1. Greek Medicine and Hippocrates

WE have learned to associate, almost by instinct, the science of medicine with bacteria, with chemistry, with clinical thermometers, disinfectants, and all the apparatus of careful nursing. All such associations, if we wish even dimly to appreciate the work of Hippocrates and of his predecessors, we must endeavour to break ; we must unthink the greater part of those habits of thought which education has made second nature. The Greek knew that there were certain collections of morbid phenomena which he called diseases ; that these diseases normally ran a certain course ; that their origin was not unconnected with geographical and atmospheric environment ; that the patient, in order to recover his health, must modify his ordinary mode of living. Beyond this he knew, and could know, nothing, and was compelled to fill up the blanks in his knowledge by having recourse to conjecture and hypothesis. In doing so he was obeying a human instinct which assures us that progress requires the use of stop-gaps where complete and accurate knowledge is unattainable, and that a working hypothesis, although wrong, is better than no hypothesis at all. System, an organized scheme, is of greater value than chaos. Yet however healthy such an instinct may be, it has

[p. x] added considerably to the difficulties of the historian in his attempts so to reconstruct the past as to make it intelligible to modern readers.

Primitive man regards everything he cannot explain as the work of a god. To him the abnormal, the unusual, is divine. The uncharted region of mysterious phenomena is the peculiar realm of supernatural forces. "It is the work of heaven" is a sufficient answer when the human intelligence can give no satisfactory explanation.

The fifth century B.C. witnessed the supreme effort of the Greeks to cast aside this incubus in all spheres of thought. They came to realize that to attribute an event to the action of a god leaves us just where we were, and that to call normal phenomena natural and abnormal divine is to introduce an unscientific dualism, in that what is divine (because mysterious) in one generation may be natural (because understood) in the next, while, on the other hand, however fully we may understand a phenomenon, there must always be a mysterious and unexplained element in it. All phenomena are equally divine and equally natural.

But this realization did not come all at once, and in the science of medicine it was peculiarly slow. There is something arresting in the spread of an epidemic and in the onset of epilepsy or of a pernicious fever. It is hard for most minds, even scientific minds, not to see the working of a god in them. On the other hand, the efficacy of human means to relieve pain is so obvious that even in Homer, our first literary authority for Greek medicine, rational treatment is fully recognized.

As the divine origin of disease was gradually

[p. xi] discarded, another element, equally disturbing, and equally opposed to the progress of scientific medicine, asserted itself. Philosophy superseded religion. Greek philosophy sought for uniformity in the multiplicity of phenomena, and the desire to find this uniformity led to guesswork and to neglect of fact in the attempt to frame a comprehensive theory. The same impulse which made Thales declare that all things are water led the writer of a treatise1 in the Hippocratic Corpus to maintain that all diseases are caused by air. As Daremberg2 says, " the philosophers tried to explain nature while shutting their eyes." The first philosophers to take a serious interest in medicine were the Pythagoreans. Alcmaeon3 of Croton, although perhaps not strictly a Pythagorean, was closely connected with the sect, and appears to have exercised considerable influence upon the Hippocratic school. The founder of empirical psychology and a student of astronomy, he held that health consists of a state of balance between certain " opposites," and disease an undue preponderance of one of them.4 Philolaus, who flourished about 440 B.C., held that bile, blood, and phlegm were the causes of disease. In this case we have a Pythagorean philosopher who tried to include medical

[p. xii] theory in his philosophical system.5 Empedocles, who flourished somewhat earlier than Philolaus, was a " medicine-man " rather than a physician, though he is called by Galen the founder of the Italian school of medicine.6 The medical side of his teaching was partly magic and quackery.

This combination of medicine and philosophy is clearly marked in the Hippocratic collection. There are some treatises which seek to explain medical phenomena by a priori assumptions, after the manner of the philosophers with their method of ὑποθές1εις2 or postulates ; there are others which strongly oppose this method. The Roman Celsus in his preface7 asserts that Hippocrates separated medicine from philosophy, and it is a fact that the best works of the Hippocratic school are as free from philosophic assumptions as they are from religious dogma. But before attempting to estimate the work of Hippocrates it is necessary to consider, not only the doctrine of the philosophers, but also the possibly pre-Hippocratic books in the Corpus. These are the Prenotions of Cos and the First Prorrhetic,8 and perhaps the treatise--in Latin and Arabic, the Greek original having mostly perished--on the number seven (περὶ ἑβδομάδων).

