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, 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.
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.
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), 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 = 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.