Part 9

The general state of health of the body was considered by the Hippocratists to depend on the distribution of the four elements, earth, air, fire, and water, whose mixture (_crasis_) and cardinal properties, dryness, warmth, coldness, and moistness, form the body and its constituents. To these correspond the cardinal fluids, blood, phlegm, yellow bile and black bile. The fundamental condition of life is the _innate heat_, the abdication of which is death. This innate heat is greatest in youth when most fuel is therefore required, but gradually declines with age. Another necessity for the support of life is the _pneuma_ which circulates in the vessels. All this may seem fanciful enough, but we may remember that the first half of the nineteenth century had waned before the doctrine of the humours which had then lasted for at least twenty-two centuries became obsolete, and perhaps it still survives in certain modern scientific developments. Moreover, the finest and most characteristic of the Hippocratic works either do not mention or but casually refer to these theories which are not essential to their main pre-occupation. Their task of observation of symptoms, of the separation of the essentials from the accidents of disease, and of generalization from experience could go on unaffected by any view of the nature of man and of the world. Even treatment, which must almost of necessity be based on _some_ theory of causation, was little deflected by a view of elements and humours on which it was impossible to act directly, while therapeutics was further safeguarded from such influence by the doctrine of _Nature as the healer of diseases_, νούσων φύσεις ἰητροί, the _vis medicatrix naturae_ of the later Latin writers and of the present day.

Diseases are to be cured, in the Hippocratic view, by restoring the disturbed harmony in the relation of the elements and humours. These, in fact, tend naturally to an equilibrium and in most cases if left to themselves will be brought to this state by the natural tendency to recovery. The process is known as _pepsis_ or, to give it the Latin form, _coctio_, and the turning-point at which the effects of this process exhibit themselves is the _crisis_, a term which, together with some of its original content, has still a place in medicine. Such a turning-point does in fact occur in many diseases, especially those of a zymotic character, on certain special days, though undue emphasis was laid by the Greek physicians upon the exact numerical character of the event. It was no unimportant duty of the physician to assist nature by bringing his remedies to bear at the critical times. If the crisis is wanting, or if the remedies are applied at the wrong moment, the disease may become incurable. But diseases were only immediately or proximately caused by disturbances in the balance or harmony of the humours. This was a mere hypothesis, as the Hippocratists themselves well knew. There were other more remote causes which came into the actual purview of the physician, conditions which he could and did study. Such conditions were, for instance, injudicious modes of life, exposure to climatic changes, advancing age, and the like. Many of these could be directly corrected. But for those that could not there were various therapeutic measures at hand.

That human bodies are and normally remain in a state of health, and that on the whole they tend to recover from disease, is an attitude so familiar to us to-day that we scarcely need to be reminded of it. We live some twenty-three centuries later than Hippocrates; for some sixteen of those centuries the civilized world thought that to retain health periodical bleedings and potions were necessary; for the last century or two we have been gradually returning on the Hippocratic position!

The chief glory of the Hippocratic collection regarded from the clinical point of view is perhaps the actual description of cases. A number of these—forty-two in all—have survived.[118] They are not only unique as a collection for nearly 2,000 years, but they are still to this day models of what succinct clinical records should be, clear and short, without a superfluous word, yet with all that is most essential, and exhibiting merely a desire to record the most important facts without the least attempt to prejudge the case. They illustrate to the full the Greek genius for seizing on the essential. The writer show’s not the least wish to exalt his own skill. He seeks merely to put the data before the reader for his guidance under like circumstances. It is a reflex of the spirit of full honesty in which these men lived and worked that the great majority of the cases are recorded to have died. Two of this remarkable little collection may be given:

‘The woman with quinsy, who lodged with Aristion: her complaint began in the tongue; voice inarticulate; tongue red and parched. _First day_, shivered, then became heated. _Third day_, rigor, acute fever; reddish and hard swelling on both sides of neck and chest; extremities cold and livid; respiration elevated; drink returned by the nose; she could not swallow; alvine and urinary discharges suppressed. _Fourth day_, all symptoms exacerbated. _Fifth day_, she died.’

[118] They are to be found as an Appendix to Books I and III of the _Epidemics_ and embedded in 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.[119] 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’.

[119] 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 Asklepius 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.’[120]

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 ἐγκοίμησις, _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.[121] 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.

[120] 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).

[121] 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.[122] 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[123] (see Figs. 3, 4).

[122] 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.

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

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 notebook κατ’ ἰητρεῖον, _Concerning the Surgery_, or the more elaborate treatise περὶ ἰητροῦ, _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 Ionic origin which is of the fifth century and therefore about contemporary with Hippocrates himself (see fig. 5). There are also several beautiful representations on vases of the actual processes of bandaging (fig. 6).

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.’[124]

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.’[125]

[124] 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.’

[125] The extreme of treatment refers in the original to the extreme restriction of diet, ἐς ἀκριβείην, but the meaning of the Aphorism has always been taken as more generalized.

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