From MS. of APOLLONIUS OF KITIUM, of Ninth CenturyCopied from a pre-Christian originalFig. 3.REDUCING DISLOCATED SHOULDERFig. 4.REDUCING DISLOCATED JAW
From MS. of APOLLONIUS OF KITIUM, of Ninth CenturyCopied from a pre-Christian original
Fig. 3.REDUCING DISLOCATED SHOULDER
Fig. 3.REDUCING DISLOCATED SHOULDER
Fig. 4.REDUCING DISLOCATED JAW
Fig. 4.REDUCING DISLOCATED JAW
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 asempyema(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 heritagefrom 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 theAphorismsfrom which we may permit ourselves a few quotations:
Fig. 5.A GREEK CLINIC OF ABOUT 400b.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 asAchondroplasia; 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 Vᵉ 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.)
Fig. 5.A GREEK CLINIC OF ABOUT 400b.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 asAchondroplasia; 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 Vᵉ 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.)
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 asAchondroplasia; 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 Vᵉ 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.)
Fig. 6.A kylix from the Berlin Museum of about 490b. c.It bears the inscriptionΣΟΣΙΑΣ ΕΠΟΙΗΣΕΝ,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!
Fig. 6.
A kylix from the Berlin Museum of about 490b. c.It bears the inscriptionΣΟΣΙΑΣ ΕΠΟΙΗΣΕΝ,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!
‘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]
‘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.’
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 ofAphorismswas 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 ofAphorismswas well known and closely studied at the Cathedral school of Chartres. From France theAphorismsreached 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 frequentlyrecurring 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 diseasetetanus, 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 theAphorismsfor 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.
‘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 passiveobservation; 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 περὶ νούσων,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 asHippocratic 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 knownpleuritic rubwhich 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 allantiquity were as yet ignorant of the nature, and were but dimly aware of the existence, of infection.[126]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 commonconsent 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.
Fig. 7.ATHENIAN FUNERARY MONUMENTSecond centurya. d.British MuseumInscription reads: ‘Jason, also called Dekmos, the Acharnian, a physician’,followed by his genealogy. By side of patient stands a cupping vessel.
Fig. 7.ATHENIAN FUNERARY MONUMENTSecond centurya. 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.
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, andMethodists 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.[127]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 onanatomy 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 thetorcular 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 thecalamus scriptorius, which still bears the name which he gave it (κάλαμος ῷ γράφομεν), because it seemed to him, as Galen tells us, to resemble the pens then in use in Alexandria.[128]We still use, too, his termduodenum(δωδεκαδάκτυλος ἔκφυσις = twelve-finger extension), for as Galen assures us, Herophilus ‘so named the first part of the intestine before it is rolled into folds‘.[129]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.
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.’[130]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.[131]
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 100b. c.In his book περὶ αἰτιῶν,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 aligament 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’.[132]This passage contains the first description of the structure known to modern anatomists as theligamentum 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.
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 centuryb. 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 withit 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 thearea Celsi, a not uncommon disease of the skin. TheDe re medicais 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.
After Celsus comes Dioscorides in the first centurya. 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.
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.
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.
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.
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 himOn goutwas 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.[133]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.[134]We may assist our imagination a little further, in forming an idea of what such diagrams were like, with the help ofcertain 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.[135]
Aretaeus of Cappadocia was probably a contemporary of Galen (second half of the second centurya. d.). As a clinical author his reputation stands high, perhaps too high, his descriptions of pneumonia, emphysema, 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.[136]He is philologically interesting as still using the Ionic dialect.
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 whose remains, along with the Hippocratic collection, formed the main medical legacy of Greece to the Western world.
Some of Galen’s works are mere drug lists, little superior to those of Dioscorides;[137]with the depression of the intelligence that corresponded with the break up of the Roman Empire, it was these that were chiefly seized on and distributed in the West. Attractive too to the debased intellect of the late Roman world were certain spurious, superstitious, and astrological works that circulated in the name of Galen and Hippocrates.[138]The Greek medical writers after Galen were but his imitators and abstractors, but through some of them Galen’s works reached the West at a very early period in the Middle Ages. Such abstractors who were early translated into Latin were Oribasius (325-403), Paul of Aegina (625-690), and Alexander of Tralles (525-605). Of the best and most scientific of Galen’s works the Middle Ages knew little or nothing.
