the whole the general tendency of modern research is to give less weight to Mesopotamian and more to Egyptian sources than had previously been admitted; thus, as an instance, some prescriptions in the Ebers papyrus of the eighteenth dynasty (about the sixteenth century b. c.) discovered at Thebes in 1872 resemble certain formulae in the Corpus Hippocraticum. A number of drugs, too, habitually used by the Greeks, such as Andropogon, Cardamoms, and Sesame orientalis, are of Indian origin. There are also the Minoan cultures to be considered, and our knowledge is not yet sufficient to speak of the heritage that Greek medicine may or may not have derived from that source, though it seems not improbable that Greek hygiene may here owe a debt.[102] Omitting, therefore, this early epoch, we pass direct to the later period, between the sixth and fourth centuries, from which documents have actually come down to us.

The earliest medical school of which we have definite information is that of Cnidus, a Lacedaemonian colony in Asiatic Doris. Its origin may perhaps reach back to the seventh century b. c. We have actual records that the teachers of Cnidus were accustomed to collect systematically the phenomena of disease, of which they had produced a very complex classification, and we probably possess also several of their actual works. The physicians of Cos, their only contemporary critics whose writings have survived, considered that the Cnidian physicians paid too much attention to the actual sensations of the patient and to the physical signs of the disease. The most important of the Cnidian doctrines were drawn up in a series of Sentences or Aphorisms, and these, it appears, inculcated a treatment along Egyptian lines of the symptom or at most the disease, rather than the patient, a statement borne out by the contents of the gynaecological works of probable Cnidian origin included in the so-called ‘Hippocratic Collection’. A few names of Cnidian physicians have, moreover, come down to us with titles of their works, and a later statement that they practised anatomy. There can be little doubt too that the Cnidian school drew also on Persian and Indian Medicine.

The origin of the school of the neighbouring island of Cos was a little later than that of Cnidus and probably dates from the sixth century b. c. Of the Coan school, or at least of the general tendencies that it represented, we have a magnificent and copious literary monument in the Corpus Hippocraticum, a collection which was probably put together in the early part of the third century b. c. by a commission of Alexandrian scholars at the order of the book-loving Ptolemy Soter (reigned 323-285 b. c.). The elements of which this collection is composed are of varying dates from the sixth to the fourth century b. c., and of varying value and origin, but they mainly represent the point of view of physicians of the eastern part of the Greek world in the fifth and fourth centuries.

The most obvious feature, the outstanding element that at once strikes the modern observer in these ‘Coan’ writings, is the enormous emphasis laid on the actual course of disease. ‘It appears to me a most excellent thing’, so opens one of the greatest of the Hippocratic works, ‘for a physician to cultivate pronoia.[103] Foreknowing and foretelling in the presence of the sick the past, present, and future (of their symptoms) and explaining all that the patients are neglecting, he would be believed to understand their condition, so that men would have confidence to entrust themselves to his care.... Thus he would win just respect and be a good physician. By an earlier forecast in each case he would be more able to tend those aright who have a chance of surviving, and by foreseeing and stating who will die, and who will survive, he will escape blame....’[104]

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.

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’, ?f?t?? ?e???, 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; ???? ? ???? ? ?et??a ??? ??sa s????ate? ???, ???? t?? ??s?? p?e?a ?a? ??? pe????e? ‘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.

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.

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 pe?? ?a?d???, 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]

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 ?a?a??e??a?, Precepts:

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]

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:

‘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]

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.

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?? ?at? ?????p??, 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, ???s?? f?se?? ??t???, 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.’

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’.

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:

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 ??????s??, 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.

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).

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 ?at’ ??t?e???, Concerning the Surgery, or the more elaborate treatise pe?? ??t???, 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).

From MS. of APOLLONIUS OF KITIUM, of Ninth Century
Copied from a pre-Christian original