Part 8

Just as the Cnidians by dividing up diseases according to symptoms over-emphasized diagnosis and over-elaborated treatment, so the Coans laid very great force on prognosis and adopted therefore a largely expectant attitude towards diseases. Both Cnidian and Coan physicians were held together by a common bond which was, historically if not actually, related to temple worship. Physicians leagued together in the name of a god, as were the Asclepiadae, might escape, and did escape, the baser theurgic elements of temple medicine. Of these they were as devoid as a modern Catholic physician might be expected to be free from the absurdities of Lourdes. But the extreme cult of prognosis among the Coans may not improbably be traced back to the medical lore of the temple soothsayers whose divine omens were replaced by indications of a physical nature in the patient himself.[105] We are tempted too to link it with that process of astronomical and astrological prognosis practised in the Mesopotamian civilizations from which Ionia imitated and derived so much. Religion had thus the same relation to medicine that it would have with a modern ‘religious’ medical man as suggesting the motive and determining the general direction of his practice though without influence on the details and method.

[105] There is a discussion of the relation of the Asclepiadae to temple practice in an article by E. T. Withington, ‘The Asclepiadae and the Priest of Asclepius,’ in _Studies in the History and Method of Science_, edited by Charles Singer, vol. ii, Oxford, 1921.

During the development of the Coan medical school along these lines in the sixth and fifth centuries, there was going on a most remarkable movement at the very other extreme of the Greek world. Into the course and general importance of Sicilian philosophy it is not our place to enter, but that extraordinary movement was not without its repercussion on medical theory and practice. Very important in this direction was Empedocles of Agrigentum (_c._ 500-_c._ 430 B. C.). His view that the blood is the seat of the ‘innate heat’, ἔμφυτον θερμόν, he took from folk belief—‘the blood is the life’—and this innate heat he closely identified with soul. More profitable was his doctrine that breathing takes place not only through what are now known as the respiratory passages but also through the pores of the skin. His teaching led to a belief in the heart as the centre of the vascular system and the chief organ of the ‘pneuma’ which was distributed by the blood vessels. This pneuma was equivalent to both soul and life, but it was something more. It was identified with air and breath, and the pneuma could be seen to rise as shimmering steam from the shed blood of the sacrificial victim—for was not the blood its natural home? There was a pneuma, too, that interpenetrated the universe around us and gave it those qualities of life that it was felt to possess. Anaximenes (_c._ 610-_c._ 545 B. C.), an Ionian predecessor of Empedocles, may be said to have defined for us these functions of the pneuma; οῖον ἡ ψυχὴ ἡ ἡμετέρα ἀὴρ οῧσα συγκρατεί ἡμᾶς, ὅλον τὸν κόσμον πνεῦμα καὶ ἀὴρ περιέχει ‘As our soul, being air, sustains us, so pneuma and air pervade the whole universe’;[106] but it is the speculation of Empedocles himself that came to be regarded as the basis of the Pneumatic School in Medicine which had later very important developments.

[106] The works of Anaximenes are lost. This phrase of his, however, is preserved by the later writer Aetios.

Another early member of the Western school who made important contributions to medical doctrine—in which relation alone we need consider him—was Pythagoras of Samos (_c._ 580-_c._ 490 B. C.). For him number, as the purest conception, formed the basis of philosophy. Unity was the symbol of perfection and corresponded to God Himself. The material universe was represented by 2, and was divided by the number 12, whence we have 3 worlds and 4 spheres. These in turn, according at least to the later Pythagoreans, give rise to the four elements, earth, air, fire, and water—a primary doctrine of medicine and of science derived perhaps from ancient Egypt and surviving for more than two millennia. The Pythagoreans taught, too, of the existence of an animal soul, an emanation of the soul of the universe. In all this we may distinguish the germ of that doctrine of the relation of man and universe, microcosm and macrocosm, which, suppressed as irrelevant in the Hippocratic works, reappears in the Platonic and especially in the Neoplatonic writings, and forms a very important dogma in later medicine.

A pupil of Pythagoras and an older contemporary of Empedocles was Alcmaeon of Croton (_c._ 500 B. C.), who began to construct a positive basis for medical science by the practice of dissection of animals, and discovered the optic nerves and the Eustachian tubes. He even extended his researches to Embryology, describing the head of the foetus as the first part to be developed—a justifiable deduction from appearances. Alcmaeon introduced also the doctrine that health depends on harmony, disease on discord of the elements within the body. Curiosity as to the distribution of the vessels was excited by Empedocles and Alcmaeon and led to further dissection, and Alcmaeon’s pupils Acron (_c._ 480 B. C.) and Pausanias (_c._ 480 B. C.), and the later Philistion of Lokri,[107] the contemporary of Plato, all made anatomical investigations.

