CHAPTER VI. The Beginnings of a Rational System of Medicine in Greece

THE BEGINNINGS OF A RATIONAL SYSTEM OF MEDICINE IN GREECE

With the lapse of time the religious and mystical features of the treatment carried on at the Asclepieia gave place, more and more, to rational methods, and eventually--it is scarcely possible to mention a date, but probably not many years before the Hippocratic period--these institutions became centres for the spread of medical knowledge of the most practical kind. This is particularly true of the Asclepieion at Cos, where Hippocrates is believed to have received his medical training. It is interesting to note that the mystical features of the temple treatment--features which certainly did not originate with Aesculapius himself or with his sons, Machaon and Podalirius--eventually proved powerless to stay the slow but sure advance of sound medical knowledge. Even during the period when these false elements seemed to be most strongly rooted in the temple methods, there were forces at work which in due time deprived them of much of their pernicious power. This result was inevitable, for an organization which, in order to prosper in its work of doing good to humanity, depended upon the natural superstitiousness of the people, could not possibly thrive for an indefinite length of time. That the evil results did not develop sooner than they did simply shows how powerful and stubborn is the force of superstition. In the absence of trustworthy historical evidence, hypothetical statements only can be brought forward, but there can scarcely be any doubt but that a genuine belief in the power of Aesculapius (deified) to cure disease and restore health persisted for centuries.

The custom of recording the case histories on tablets or on the columns of the temple,--for at this period writing was in general use,--and also that of dedicating to the god images which represented (sometimes with a remarkable degree of truthfulness) the pathological condition for which the patient sought relief, contributed very greatly to the substitution of sound learning for religious mysticism and poorly concealed humbuggery.

Among the interesting objects which may be seen at the Museum of the History of Medicine in Jena, Germany, there are several of these terra-cotta images (votive offerings) representing pathological conditions; and among them the writer noticed more particularly one which reproduced faithfully, though in diminutive size, the appearances presented by cancer of the female breast. (Fig. 7.) There were also a very carefully modeled statuette of the trunk of a woman affected with ascites, and an admirable representation of a case of facial paralysis. (Fig. 8.) These objects were obtained by Professor Meyer-Steineg on the occasion of a recent visit to the ruins of the temple of Cos and other similar ruins in Greece and Asia Minor. The British Museum possesses many objects of the same character.

The original is in the National Museum at Athens.]

(Courtesy of Prof. Dr. Meyer-Steineg, of Jena, Germany.)]

It is not known at what precise date the iatreia, or small private hospitals, first made their appearance, but it was about the time when the religious character of the therapeutic work done in the Asclepieia gave place to treatment of a more distinctly medical character. Then, in addition to these iatreia, there were schools for gladiators and institutions in which gymnastic exercises were zealously cultivated; and in these places there was a frequent demand for advice in regard to questions of diet, and for surgical aid in the setting of broken bones, the reducing of dislocations, and the curing of bruises and sprains. As may readily be understood, the Asclepieia could not furnish the sort of professional aid which these institutions needed, and thus a further stimulus was given to the complete separation of the two kinds of medical practice--that connected with the temple and that conducted by outside physicians.

In Plato’s “Republic” (Book III., Chapter 15) mention is made of a certain Herodicus (of Selymbria; about 450 B. C.) who effected many cures by a method of treatment which combined athletic exercises with dieting. He gained considerable celebrity in this way, and is undoubtedly entitled to the credit of having been the first to call serious attention to the value of this plan of treating certain maladies. But, unfortunately, he made use of it in not a few instances where it proved harmful rather than beneficial to the patient, and thus brought discredit upon the method.

