Book III

.

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

'In Thasos, the wife of Delearces who lodged on the plain, through sorrow was seized with an acute and shivering fever. From first to last she always wrapped herself up in her bedclothes; kept silent, fumbled, picked, bored and gathered hairs [from the clothes]; tears, and again laughter; no sleep; bowels irritable, but 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.[78] Recently it has been partially explained on a physiological basis. We may note that there is another and even better pen-picture of Cheyne-Stokes respiration in the Hippocratic collection. It is in the famous case of 'Philescos who lived by the wall and who took to his bed on the first day of acute fever'. About the middle of the sixth day he died and the physician notes that 'the respiration throughout was _like that of a person recollecting himself_ and was large and rare'. Cheyne-Stokes breathing is admirably described as 'that of a person recollecting himself'.

[78] John Cheyne (1777-1836) described this type of respiration in the _Dublin Hospital Reports_, 1818, ii, p. 216. An extreme case of this condition had been described by Cheyne's namesake George Cheyne (1671-1743) as the famous 'Case of the Hon. Col. Townshend' in his _English Malady_, London, 1733. William Stokes (1804-78) published his account of Cheyne-Stokes breathing in the _Dublin Quarterly Journal of the Medical Sciences_, 1846, ii, p. 73.

Such records as these may be contrasted with certain others that have come down from Greek antiquity. We may instance two steles discovered at Epidaurus in 1885, bearing accounts of forty-four temple cures. The following two are fair samples of the cures there described:

'_Aristagora of Troizen._ She had tape-worm, and while she slept in the Temple of Asclepius at Troizen, she saw a vision. She thought that, as the god was not present, but was away in Epidaurus, his sons cut off her head, but were unable to put it back again. Then they sent a messenger to Asclepius asking him to come to Troizen. Meanwhile day came, and the priest actually saw her head cut off from the body. The next night Aristagora had a dream. She thought the god came from Epidaurus and fastened her head on to her neck. Then he cut open her belly, and stitched it up again. So she was cured.'

'A man had an abdominal abscess. He saw a vision, and thought that the god ordered the slaves who accompanied him to lift him up and hold him, so that his abdomen could be cut open. The man tried to get away, but his slaves caught him and bound him. So Asclepius cut him open, rid him of the abscess, and then stitched him up again, releasing him from his bonds. Straightway he departed cured, and the floor of the Abaton was covered with blood.'[79]

[79] The Epidaurian inscriptions are given by M. Fraenkel in the _Corpus Inscriptionum Graecarum_ IV, 951-6, and are discussed by Mary Hamilton (Mrs. Guy Dickins), _Incubation_, St. Andrews, 1906, from whose translation I have quoted. Further inscriptions are given by Cavvadias in the _Archaiologike Ephemeris_, 1918, p. 155 (issued 1921).

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 εγκοιμησις {enkoimêsis}, _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.[80] 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.

[80] We are almost told as much in the apocryphal _Gospel of Nicodemus_, § 1, a work probably composed about the end of the fourth century.

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.[81] 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[82] (see Figs. 3, 4).

[81] Astley Paston Cooper, _Treatise on Dislocations and Fractures of the Joints_, London, 1822, and _Observations on Fractures of the Neck and the Thighbone_, &c., London, 1823.

[82] This famous manuscript is known as Laurentian, Plutarch 74, 7, and its figures have been reproduced by H. Schöne, _Apollonius von Kitium_, Leipzig, 1896.

[Illustration: From MS. of APOLLONIUS OF KITIUM, of Ninth Century Copied from pre-christian original

Fig. 3 REDUCING DISLOCATED SHOULDER

Fig. 4 REDUCING DISLOCATED JAW]

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 note-book κατ' ιητρειον {kat' iêtreion}, _Concerning the Surgery_, or the more elaborate treatise περι ιητρου {peri iêtrou}, _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 Attic origin of the earlier part of the fifth century, and, therefore, a generation before Hippocrates (see fig. 5). There are also several beautiful representations on vases of the actual processes of bandaging (fig. 6).

[Illustration: FIG. 5. A GREEK CLINIC OF ABOUT 480-470 B. C. From a vase-painting.

