Part 16

The period given by the Aphorisms for the maximum frequency of onset of the disease is closely borne out by modern observations. The second Aphorism is equally valid; continued diarrhœa is a very frequent antecedent of the fatal event in chronic phthisis, and post-mortem examination has shown that secondary involvement of the bowel is an exceedingly common condition in this disease.

No less remarkable is the following saying: ‘In jaundice it is a grave matter if the liver becomes indurated.’ Jaundice is a common and comparatively trivial symptom following or accompanying a large variety of diseases. In and by itself it is of little importance and almost always disappears spontaneously. There is a small group of pathological conditions, however, in which this is not the case. The commonest and most important of these are the fatal affections of cirrhosis and cancer of the liver in which that organ may be felt to be enlarged and hardened. If therefore the liver can be so felt in a case of jaundice, it is, as the Aphorism says, of gravest import. Representations of such cases have actually come down to us from Greek times. Thus on a monument erected at Athens to the memory of a physician who died in the second century of the Christian era we may see the process of clinical examination (fig. 7). The physician is palpating the liver of a dwarfish figure whose swollen belly, wasted limbs, and anxious look tell of some such condition as that described in the Aphorism. The ridge caused by the enlarged liver can even be detected on the statue.

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

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 περὶ νούσων, 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. 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.

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 περὶ διαφορᾶς πυρετῶν, 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.

Second century A. D. British Museum

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

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. 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.

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 (κάλαμος ῷ γράφομεν), because it seemed to him, as Galen tells us, to resemble the pens then in use in Alexandria. We still use, too, his term duodenum (δωδεκαδάκτυλος ἔκφυσις = twelve-finger extension), for as Galen assures us, Herophilus ‘so named the first part of the intestine before it is rolled into folds‘. 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.

Galen, περὶ ἀνατομικῶν ἐγχειρήσεων, On anatomical preparations, ix. 5 (last sentence).

Galen, περὶ φλεβῶν καὶ ἀρτηριων ανατομῆς, 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.’ 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.

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.

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 περὶ αἰτιῶν, 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’. 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.

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

After the establishment of the school at Alexandria, medical teaching rapidly became organized, but throughout the whole course of antiquity it suffered from the absence of anything in the nature of a state diploma. Any one could practise, with the result that many quacks, cranks, and fanatics were to be found among the ranks of the practitioners who often were or had been slaves. The great Alexandrian school, however, did much to preserve some sort of professional standard, and above all its anatomical discipline helped to this end.

Between the founding of the Alexandrian school and Galen we are not rich in medical writings. Apart from fragments and minor productions, the works of only five authors have survived from this period of over four hundred years, namely, Celsus, Dioscorides, Aretaeus of Cappadocia, and two Ephesian authors bearing the names of Rufus and Soranus.

The work of Celsus of the end of the first century B. C. is a Latin treatise, probably translated from Greek, and is the surviving medical volume of a complete cyclopaedia of knowledge. In spite of its unpromising origin it is an excellent compendium of its subject and shows a good deal of advance in many respects beyond the Hippocratic position. The moral tone too is very high, though without the lofty and detached beauty of Hippocrates. Anatomy has greatly improved, and with it surgical procedure, and the work is probably representative of the best Alexandrian practice. The pharmacopœia is more copious, but has not yet become burdensome. The general line of treatment is sensible and humane and the language concise and clear. Among other items he describes dental practice, with the indications for and methods of tooth extraction, the wiring of teeth, and perhaps a dental mirror. There is an excellent account of what might be thought to be the modern operation for removal of the tonsils. Celsus is still commemorated in modern medicine by the area Celsi, a not uncommon disease of the skin. The De re medica is in fact one of the very best medical text-books that have come down to us from antiquity. It has had a romantic history. Forgotten during the Middle Ages, it was brought to light by the classical scholar Guarino of Verona (1374-1460) in 1426, and a better copy was discovered by his friend Lamola in 1427. Another copy was found by Thomas Parentucelli (1397-1455), afterwards Pope Nicholas V in 1443, and the text was later studied by Politian (1454-94). Though one of the latest of the great classical medical texts to be discovered, it was one of the first to be printed (Florence, 1478), and it ran through very many early editions and had great influence on the medical renaissance.

After Celsus comes Dioscorides in the first century A. D. He was a Greek military surgeon of Cilician origin who served under Nero, and in him the Greek intellect is obviously beginning to flag. His work is prodigiously important for the history of botany, yet so far as rational medicine is concerned he is almost negligible. He begins at the wrong end, either giving lists of drugs with the symptoms that they are said to cure or to relieve, or lists of symptoms with a series of named drugs. Clinical observation and record are wholly absent, and the spirit of Hippocrates has departed from this elaborate pharmacopœia.

In centre is represented a folding case containing scalpels of various forms. On either side are cupping vessels.]

With the second century of the Christian era we terminate the creative period of Greek medicine. We are provided with the works of four important writers of this century, of whom three, Rufus of Ephesus, Soranus of Ephesus, and Aretaeus of Cappadocia, though valuable for forming a picture of the state of medicine in their day, were without substantial influence on the course of medicine in later ages.