Later Galen and Hippocrates became a little more accessible, not by translation from the Greek, but by translation from the Arabic of a Syriac version. The first work to be so rendered was a version ofAphorismsof Hippocrates which, however, as we have seen, were already available in Latin dress, together with the HippocraticRegimen in acute diseases, and certain works of Galen as corruptly interpreted by Isaac Judaeus. These were rendered from Arabic into Latin by Constantine, an African adventurer who became a monk at Monte Cassino and died there in 1087. Constantine was a wretched craftsman with an imperfect knowledge of both Arabic and Latin. More effectivewas the great twelfth century translator from the Arabic, Gerard of Cremona (died 1185), who turned many medical works into Latin from Arabic, and who was followed by a whole host of imitators. Yet more important for the advance of medicine, however, was the learned revival of the thirteenth century. In the main that revival was based on translations from Arabic, but a certain number of works were also rendered direct from the Greek. During the thirteenth century Aristotle’s scientific works began to be treated in this way, but more important for the course of medicine were those of Galen, and they had to wait till the following century. The long treatise of Galen, περὶ χρείας τῶν ἐν ἀνθρώπου σώματι μορίων,On the uses of the bodily parts in man, was translated from the Greek into Latin by Nicholas of Reggio in the earlier part of the fourteenth century. This work, with all its defects, was by far the best account of the human body then available. Many manuscripts of the Latin version have survived, and it was translated into several vernaculars, including English, and profoundly influenced surgery. The rendering into Latin of this treatise, and its wide distribution, may be regarded as the starting-point of modern scientific medicine. Its appearance is moreover a part of the phenomenon of the revived interest in dissection which had begun to be practised in the Universities in the thirteenth century,[139]and was a generally accepted discipline in the fourteenth and fifteenth.[140]
Until the end of the fifteenth century progress in anatomy was almost imperceptible. During the fifteenth century more Galenic and Hippocratic texts were recovered and gradually turned into Latin, but still without vitally affecting the course of Anatomy. The actual printing of collected editions of Hippocrates and Galen came rather late, for the debased taste of the Renaissance physicians continued to prefer Dioscorides and the Arabs, of whom numerous editions appeared, so that medicine made no advance corresponding to the progress of scholarship. The Hippocratic works were first printed in 1525, and an isolated edition of the inferior Galen in 1490, but the real advance in Medicine was not made by direct study of these works. So long as they were treated in the old scholastic spirit such works were of no more value than those of the Arabists or others inherited from the Middle Ages. Even Hippocrates can be spoilt by a commentary, and it was not until the investigator began actually to compare his own observations with those of Hippocrates and Galen that the real value of these works became apparent. The department in which this happened first was Anatomy, and such revolutionaries as Leonardo da Vinci (1452-1518), who never published, and Vesalius (1514-1564), whose great work appeared in 1543, were really basing their work on Galen, though they were much occupied in proving Galen’s errors. Antonio Benivieni (died 1502), an eager prophet of the new spirit, revived the Hippocratic tradition by actually collecting notes of a few cases with accompanying records of deaths and post-mortem findings, among which it is interesting to observe a case of appendicitis.[141]His example was occasionally followed during the sixteenth century, as for instance, by the Portuguese Jewish physician Amatus Lusitanus (1511-c.1562), who printed no fewer than seven hundred cases; but the real revival of the Hippocratic tradition came in the next century with Sydenham (1624-1689) and Boerhaave (1668-1738), who were consciously working on the Hippocratic basis and endeavouring to extend the Hippocratic experience.
Lastly surgery came to profit by the revival. The greatest of the sixteenth century surgeons, the lovable and loving Ambroise Paré (1510-1590), though he was, as he himself humbly confessed, an ignorant man knowing neither Latin nor Greek, can be shown to have derived much from the works of antiquity, which were circulating in translation in his day and were thus filtering down to the unlearned.
Texts of Hippocrates and of Galen had formed an integral part in the medical instruction of the universities from their commencement in the thirteenth century. The first Greek text of theAphorismsof Hippocrates appeared in 1532, edited by no less a hand than that of François Rabelais. With the further recovery of the Greek texts and preparation of better translations, these became almost the sole mode of instruction during the fifteenth and sixteenth centuries. The translators became legion and their competence varied. One highly skilled translator, however, is of special interest to English readers. Thomas Linacre (1460?-1524), Physician to Henry VIII, Tutor to the Princess Mary, founder and first president of the College of Physicians, a benefactor of both the ancient Universities and one of the earliest, ablest, most typical, and most exasperating of the English humanists, spent much energy on this work of translation for which his abilities peculiarly fitted him. He was responsible for no less than six important works of Galen, of which one, theDe temperamentis et de inaequali intemperie, printed at Cambridge in 1521, was among the earliest books impressed in that town and is said to be the first printed in England for which Greek types were used. It has been honoured by reproduction in facsimile in modern times. Such works as these, purely literary efforts, had great vogue for a century and more, and were much in use in the Universities. These humanisticproducts sometimes produced, among the advocates of the new scientific method, a degree of fury which was only rivalled by that of some of the humanists themselves towards the translators from the Arabic. But these are now dead fires. As the clinical and scientific methods of teaching gained ground, textual studies receded in medical education, as Hippocrates and Galen themselves would have wished them to recede.
The texts of Hippocrates and Galen have now ceased to occupy a place in any medical curriculum. Yet all who know these writings, know too, not only that their spirit is still with us, but that the works themselves form the background of modern practice, and that their very phraseology is still in use at the bedside. Modern medicine may be truly described as in essence a creation of the Greeks. To realize the nature of our medical system, some knowledge of its Greek sources is essential. It would indeed be a bad day for medicine if ever this debt to the Greeks were forgotten, and the loss would be at least as much ethical as intellectual. But there is happily no fear of this, for the figure and spirit of Hippocrates are more real and living to-day than they have been since the great collapse of the Greek scientific intellect in the third and fourth centuries of the Christian era.
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