In the centre sits a physician holding a lancet and bleeding a patient from the median vein at the bend of the right elbow into a large open basin. Above and behind the physician are suspended three cupping vessels. To the right sits another patient awaiting his turn; his left arm is bandaged in the region of the biceps. The figure beyond him smells a flower, perhaps as a preservative against infection. Behind the physician stands a man leaning on a staff; he is wounded in the left leg, which is bandaged. By his side stands a dwarfish figure with disproportionately large head, whose body exhibits deformities typical of the developmental disease now known as _Achondroplasia_; in addition to these deformities we note that his body is hairy and the bridge of his nose sunken; on his back he carries a hare which is almost as tall as himself. Talking to the dwarf is a man leaning on a long staff, who has the remains of a bandage round his chest.

See E. Pottier, 'Une Clinique grecque au V^{e} siècle (vase antique du collection Peztel)', _Fondation Eugène Piot, Monuments et Mémoires_, xiii. 149, Paris, 1906. (Some of our interpretations differ from those of M. Pottier.)]

[Illustration: FIG. 6. A kylix from the Berlin Museum of about 490 B. C. It bears the inscription ΣΟΣΙΑΣ ΕΠΟΙΗΣΕΝ {SOSIAS EPOIÊSEN}, _Sosias made_ (_me_), and represents Achilles bandaging Patroclus, the names of the two heroes being written round the margin. The painter is Euphronios, and the work is regarded as the masterpiece of that great artist. The left upper arm of Patroclus is injured, and Achilles is bandaging it with a two-rolled bandage, which he is trying to bring down to extend over the elbow. The treatment of the hands, a department in which Euphronios excelled, is particularly fine. Achilles was not a trained surgeon, and it will be observed, from the position of the two tails of the bandage, that he will have some difficulty when it comes to its final fastening!]

Among the surgical procedures of which descriptions are to be found in the Hippocratic writings are the opening of the chest for the condition known as _empyema_ (accumulation of pus within the pleura frequently following pneumonia), and trephining the skull in cases of fracture of that part--two fundamental operations of modern surgery. Surgical art has advanced enormously in our own times, yet a text-book containing much that is useful to this day might be prepared from these surgical contents of the collection alone.

When we pass to the works on Medicine, in the restricted sense, we enter into a region more difficult and perhaps even more fascinating. We are no longer dealing with simple lesions of known origin, but with the effects of disease and degeneration, of the essential character of which the Hippocratic writers could in the nature of the case know very little. Rigidly guarding themselves from any attempt to explain disease by more immediate and hypothetical causes and thus diverting the reader's energies in the medically useless direction of vague speculation--the prevalent mental vice of the Greeks--the best of these physicians are content if they can put forward generalized conclusions from actually observed cases. Many of their thoughts have now become household words, and they have become so, largely as a direct heritage from these ancient physicians. But it must be remembered that ideas so familiar to us were with them the result of long and carefully recorded experience and are like nothing that we encounter in the medicine of other ancient nations. Such conclusions are best set forth perhaps in the wonderful book of the _Aphorisms_ from which we may permit ourselves a few quotations:

'Life is short, and the Art long; the opportunity fleeting; experiment dangerous, and judgement difficult. Yet we must be prepared not only to do our duty ourselves, but also patient, attendants, and external circumstances must co-operate.'[83]

[83] The first lines are the source of the famous lines in Goethe's _Faust_:

'Ach Gott! die Kunst ist lang Und kurz ist unser Leben, Mir wird bei meinem kritischen Bestreben Doch oft um Kopf und Busen bang.'

In this one memorable paragraph, so condensed in the original as to be almost untranslatable, he who 'first separated medicine from philosophy' puts aside at once all speculative interest while in the actual presence of the sick. His whole energy is concentrated on the case in hand with that peculiar attitude, at once impersonal and intensely personal, that has since been the mark of the physician, and that has made of Medicine both a science and an art.

'For extreme diseases, extreme methods of cure.'[84]

'The aged endure fasting most easily; next adults; next young persons, and least of all children, and especially such as are the most lively.'

'Growing bodies have the most innate heat; they therefore require the most nourishment, and if they have it not they waste. In the aged there is little heat, and therefore they require little fuel, for it would be extinguished by much. Similarly fevers in the aged are not so acute, because their bodies are cold.'

'In disease sleep that is laborious is a deadly symptom; but if sleep relieves it is not deadly.'

'Sleep that puts an end to delirium is a good symptom.'

'If a convalescent eats well, but does not put on flesh, it is a bad symptom.'

'Food or drink which is a little less good but more palatable is to be preferred to such that is better but less palatable.'

'The old have generally fewer complaints than young; but those chronic diseases which do befall them generally never leave them.'

[84] The extreme of treatment refers in the original to the extreme restriction of diet, ες ακριβειην {es akribeiên}, but the meaning of the Aphorism has always been taken as more generalized.

