Part 12

‘In cases of jaundice, hardening of the liver is a bad sign.’

‘We should observe the appearance of the eyes in sleep. If any of the white show through the eyelids when closing, this is a bad sign and very dangerous, unless it be due to diarrhoea or taking a purgative.’

‘An attack of delirium with laughter is less dangerous than with despondency.’

‘Apoplexy is commonest between the ages of forty and sixty.’

‘If you give the same nutriment to a patient in a fever and to a person in health, the patient’s disease is aggravated by what adds strength to the healthy man.’

The chief clinical achievement of the Hippocratic Collection lies in the descriptions of actual cases. These descriptions are not only without parallel during nearly 2,000 years, but they are models of what succinct clinical records should be. They are clear and short, they give all the leading features and yet they show no attempt to prejudge the importance of any particular feature. The records of these cases illustrate the Greek genius for seizing the essential. The writer does not betray the least wish to exalt his own skill. He seeks merely to put the data before the reader for his guidance under like circumstances. It is a reflex of the spirit of honesty in which these men worked that in the great majority of the cases they record death ensued. Two of these remarkable descriptions may be given:

‘The woman with quinsy, who lodged with Aristion; her complaint began in the tongue; voice inarticulate; tongue red and parched. First day, shivered, then became heated. Third day, rigor, acute fever; reddish and hard swelling on both sides of neck and chest; extremities cold and livid; respiration elevated; drink returned by the nose; she could not swallow; alvine and urinary discharges suppressed. Fourth day, all symptoms exacerbated. Fifth day, died.’

This was a case of Diphtheria. The quinsy, the paralysis of the palate leading to return of the food through the nose, and the difficulty with speech and swallowing are typical results of this affection which was here complicated by a spread of the septic processes into the neck and chest, a not uncommon event in the disease. The rapid onset of the conditions is rather unusual, but may be explained if we regard the case as a mild and unnoticed diphtheria, subsequently complicated by paralysis and by secondary septic infection, for which reason she came under observation.

‘In Thasos, the wife of Delearces, who lodged on the plain, through sorrow was seized with an acute and shivering fever. From first to last she always wrapped herself up in her bedclothes; kept silent, fumbled, picked, bored, and gathered hairs [from the clothes]; tears and again laughter; no sleep; bowels irritable but passed nothing; when urged drank a little; urine thin and scanty; to the touch the fever was slight; coldness of the extremities. Ninth day, talked much incoherently, and again sank into silence. Fourteenth day, breathing rare, large and spaced, and again hurried. Seventeenth day, after stimulation of the bowels she passed even drinks, nor could retain anything; totally insensible; skin parched and tense. Twentieth day, much talk, and again became composed, then voiceless; respiration hurried. Twenty-first day, died. Her respiration throughout was rare and large; she was totally insensible; always wrapped up in her bedclothes; throughout either much talk, or complete silence.’

We have here a description of low muttering delirium, a common end of continued fevers, as, for instance, Typhoid. It resembles the condition known to physicians as the ‘typhoid state’. Incidentally the case contains a reference to a type of breathing common among the dying. The respiration becomes deep and slow, as it sinks gradually into quietude and becomes rarer and rarer until it seems to cease altogether, and then it slowly becomes more rapid and so on alternately. This type of breathing is known to physicians as ‘Cheyne-Stokes’ respiration, in commemoration of two distinguished Irish physicians of the last century who brought it to the attention of medical men. In our own time it has been partially explained on a physiological basis.

We may note that there is another and even better pen-picture of Cheyne-Stokes respiration in the Hippocratic Collection. We read of one ‘Philescos who lived by the wall and who took to his bed on the first day of acute fever.’ About the middle of the sixth day he died, and the physician notes that ‘the respiration throughout was like that of a person recollecting himself and was large and rare’. Cheyne-Stokes breathing is admirably described as ‘that of a person recollecting himself’.

Immense and, as some may think, overwhelming importance is laid by the Hippocratic writings upon the art of ‘Prognosis’, that is of predicting the course which the disease will take. The work to which the title Prognostics is attached represents a very lofty standard of practice. We quote from it a description of the signs of death to which the name of Hippocratic facies has become attached. It is imitated by Shakespeare in his description of the death of Falstaff in Henry V (Act II, Scene 3).

‘You should observe thus in acute diseases; first the countenance of the patient, if it be like those of persons in health, and especially if it be like itself, for this is best of all. But the opposite are the worst, such as these: a sharp nose, hollow eyes, collapsed temples; the ears cold, contracted, and their lobes turned out; the skin about the forehead rough, stretched and parched; the colour of the face greenish, dusky, livid or leaden.

‘If the countenance be such at the beginning of the disease, and if this cannot be accounted for by the symptoms, inquiry must be made whether the patient has been sleepless, whether his bowels have been very loose, or whether he has wanted food. If any of these be confessed, the danger is to be reckoned so far the less, and it will become obvious in a day and night whether or no the appearance come of these. But if no such cause exist and if the symptoms do not subside in this time, be it known for certain that the end is at hand.’

These glimpses will give some idea of Rational Medicine in the making. In the fourth century B.C. Medicine emerges as a definite part of the scientific consciousness. Rational Medicine is now in being.

§ 4. Aristotle.

During the fourth century B.C. there lived and worked one whose thought has stamped itself on the whole subsequent course of the biological and medical sciences, and indeed of all Science.