[107] For the work of these physicians see especially M. Wellmann, _Fragmentsammlung der griechischen Aerzte_, Bd. I, Berlin, 1901.

The views of Empedocles, and especially his doctrine that regarded the heart as the main site of the pneuma, though rejected by the Coan school as a whole, were not without influence on Ionia. Diogenes of Apollonia, the philosopher of pneumatism, a late fifth century writer who must have been contemporary with Hippocrates the Great, himself made an investigation of the blood vessels; and the influence of the same school may be traced in a little work περὶ καρδίης, _On the heart_, which is the best anatomical treatise of the Hippocratic Collection. This work describes the aorta and the pulmonary artery as well as the three valves at the root of each of the great vessels, and it speaks of experiments to test their validity. It treats of the pericardium and of the pericardial fluid and perhaps of the musculi papillares, and contrasts the thickness of the walls of right and left ventricles. The author considers that the left ventricle is empty of blood—as indeed it is after death—and is the source of the innate heat and of the absolute intelligence. These views fit in with the doctrines of Empedocles, so that we may perhaps even venture to regard this work as a surviving document of the Sicilian school. It is interesting to observe that we have here the first hint of human dissection, for the author tells us that the hearts of animals may be compared to that of man. The distinction of having been the first to write on human anatomy, as such, belongs however, probably to a later writer, Diocles, son of Archidamus of Carystus, who lived in the fourth century B. C.[108]

[108] Galen, περὶ ἀνατομικῶν ἐγχειρήσεων, _On anatomical preparations_, § 1, K. II, p. 282.

We may now turn to the Hippocratic Corpus as a whole. This collection consists of about 60 or 70 separate works, written at various periods and in various states of preservation. At best only a very small proportion of them can be attributed to Hippocrates, but the discussion of the general question of the ‘genuineness’ of the works is now admitted to be futile, for it is certain that we have no criteria whatever to determine whether or no a particular work be from the pen of the Father of Medicine, and the most we can ever say of such a treatise is that it appears to be of his school and in his spirit. Yet among the great gifts of this collection to our time and to all time are two which stand out above all others, the picture of a man, and the picture of a method.

The man is Hippocrates himself. Of the actual details of his life we know next to nothing. His period of greatest activity falls about 400 B. C. He seems to have led a wandering life. Born of a long line of physicians in the island of Cos, he exerted his activities in Thrace, Abdera, Delos, the Propontis (Cyzicus), Thasos, Thessaly (notably at Larissa and Meliboea), Athens, and elsewhere, dying at Larissa in extreme old age about the year 377 B. C. He had many pupils, among whom were his two sons Thessalus and Dracon, who also undertook journeys, his son-in-law Polybus, of whose works a fragment has been preserved for us by Aristotle,[109] together with three other Coans bearing the names Apollonius, Dexippus, and Praxagoras. This is practically all we know of him with certainty. But though this glimpse is very dim and distant, yet we cannot exaggerate the influence on the course of medicine and the value for physicians of all time of the traditional picture that was early formed of him and that may indeed well be drawn again from the works bearing his name. In beauty and dignity that figure is beyond praise. Perhaps gaining in stateliness what he loses in clearness, Hippocrates will ever remain the type of the perfect physician. Learned, observant, humane, with a profound reverence for the claims of his patients, but an overmastering desire that his experience shall benefit others, orderly and calm, disturbed only by anxiety to record his knowledge for the use of his brother physicians and for the relief of suffering, grave, thoughtful and reticent, pure of mind and master of his passions, this is no overdrawn picture of the Father of Medicine as he appeared to his contemporaries and successors. It is a figure of character and virtue which has had an ethical value to medical men of all ages comparable only to the influence exerted on their followers by the founders of the great religions. If one needed a maxim to place upon the statue of Hippocrates, none could be found better than that from the book Παραγγελίαι, _Precepts_:

ἢν γὰρ παρῆ φιλανθρωπίη πάρεστὶ καὶ φιλοτεχνίη ‘Where the love of man is, there also is love of the Art.’[110]

[109] _Historia animalium_, iii. 3, where it is ascribed to Polybus. The same passage is, however, repeated twice in the Hippocratic writings, viz. in the περὶ φύσιος ἀνθρώπου, _On the nature of man_, Littré, vi. 58, and in the περὶ ὀστέων φύσιος, _On the nature of bones_, Littré, ix. 174.

[110] Παραγγελίαι, § 6.