Already previous to the time at which the changes mentioned above took place, there had occurred still other changes in the character and practice of medicine. The business of cutting for stone in the bladder, for example, had been left entirely in the hands of men who made a specialty of this branch of medicine--men who might truthfully be called medical artisans. Then there was another class of men who devoted their energies to collecting medicinal roots and plants. They were a necessity to physicians, and constituted the first representatives of the modern apothecary. Still another change in the status of the Greek physicians had been slowly developing throughout this pre-Hippocratic period, a change which tended more and more to make them men of self-reliance and of considerable importance in their respective communities, and which indicated very clearly that they were steadily growing in skill and breadth of knowledge. As evidence of the correctness of this statement it is sufficient to mention the fact that Greek physicians had established so good a reputation that they were frequently called to see important cases at a great distance--in Egypt, in Persia, etc. But before further consideration is given to this subject of the development of the Greek physician during the period immediately preceding the appearance of the Hippocratic writings, it seems advisable to say a few words concerning the facilities for medical instruction which were available at that time.

Medical Instruction in Connection with the Asclepieia.-- It does not appear clearly in any of the published descriptions of these ancient Greek sanatoria just what were the relations between the priests and the men who utilized all this rich clinical material--records of all sorts of diseases, and the means (other than religious) employed in treating them, pictures or plastic reproductions of the visible pathological lesions, etc.--for the purpose of instructing the younger men who contemplated engaging in the practice of medicine. The modern teachers of the art know very well how difficult is the task of combining in a satisfactory manner these two things--the safeguarding of the patient’s interests and the utilization of their maladies as object lessons for men who are preparing to cure or relieve the bodily ills of those who may at some future moment need their professional services. To them, therefore, it would be a matter of very great interest to learn how this difficult problem had been solved nearly twenty-five hundred years ago. But, unfortunately, no satisfactory data upon which a trustworthy account might be founded are obtainable, and we are obliged to fall back upon such aid as our imagination may furnish. From Puschmann’s work on medical teaching in ancient times the following statement relating to the subject has been taken:--

The priests in the Aesculapian temples were not, as is generally assumed, physicians in the ordinary sense. They may have acquired some knowledge of the art, and they may even in some instances have been regularly trained physicians, but the important fact remains that they wished it to be understood that the treatment carried out in the temple was in accordance with revelations made to them by the god Aesculapius, and not the mere fruit of human knowledge. Consequently the intervention of regular physicians in the temple management of the sick must have appeared to them quite superfluous. For this reason, therefore, it is not likely that there existed, on the part of either the temple priests or the physicians, any feeling of animosity or opposition. It is more likely that the contrary was the case, for the evidence shows that the physicians--the Asclepiadae--paid most humble reverence to the sacred relics of Aesculapius, and placed the most implicit confidence in the opinions which he was supposed to give in desperate cases.

(Courtesy of Prof. Dr. Meyer-Steineg, Jenaer medizinisch-historische Beiträge, Heft 2, 1912.)]

While Puschmann does not say to what period in the history of these temples his statement applies, it is safe to assume that he had in mind only the earlier stages. When the systematic teachings of medical pupils began, those physicians who gave the instruction--viz., the Asclepiadae who were not at the same time priests--took up their abode somewhere in the neighborhood of the temple. Thus, medical schools were formed at different places, those of Rhodes, Crotone, Cyrene, Cos and Cnidus attaining the greatest celebrity. The pupil paid a fee for his instruction, and when his training was believed to be completed he was admitted into the association or brotherhood of the Asclepiadae upon taking the following oath, which for ages past has been known as “The Hippocratic Oath,” but which is now believed to have been formulated long before the time of Hippocrates:--

THE HIPPOCRATIC OATH

I swear by Apollo the Physician and Aesculapius, and Hygieia and Panacea and all the gods and all the goddesses--and I make them my judges--that this mine oath and this my written engagement I will fulfil as far as power and discernment shall be mine.

Him who taught me this art I will esteem even as I do my parents; he shall partake of my livelihood, and, if in want, shall share my goods. I will regard his issue as my brothers and will teach them this art without fee or written engagement if they shall wish to learn it.