Aristotle (384-322 B.C.) was a provincial Greek and son of a Macedonian physician. At seventeen he became a pupil of Plato at Athens. After Plato’s death in 347 Aristotle crossed the Aegean to reside in Asia Minor. The main part of his biological observations was made during his stay there. In 342 B.C., at the request of King Philip of Macedon, Aristotle became tutor to Philip’s son, Alexander the Great. He remained in Macedon for seven years. About 336, when Alexander departed for the invasion of Asia, Aristotle returned to Athens, where he taught for the rest of his life. He died in 322 B.C., a few months after his pupil Alexander.

Aristotle was the great codifier of ancient Science. On him all subsequent biological development, including that of modern times, is surely based. In his wonderful biological works, which are still read by naturalists, he discusses many problems current to this very day. He laid the basis of the doctrine of Organic Evolution in his teaching concerning the Scala Naturae ‘Ladder of Nature’ (Fig. 10). He developed coherent theories of Generation and Heredity. He founded Comparative Anatomy and he dissected many animals. He did not, however, anatomize the human body.

Aristotle gave good descriptions of some organs, regarded from the standpoint of Comparative Anatomy. These descriptions he sometimes illustrated by drawings,

the first anatomical figures of which we have a record. In some cases these drawings can be restored with confidence. Thus, he gave an account of the uterus, the nomenclature of which has been retained in more or less modified form to our own time (Fig. 11). Among the best anatomical descriptions given by Aristotle is that of the ruminant stomach. Perhaps his most extraordinary anatomical feat is his account of the development of the dogfish Mustelus laevis, which he showed was attached to its mother’s womb in a way very similar to the embryo of a mammal (Fig. 12). This raised the admiration of the greatest modern morphologist, Johannes Müller (1807-58, pp. 211-13), and would in itself be sufficient to establish the claim of Aristotle to a place in the front rank of observing naturalists. Aristotle gave fairly accurate descriptions of the branches of the great veins and of the superficial vessels of the arm of mammals. He realized that the arteries are usually accompanied by veins. He described the generative and digestive organs of cephalopod Molluscs, and many other parts of many other animals.

FIG. 11. The womb with the names of its parts as given by Aristotle. These names remain, in various forms, in modern anatomy.

FIG. 12. Embryo dogfish, Mustelus laevis, after Johannes Müller. The little creature is shown attached to the wall of its mother’s womb, somewhat after the manner of a mammal.

Something should be said of the errors of Aristotle. Though an excellent Naturalist, he was in general much weaker in Physiology. Thus, he made no proper distinction between arteries and veins. He failed to trace any adequate relations between the sense organs, the nerves, and the brain. His refusal to attach great importance to the brain is remarkable. Primacy he placed with the heart, which he regarded also as the seat of the intelligence. This was contrary not only to the medical opinion of his day, but also to the popular view, voiced, for instance, by Aristophanes in his play The Clouds, written about 400 B.C., where we read of a man who had concussion of the brain. Moreover, Aristotle’s teacher Plato placed the seat of thought and feeling in the brain. From all we know of Aristotle, it seems probable that he did not take up this attitude without evidence. It seems likely that he had experimented on the brain and found it devoid of sensation. Hence his view, opposed to current belief, that it is not associated with thought. Aristotle regarded the brain simply as an agent for cooling the heart, and preventing it from being over-heated. This cooling process, he considered, was effected by the secretion of phlegm (pituita), an idea still preserved in our anatomical term the pituitary body.

The views of Aristotle have had a vast influence in determining the direction of medical thought. For more than two thousand years Aristotelian philosophy, in more or less corrupted form, constituted the main intellectual food of mankind. Without some knowledge of the biological verdicts of Aristotle, it is impossible to understand the course taken by Rational Medicine. The influence of Aristotle is specially evident in certain basic biological conceptions.

The problem of the nature of Generation is one in which Aristotle never ceased to take an interest. Among the methods by which he sought to solve it was embryological investigation. His most important embryological researches were made upon the chick. His choice was most fortunate, and the chick has remained, to this day, the classical subject of embryological research. Aristotle asserts that the first signs of life in the hen’s egg are noticeable on the third day, the heart being visible as a palpitating blood-spot. As it develops, two meandering blood-vessels extend to the surrounding tunics. A little later, he observes, the body becomes distinguishable, at first very small and white, the head being clearly distinguished and the eyes very large (Figs. 46-7, p. 117). To follow the main features of the later stages was a comparatively easy task.

Aristotle was greatly impressed by these phenomena. He lays stress on the early appearance of the heart in the embryo. Corresponding to the general gradational view that he had formed of Nature, he held that the most primitive and fundamentally important organs make their appearance before the others. Among the organs all give place to the heart, which he considered the first to live and the last to die. In the heart, as we have seen, he placed the seat of the intelligence.

Thus, not only in his account of the ‘Ladder of Nature’, but also in his theories of individual development, Aristotle exhibits some approach to evolutionary doctrine. This is somewhat obscured, however, by his peculiar view of the nature of procreation. On this topic his general conclusion is that the material substance of the embryo is contributed by the female, but that this is mere passive formable material, almost as though it were the soil in which the embryo grows. The male, by giving the principle of life, the soul (psyche), contributes the essential generative agency. But this soul is not material, and it is not, therefore, theoretically necessary for anything material to pass from male to female. The material which does in fact pass with the semen of the male is, as the older philosophers would have said, an accident, not an essential. The essential contribution of the male is not matter but form and principle.