The numerous busts of him which have reached our time are no portraits. But the best of them are something much better and more helpful to us than any portrait. They are idealized representations of the kind of man a physician should be and was in the eyes of the best and wisest of the Greeks. (See Fig. 1.)

The method of the Hippocratic writers is that known to-day as the ‘inductive’. Without the vast scientific heritage that is in our own hands, with only a comparatively small number of observations drawn from the Coan and neighbouring schools, surrounded by all manner of bizarre oriental religions in which no adequate relation of cause and effect was recognized, and above all constantly urged by the exuberant genius for speculation of that Greek people in the midst of whom they lived and whose intellectual temptations they shared, they remain nevertheless, for the most part, patient observers of fact, sceptical of the marvellous and the unverifiable, hesitating to theorize beyond the data, yet eager always to generalize from actual experience; calm, faithful, effective servants of the sick. There is almost no type of mental activity known to us that was not exhibited by the Greeks and cannot be paralleled from their writings; but careful and constant return to verification from experience, expressed in a record of actual observations—the habitual method adopted in modern scientific departments—is rare among them except in these early medical authors.

The spirit of their practice cannot be better illustrated than by the words of the so-called ‘Hippocratic oath’:

‘I swear by Apollo the healer, and Asclepius, and Hygieia, and All-heal (Panacea) and all the gods and goddesses ... that, according to my ability and judgement, I will keep this Oath and this stipulation—to reckon him who taught me this Art as dear to me as those who bore me ... to look upon his offspring as my own brothers, and to teach them this Art, if they would learn it, without fee or stipulation. By precept, lecture, and all other modes of instruction, I will impart a knowledge of the Art to my own sons, and those of my teacher, and to disciples bound by a stipulation and oath according to the Law of Medicine, but to none other. I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; nor will I aid a woman to produce abortion. With purity and holiness I will pass my life and practise my Art.... Into whatever houses I enter, I will go there for the benefit of the sick, and will abstain from every act of mischief and corruption; and above all from seduction.... Whatever in my professional practice—or even not in connexion with it—I see or hear in the lives of men which ought not to be spoken of abroad, I will not divulge, deeming that on such matters we should be silent. While I keep this Oath unviolated, may it be granted me to enjoy life and the practice of the Art, always respected among men, but should I break or violate this Oath, may the reverse be my lot.’

Respected equally throughout the ages by Arab, Jew, and Christian, the oath remains the watchword of the profession of medicine.[111] The ethical value of such a declaration could not escape the attention even of a Byzantine formalist, and it is interesting to observe that in our oldest Greek manuscript of the Hippocratic text, dating from the tenth century, this magnificent passage is headed by the words ‘from the oath of Hippocrates according as it may be sworn by a Christian.’[112]

[111] It must, however, be admitted that even in the Hippocratic collection itself are cases of breach of the oath. Such, for instance, is the induction of abortion related in περὶ φύσιος παιδίον, _On the nature of the embryo_. There is evidence, however, that the author of this work was not a medical practitioner.

[112] Rome Urbinas 64, fo. 116.

When we examine the Hippocratic corpus more closely, we discern that not only are the treatises by many hands, but there is not even a uniform opinion and doctrine running through them. This is well brought out by some of the more famous of the phrases of this remarkable collection. Thus a well-known passage from the _Airs, Waters, and Places_ tells us that the Scythians attribute a certain physical disability to a god, ‘but it appears to me’, says the author, ‘that these affections are just as much divine as are all others and that no disease is either more divine or more human than another, but that all are equally divine, for each of them has its own nature, and none of them arise without a natural cause.’ But, on the other hand, the author of the great work on _Prognostics_ advises us that when the physician is called in he must seek to ascertain the nature of the affections that he is treating, and especially ‘if there be anything divine in the disease, and to learn a foreknowledge of this also.’[113] We may note too that this sentence almost immediately precedes what is perhaps the most famous of all the Hippocratic sentences, the description of what has since been termed the _Hippocratic facies_. This wonderful description of the signs of death may be given as an illustration of the habitual attitude of the Hippocratic school towards prognosis and of the very careful way in which they noted details:

[113] Kühlewein, i. 79, regards this as an interpolated passage.