I will give instruction by precept, by discourse, and in all other ways, to my own sons, to those of him who taught me, to disciples bound by written engagements and sworn according to medical law, and to no other person.

So far as power and discernment shall be mine, I will carry out regimen for the benefit of the sick and will keep them from harm and wrong. To none will I give a deadly drug even if solicited, nor offer counsel to such an end; likewise to no woman will I give a destructive suppository; but guiltless and hallowed will I keep my life and mine art. I will cut no one whatever for the stone, but will give way to those who work at this practice.

Into whatsoever houses I shall enter I will go for the benefit of the sick, holding aloof from all voluntary wrong and corruption, including venereal acts upon the bodies of females and males whether free or slaves. Whatsoever in my practice or not in my practice I shall see or hear amid the lives of men which ought not to be noised abroad--as to this I will keep silence, holding such things unfitting to be spoken.

And now if I shall fulfil this oath and break it not, may the fruits of life and of art be mine, may I be honored of all men for all time; the opposite if I shall transgress and be forsworn.

(Translated from the Greek by the late John G. Curtis, M.D., of New York.)

While at first, according to Puschmann, many physicians did not belong to the Aesculapian Brotherhood, there came a time when all were known as Asclepiadae.

Influence of the Schools of Philosophy on the Growth of Medical Knowledge.--About the beginning of the sixth century B. C. there developed, in Greece and its colonies, schools of philosophy which exerted a most excellent influence upon the growth of medicine. The first of these was the one known as the Ionian School, whose founders and chief representatives were Thales, of Miletus in Ionia (born in 640, died in 548 B. C.), and his pupils Anaximander and Anaximenes. The guiding principle of these men was to study natural phenomena and to learn, if possible, their causes and the laws of their action. Physiology, therefore, became one of their special studies, and thus they contributed to the laying of one of the most important foundation-stones of medicine. Thanks to the good quality of the work of instruction that had thus far been carried on at Cos, Cnidus, and other Asclepieia, medicine had by this time reached a sufficient degree of development for its devotees to derive a full measure of benefit from the new teaching of the philosophers. Well grounded in the observation of disease in its different forms and modes of behavior, and also familiarized with the ordinary methods of treatment, these physicians needed to be shown a new route along which they might advance to greater heights of knowledge, and they also needed to be stimulated to further endeavor. The introduction of the new school accomplished both of these purposes. It taught the men of the older organizations that they must make much greater use of their reasoning powers than they had hitherto done, and at the same time, through the creation of a group of rival physicians, it supplied them with the required stimulus. Another important school of philosophy was that known as the Eleatic School, which flourished at Elea, in Lower Italy, its leaders being natives of that city. The most prominent men connected with this school were Parmenides (born about 540 B. C.) and Xenophanes of Colophon, in Asia Minor, whose contributions to mental science formed the basis of Plato’s metaphysics.

The period roughly embraced between the years 500 and 300 B. C. represents the most brilliant age of Greek intellectual and artistic activity. During this time there came into prominence such philosophers, historians, poets, physicians, artists and generals of armies as had never before been marshaled in historic array in so rapid succession. Even at this late day the names of these great men are almost household words--such names, for example, as Pythagoras, Alcmaeon, Anaxagoras, Aristotle, Plato, Socrates, Sophocles, Aeschylus, Euripides, Aristophanes, Pindar, Xenophon, Demosthenes, Democedes, Hippocrates the Great, Phidias, Praxiteles, Zeuxis, Apelles, Darius I., Alexander the Great, and many others of almost equal celebrity. During the centuries immediately preceding this golden age of Greek history, there seem to have been very few men of great merit in any of the branches of learning or in the fields of war or art, but this impression is certainly false. It is doubtless to be explained by the fact that large quantities of documentary evidence relating to these years have been entirely lost. Daniel Le Clerc, for instance, states that, of the separate histories of the descendants of Aesculapius which were written by Eratosthenes, Pherecydes, Apollodorus, Arius of Tarsus and Polyanthus of Cyrene, not one has come down to our time. If, then, in the single department of medicine, the destruction of documentary evidence was as great as is here represented, how enormous must have been the loss of precious historical materials in all the departments of human activity taken together. We may, therefore, safely assume that this golden age, which lasted only about two hundred years, represents simply the culmination of an even longer period of slow but steady development, a period of creditable though perhaps less brilliant achievements.