Here we have a group of observations, some of which have become literally household words, nor is it difficult to understand how such sayings have passed from professional into lay keeping. This magnificent book of _Aphorisms_ was very early translated into Latin, probably before and certainly not later than the sixth century of the Christian era, and thus became accessible throughout the West. Manuscripts of this Latin version, dating from the ninth and tenth centuries of our era, have survived in the actual places in which they were written, at Monte Cassino in Southern Italy and at Einsiedeln in Switzerland, and in 991 the book of _Aphorisms_ was well known and closely studied at the Cathedral school of Chartres. From France the _Aphorisms_ reached England, and they are mentioned in documents of the tenth or eleventh century. By now, too, the book had been translated into Syriac and later into Arabic and Hebrew, so that in the true mediaeval period it was known both East and West, and in the vernacular as well as the classical tongues. From the oriental dialects several further translations were again made into Latin. An enormous number of manuscripts of the work have survived in almost every Western dialect, and these show on the whole that the text has been surprisingly little tampered with. In the middle of the thirteenth century some of the better-known Aphorisms were absorbed into a very popular Latin poem that went forth in the name of the medical school of Salerno, though with a false ascription to a yet earlier date. The Salernitan poem, being itself translated into every European vernacular, further helped to bring Hippocrates into every home.

But by no means all the Aphorisms are of a kind that could well become absorbed into folk medicine. It is only those concerning frequently recurring states to which this fate could befall. The book contains also a number of notes on rare conditions seldom seen or noted save by medical men. Such are the following very acute observations:

'Spasm supervening on a wound is fatal.'

'Those seized with tetanus die within four days, or if they survive so long they recover.'

'A convulsion, or hiccup, supervening on a copious discharge of blood is bad.'

'If after severe and grave wounds no swelling appears, it is very serious.'

These four sentences all concern wounds. The first two refer to the disease _tetanus_, which is very liable to supervene on wounds fouled with earth, especially in hot and moist localities. The disease is characterized by a series of painful muscular contractions which in the more severe and fatal form may become a continuous spasm, a type that is referred to in the first sentence. It is true of tetanus that the later the onset after the wound is sustained the better the chance of recovery. This is brought out by the second sentence. The third and fourth sentences record untoward symptoms following a severe wound, now well recognized and watched for by every surgeon. There were, of course, innumerable illustrations of the truth of these Aphorisms in extensive wounds, especially those involving crushed limbs, in the late war.

'Phthisis occurs most commonly between the ages of eighteen and thirty-five.'

'Diarrhœa supervening on phthisis is mortal.'

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.

[Illustration: Fig. 7. ATHENIAN FUNERARY MONUMENT 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.]

'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 περι νουσων {peri nousôn}, _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.[85] 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.

[85] 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 περι διαφορας πυρετων {peri diaphoras pyretôn}, _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.

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.[86] 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.

[86] 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 (καλαμος ὡ γραφομεν {kalamos hô graphomen}), because it seemed to him, as Galen tells us, to resemble the pens then in use in Alexandria.[87] We still use, too, his term _duodenum_ (δωδεκαδακτυλος εκφυσις {dôdekadaktylos ekphysis} = twelve-finger extension), for as Galen assures us, Herophilus 'so named the first part of the intestine before it is rolled into folds'.[88] 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.

[87] Galen, περι ανατομικων εγχειρησεων {peri anatomikôn encheirêseôn}, _On anatomical preparations_, ix. 5 (last sentence).

[88] Galen, περι φλεβων και αρτηριων ανατομης {peri phlebôn kai artêriôn anatomês}, _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.'[89] 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.[90]

[89] 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.

[90] 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 περι αιτιων {peri aitiôn}, _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'.[91] 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.

[91] 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.

[Illustration: Fig. 8. VOTIVE TABLET representing cupping and bleeding instruments from Temple of Asclepius at Athens. In centre is represented a folding case containing scalpels of various forms. On either side are cupping vessels.]

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.

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.

Rufus of Ephesus, a little junior to Dioscorides, has left us the first formal work on human anatomy and is of some importance in the history of comparative anatomy. In medicine he is memorable as the first to have described bubonic plague, and in surgery for his description of the methods of arresting haemorrhage and his knowledge of the anatomy of the eye. A work by him _On gout_ was translated into Latin in the sixth century, but remained unknown till modern times.