‘He [the physician] should observe thus in acute diseases: first, the countenance of the patient, if it be like to those who are in health, _and especially if it be like itself, for this would be the best_; but the more unlike to this, the worse it is; such would be these: _sharp nose, hollow eyes, collapsed temples_; _ears cold, contracted, and their lobes turned out_; _skin about the forehead rough, distended, and parched_; _the colour of the whole face greenish or dusky_. If the countenance be so at the beginning of the disease, and if this cannot be accounted for from the other symptoms, inquiry must be made whether he has passed a sleepless night; whether his bowels have been very loose; or whether he is suffering from hunger; and if any of these be admitted the danger may be reckoned as less; and it may be judged in the course of a day and night if the appearance of the countenance proceed from these. But if none of these be said to exist, and the symptoms do not subside in that time, be it known for certain that death is at hand.’[114]

Again, in the work _On the Art [of Medicine]_ we read: ‘I hold it to be physicianly to abstain from treating those who are overwhelmed by disease’,[115] a prudent if inhumane procedure among a people who might regard the doctor’s powers as partaking of the nature of magic, and perhaps a wise course to follow at this day in some places not very far from Cos. Yet in the book _On Diseases_ we are advised even in the presence of an incurable disease ‘to give relief with such treatment as is possible’.[116]

[114] Littré, ii. 112; Kühlewein, i. 79. The texts vary: Kühlewein is followed except in the last sentence.

[115] Περὶ τέχνες, § 3.

[116] Περὶ νούσων α’, § 6.

Furthermore, works by authors of the Hippocratic school stand sometimes in a position of direct controversy with each other. Thus in the treatise _On the Heart_ an experiment is set forth which is held to prove that a part at least of imbibed fluid passes into the cavity of the lung and thence to the parts of the body, a popular error in antiquity which recurs in Plato’s _Timaeus_. This view, however, is specifically held to be fallacious by the author of the work _On Diseases_, who is supported by a polemical section in the surviving Menon fragment.

Passages like these have convinced all students that we have to deal in this collection with a variety of works written at different dates by different authors and under different conditions, a state that may be well understood when we reflect that among the Greeks medicine was a progressive study for a far longer period of time than has yet been the case in the Western world. An account of such a collection can therefore only be given in the most general fashion. The system or systems of medicine that we shall thus attempt to describe was in vogue up to the Alexandrian period, that is, to the beginning of the third century B. C.

Anatomy and physiology, the basis of our modern system, was still a very weak point in the knowledge of the pre-Alexandrians. The surface form of the body was intimately studied in connexion especially with fractures, but there is no evidence in the literature of the period of any closer acquaintance with human anatomical structure.[117] The same fact is well borne out by Greek Art, for in its noblest period the artist betrays no evidence of assistance derived from anatomization. Such evidence is not found until we come to sculpture of Alexandrian date, when the somewhat strained attitudes and exaggerated musculature of certain works of the school of Pergamon suggest that the artist derived hints, if not direct information, from anatomists who, we know, were active at that time. It is not improbable, however, that separate bones, if not complete skeletons, were commonly studied earlier, for the surgical works of the Hippocratic collection, and especially those on fractures and dislocations, give evidence of a knowledge of the relations of bones to each other and of their natural position in the body which could not be obtained, or only obtained with greatest difficulty, without this aid.

[117] A reference to dissection in the περὶ ἄρθρων, _On the joints_, § 1, appears of the present writer to be of Alexandrian date.

There are in the Hippocratic works a certain number of comparisons between human and animal structures that would have been made possible by surgical operations and occasional accidents. The view has been put forward that some anatomical knowledge was derived through the practice of augury from the entrails of sacrificial animals. It appears, however, improbable that a system so scientific and so little related to temple practice would have had much to learn from these sources, and, moreover, since we know that animals were actually dissected as early as the time of Alcmaeon it would be unnecessary to invoke the aid of the priests. The unknown author of the περὶ τόπων τῶν κατὰ ἄνθρωπον, _On the sites of [diseases] in man_, a work written about 400 B. C., declares indeed that ‘physical structure is the basis of medicine’, but the formal treatises on anatomy that we possess from Hippocratic times give the general anatomical standard of the corpus, and it is a very disappointing one. The tract _On Anatomy_, though probably of much later date (perhaps _c._ 330 B. C.), is inferior even to the treatise _On the Heart_ (perhaps of about 400 B. C.).

Physiology and Pathology are almost as much in the background as anatomy in the Hippocratic collection. As a formal discipline and part of medical education we find no trace of these studies among the pre-Alexandrian physicians. But the meagreness of the number of ascertained facts did not prevent much speculation among a people eager to seek the causes of things. Of that speculation we learn much from the fragments of contemporary medical writers and philosophers, from the medical works of the Alexandrian period, and to some extent from the Hippocratic writings themselves. But the wiser and more sober among the writers of the Hippocratic corpus were bent on something other than the causes of things. Their pre-occupation was primarily with the suffering patient, and the best of them therefore excluded—and we may assume consciously—all but the rarest references to such speculation.