Of the names mentioned above there are several that belong to men who were in various ways connected with the early history of medicine. Pythagoras, for example, is said to have been one of the first among the Greek philosophers to exert a strong and double impression upon the medical teaching of that period. He was born in the Island of Samos, near the coast of Asia Minor, about the year 575 B. C. After spending several years in Egypt for purposes of study, and probably visiting Babylon, at that time a great centre of learning and of artistic cultivation, he established at Crotona, in the south of Italy, a school where natural philosophy, mathematics, acoustics, etc., were taught. He also devoted some attention to anatomy, to embryology, to physiology and to therapeutics. According to his views of what constituted hygienic living a man should accustom himself to a diet of the simplest character, without meat. Pythagoras was a believer in the Chaldean doctrine that the uneven numbers possess a more important significance than the even, and that the number seven in particular has a special relationship to the phenomena of certain diseases; the crisis frequently falling on the seventh, fourteenth, or twenty-first day. Galen, it is said, expressed surprise that a man as sensible and learned as Pythagoras should have paid any attention to such trifles. Not a few of the disciples of Pythagoras were physicians, and when the brotherhood (if such it may be called) broke up, as it did in the fifth century B. C., these men traveled about from one Grecian city to another; from which fact they were given the name of “periodeuts” or ambulant physicians. Crotona was also celebrated as the birthplace of Milo, the athlete.

Democedes, who was a contemporary of Pythagoras, but not one of his disciples, was a native of Crotona. Dion Cassius, the author of a Roman history, ranks him and Hippocrates as the two most eminent physicians of antiquity. Daremberg, who derived his facts from the works of Herodotus, gives the following account of the adventures of Democedes:--

Being unable to bear any longer the frequent anger and harsh treatment of his father, Calliphon, Democedes left Crotona, and settled in practice at Aegina, on the Saronic Gulf, not far from Athens. Almost from the very start he attained marked success, and already in the second year of his residence in Aegina he was made the recipient of a pension of one talent (equal to about £240, or $1200,) out of the public treasury. During the following year he was induced, by the offer of a larger pension (100 minae, or about $3000,) to settle in Athens; and, a year later, he accepted a still larger remuneration from Polycrates, the tyrant of Samos. Having accompanied the latter on a trip to Sardis, the capital of Lydia, in Asia Minor, he fell a prisoner into the hands of the governor of that city, and was made by him a slave. Not long afterward Darius gained possession of this governor’s or satrap’s property, including all his slaves; and thus, despite all his efforts to conceal his profession through fear that a knowledge of it on the part of the king might prolong his bondage indefinitely, Democedes was unable to do so. The discovery came about in the following manner. During a hunting trip Darius broke his ankle. He called to his assistance the court physicians, who were esteemed the most skilful that could be found in all Egypt, but they failed to give him relief. By the violence of their manipulations they rather made matters worse. For seven days and nights his sufferings were so great that he was unable to obtain any sleep. Finally, on the eighth day, one of the court attendants having told Darius that there was a Greek physician among the slaves, Democedes was sent for, and he appeared before the king clad in rags and with chains on his ankles. When asked whether he knew anything about medicine he denied such knowledge, being fearful that the discovery of the truth about himself would stand in the way of his ever getting back to Greece. Darius, perceiving that he was dissimulating, ordered the attendants to fetch the whips and pinchers. Whereupon Democedes made up his mind that he had better confess the truth. He accordingly told the king that, while not possessing a thorough knowledge of the healing art, long association with a physician had familiarized him more or less with the subject. The king then asked him to take charge of the case. Democedes, following the treatment adopted by the Greek physicians in similar conditions, applied soothing remedies and soon succeeded in procuring sleep for the suffering king. Eventually he obtained a complete cure, and Darius, who had made up his mind that he would never again be able to use his limb, was naturally delighted with the result. He loaded Democedes with gifts, and, being charmed with his conversation, made him sit at the royal table and did everything possible to render court life attractive; but liberty was denied him, which was the one thing that Democedes most ardently desired. The only use which the latter made of the great influence which he had obtained over Darius was to save the Egyptian physicians from the death by crucifixion which the king had decided to inflict upon them for their lack of skill.