Soranus of Ephesus (A. D. _c._ 90-_c._ 150), an acute writer on gynaecology, has left a book which illustrates well the anatomy of his day. It exercised an influence for many centuries to come, and a Latin abstract of it prepared about the sixth century by one Moschion has come down to us in an almost contemporary manuscript.[92] It is interesting as opposing the Hippocratic theory that the male embryo is originated in the right and the female in the left half of the womb, a fallacy derived originally from Empedocles and Parmenides, but perpetuated by Latin translations of the Hippocratic treatises until the seventeenth century. His work was adorned by figures, and some of these, naturally greatly altered by copyists, but still not infinitely removed from the facts, have survived in a manuscript of the ninth century, and give us a distant idea of the appearance of ancient anatomical drawings.[93] We may assist our imagination a little further, in forming an idea of what such diagrams were like, with the help of certain other mediaeval figures representing the form and distribution of the various anatomical 'systems', veins, arteries, nerves, bones, and muscles which are probably traceable to an Alexandrian origin.[94]

[92] Leyden Voss 4° 9^{*} of the sixth century is a fragment of this work.

[93] V. Rose, _Sorani Ephesii vetus translatio Latina cum additis Graeci textus reliquiis_, Leipzig, 1882; F. Weindler, _Geschichte der gynäkologisch-anatomischen Abbildung_, Dresden, 1908.

[94] The discovery and attribution of these figures is the work of K. Sudhoff. A bibliography of his writings on the subject will be found in a 'Study in Early Renaissance Anatomy' in C. Singer's _Studies in the History and Method of Science_, vol. i, Oxford, 1917.

Aretaeus of Cappadocia was probably a contemporary of Galen (second half of the second century A. D.). As a clinical author his reputation stands high, perhaps too high, his descriptions of pneumonia, empyema, diabetes, and elephantiasis having especially drawn attention. In treatment he uses simple remedies, is not affected by polypharmacy, and suggests many ingenious mechanical devices. It would appear that Aretaeus is not an independent writer, but mainly a compiler. He relies largely on Archigenes, a distinguished physician contemporary with Juvenal, whose works have perished save the fragments preserved in this manner by Aretaeus and Aetius. Aretaeus was a very popular writer among the Greeks in all ages, but he was not translated into Latin, and was unknown in the West until the middle of the sixteenth century.[95] He is philologically interesting as still using the Ionic dialect.

[95] First Latin edition Venice, 1552; first Greek edition Paris, 1554.

There remains the huge overshadowing figure of Galen. The enormous mass of the surviving work of this man, the dictator of medicine until the revival of learning and beyond, tends to throw out of perspective the whole of Greek medical records. The works of Galen alone form about half of the mass of surviving Greek medical writings, and occupy, in the standard edition, twenty-two thick, closely-printed volumes. These cover every department of medicine, anatomy, physiology, pathology, medical theory, therapeutics, as well as clinical medicine and surgery. In style they are verbose and heavy and very frequently polemical. They are saturated with a teleology which, at times, becomes excessively tedious. In the anatomical works, masses of teleological explanation dilute the account of often imperfectly described structures. Yet to this element we owe the preservation of the mass of Galen's works, for his intensely teleological point of view appealed to the theological bias both of Western Christianity and of Eastern Islam. Intolerable as literature, his works are a valuable treasure house of medical knowledge and experience, custom, tradition, and history.

As in the case of the Hippocratic corpus, so in the case of the Galenic corpus we are dealing to some extent with material from various sources. In the case of Galen, however, we have a good standard of genuineness, for he has left us a list of his books which can be checked off against those which we actually possess. The general standpoint of the Galenic is not unlike that of the Hippocratic writings, but the noble vision of the lofty-minded, pure-souled physician has utterly passed away. In his place we have an acute, honest, very contentious fellow, bristling with energy and of prodigious industry, not unkindly, but loving strife, a thoroughly 'aggressive' character. He loves truth, but he loves argument quite as much. The value of his philosophical writings, of which some have survived, cannot be discussed here, but it is evident that he is frequently satisfied with purely verbal explanations. An ingenious physiologist, a born experimenter, an excellent anatomist and eager to improve, possessing a good knowledge of the human skeleton and an accurate acquaintance with the internal parts so far as this can be derived from a most industrious devotion to dissection of animals, equipped with all the learning of the schools of Pergamon, Smyrna, and Alexandria, and rich with the experience of a vast practice at Rome, Galen is essentially an 'efficient' man. He has the grace to acknowledge constantly and repeatedly his indebtedness to the Hippocratic writings. Such was the man