The means of escape finally presented themselves to Democedes in a most unexpected manner. Atossa, who was the wife of Darius and also the daughter of Cyrus, was afflicted with a swelling of the breast which developed into an abscess and began to burrow into the neighboring tissues. After, for a time, concealing the trouble through a sense of false modesty, she made up her mind to consult Democedes. He had the good fortune to cure her of this malady in a relatively short time. As preparations were then being made to send a number of spies to Greece with instructions to examine the coast carefully for the purpose of determining at what points the defenses were sufficiently weak to render an attack by the Persians reasonably sure of success, Democedes asked permission of Darius to accompany these men as their guide. His request was granted; and, as soon as the expedition reached Tarentum in Calabria, he delivered the Persian spies into the hands of Aristophilides, the king of that country, and then fled in all haste to Crotona, his native city. Shortly afterward these Persians, having been set at liberty by Aristophilides, made the attempt to capture Democedes and carry him off by main force, but the citizens of Crotona thwarted the attempt and compelled the men to return to Asia. Democedes then married the daughter of Milo, the athlete, and history furnishes no information regarding the subsequent career of this extraordinary man.

Daremberg calls attention to certain excellent proverbs which may be found in the writings of the Greek poets and which are of some interest to physicians. The following may serve as examples of those most widely known:--

Joy is the best physician for fatigue. (Pindar, 522–442 B. C.)

The good physician is he who knows how to employ the right remedies at the proper time; the poor one, he who, in the presence of a serious illness, loses his courage, becomes flustered, and is unable to devise any helpful method of treatment. (Aeschylus, 525–456 B. C.)

Physician, heal thyself. (Euripides, 400–406 B. C.)

Advice given to Phaedra by her nurse:--

If thou hast some ailment which thou dost not care to reveal to men, here are women who are competent to treat the condition properly. (Euripides.)

Sleep is the physician of pain, and Death is the supreme healer of maladies. (Sophocles, 495–406 B. C.)

In Plato’s writings there are to be found a few passages in which this philosopher gives his views in regard to certain matters that are not without interest to modern physicians. The following extracts are of this nature:--

There is not then, my friend, any office among the whole inhabitants of the city peculiar to the woman, considered as a woman, nor to the man, considered as a man; but the geniuses are indiscriminately diffused through both: the woman is naturally fitted for sharing in all offices, and so is the man; but in all the woman is weaker than the man.

Perfectly so.

Shall we then commit everything to the care of the men, and nothing to the care of the women?

How shall we do so?

It is therefore, I imagine, as we say, that one woman, too, is fitted by natural genius for being a physician, and another is not; one is naturally a musician, and another is not.

(From “The Republic” of Plato, translated by Spens.)

But tell me with reference to him who, accurately speaking, is a physician, whom you now mentioned, whether he is a gainer of money or one who taketh care of the sick? and speak of him who is really a physician.

One who taketh care, said he, of the sick.

* * * * *

Why then, said I, no physician as far as he is a physician, considers what is advantageous for the physician, nor enjoins it, but what is advantageous for the sick; for it hath been agreed that the accurate physician is one who taketh care of sick bodies, and not an amasser of wealth. Hath it not been agreed?

He assented. (Plato, 428–547 B. C., translated by Spens.)

But Plato’s knowledge of human anatomy and physiology was very crude and in some instances decidedly fanciful. In corroboration of this statement the following extract from the “Timaeus” may be quoted:--

And on this account, fearing to defile the Divine nature more than was absolutely necessary, they [the junior gods] lodged man’s mortal portion separately from the Divine, in a different receptacle of the body; forming the head and breast and placing the neck between, as an isthmus and limit to separate the two extremes.

In the breast, indeed, and what is called the thorax, they seated the mortal part of the soul. And as one part of it was naturally better, and another worse, they formed the cavity of the thorax into two divisions (resembling the separate dwellings of our men and women), placing the midriff as a partition between them. That part of the soul, therefore, which partakes of fortitude and spirit and loves contention they seated nearer the head between the midriff and the neck; as it is the business of the reason to unite with it in forcibly repressing the desires, whenever they will not obey the mandate and word issuing from the citadel above.

The heart, which is the head and principle of the veins as well as the fountain of the blood that impetuously circulates through all the members, they placed in a kind of sentry-house, that, in case of any outburst of anger, being informed by the reason of any evil committed in its members, owing either to some foreign cause, or else internal passions, it (the heart) might transmit through all its channels the threatenings and exhortations of reason, so as once more to reduce the body to perfect obedience, and so permit what is the best within us to maintain supreme command.

But as the gods foreknew, with respect to the palpitation of the heart under the dread of danger and the excitement of passion, that all such swellings of the inflamed spirit would be produced by fire, they formed the lungs to be a sort of protection thereto; first of all, soft and bloodless, and next internally provided with cavities perforated like a sponge, in order to cool the breath which they receive, and give the heart easy respiration and repose in its excessive heat. On this account, then, they led the channels of the windpipe into the lungs, which they placed like a soft cushion round the heart, in order that when anger rises in it to an extreme height it might fall on some yielding substance, and, so getting cool, yield cheerfully and with less trouble to the authority of reason. (Plato’s “Timaeus,” translated by Henry Davis.)

Alcmaeon, Empedocles, Diogenes of Apollonia, Anaxagoras and Pausanias, whose names are mentioned above in the list of eminent men who flourished during the golden age of Greek history, are entitled to further consideration. Alcmaeon of Crotona was a contemporary and disciple of Pythagoras. He was specially devoted to the study of anatomy and physiology, and is credited with the distinction of having been the first person to dissect animals for the purpose of learning the formation of the different parts of their bodies. With the exception of a few fragments that are to be found scattered throughout ancient medical literature, Alcmaeon’s writings have all been lost. The discovery of the optic nerve is credited to him, and Neuburger states that he deserves still greater credit for having been the first to declare that the brain is the central organ of all intellectual activity.

Of all the disciples of Pythagoras, Empedocles attained the greatest celebrity. He flourished about 444 B. C., his residence being at Agrigentum, in Sicily. Much of his reputation appears to have been due to the mystery which surrounded many of his actions. He was even reputed to have brought again to life persons who were believed to be dead. His works were all in verse, but only fragments have come down to us. He placed the seat of hearing in the labyrinth of the temporal bone. His death occurred in Peloponnesus at the age of sixty, as the result of an accident.

Anaxagoras was born at Clazomenae, in Ionia, 500 B. C. He was the teacher of Euripides, the Athenian poet, and Pericles, the greatest of Athenian statesmen. He and his contemporary, Diogenes of Apollonia, in Crete, devoted a great deal of attention to the study of anatomy. They dissected animals and made some genuine discoveries; Anaxagoras noting the existence of the lateral ventricles of the brain, and Diogenes furnishing a description--very erroneous, it is true--of the vascular system of the body. Puschmann says that, according to Aristotle, the philosophers of that period considered the study of man and his diseases the most important one to which they could devote their time and thoughts. Many of them indeed had been educated as physicians, and not a few were actual practitioners of medicine.