[p. xiii] The Prenotions of Cos and the First Prorrhetic (the latter being the earlier, although both are supposed to be earlier than Hippocrates) show that in the medical school of Cos great attention was paid to the natural history of diseases, especially to the probability of a fatal or not fatal issue. The Treatise on Seven, with its marked Pythagorean characteristics, proves, if indeed it is as early as Roscher would have us believe, that even before Hippocrates disease was considered due to a disturbance in the balance of the humours, and health to a " coction " of them, while the supposed preponderance of seven doubtless exercised some influence on the later doctrine of critical days. The work may be taken to be typical of the Italian-Sicilian school of medicine, in which a priori assumptions of the " philosophic " type were freely admitted. Besides these two schools there was also a famous one at Cnidos,9 the doctrines of which are criticised in the Hippocratic treatise Regimen in Acute Diseases. The defects of this school seem to have been :--

(1) the use of too few remedies ;

(2) faulty or imperfect prognosis ;

(3) over-elaboration in classifying diseases.10

We may now attempt to summarize the components

[p. xiv] of Greek medicine towards the end of the fifth century B.C.

(1) There was a religious element, which, however, had been generally discarded.

(2) There was a philosophic element, still very strong, which made free use of unverified postulates in discussing the causes and treatment--especially the former--of diseases.

(3) There was a rational element, which relied upon accurate observation and accumulated experience. This rationalism concluded that disease and health depended on environment and on the supposed constituents of the human frame.

Now if we take the Hippocratic collection we find that in no treatise is there any superstition,11 in many there is much " philosophy " with some sophistic rhetoric, and among the others some are merely technical handbooks, while others show signs of a great mind, dignified and reserved with all the severity of the Periclean period, which, without being distinctively original, transformed the best tendencies in Greek medicine into something which has ever since been the admiration of doctors and scientific men. It is with the last only that I am concerned at present.

I shall make no attempt to fix with definite precision which treatises are to be included in this category, and I shall confine myself for the moment to three--Prognostic, Regimen in Acute Diseases, and Epidemics I. and III. These show certain characteristics, which, although there is no internal clue to

[p. xv] either date or authorship, impress upon the reader a conviction that they were written by the same man, and at a time before the great period of Greece had passed away. They remind one, in a subtle yet very real way, of Thucydides.12

The style of each work is grave and austere. There is no attempt at " window-dressing." Language is used to express thought, not to adorn it. Not a word is thrown away. The first two treatises have a literary finish, yet there is no trace in them of sophistic rhetoric. Thought, and the expression of thought, are evenly balanced. Both are clear, dignified--even majestic.

The matter is even more striking than the style. The spirit is truly scientific, in the modern and strictest sense of the word. There is no superstition, and, except perhaps in the doctrine of critical days, no philosophy.13 Instead, there is close, even minute, observation of symptoms and their sequences, acute remarks on remedies, and recording, without inference, of the atmospheric phenomena, which preceded or accompanied certain "epidemics." Especially noteworthy are the clinical histories, admirable for their inclusion of everything that is relevant and their exclusion of all that is not.

The doctrine of these three treatises may be summarised as follows :--14

[p. xvi] (1) Diseases have a natural course, which the physician must know thoroughly,15 so as to decide whether the issue will be favourable or fatal.

(2) Diseases are caused by a disturbance16 in the composition of the constituents of the body. This disturbance is connected with atmospheric and climatic conditions.

(3) Nature tries to bring these irregularities to a normal state, apparently by the action of innate heat, which " concocts " the " crude " humours of the body.

(4) There are " critical " days at fixed dates, when the battle between nature and disease reaches a crisis.

(5) Nature may win, in which case the morbid matters in the body are either evacuated or carried off in an ἀπός1τας1ις2,17 or the " coction " of the morbid elements may not take place, in which case the patient dies.

(6) All the physician can do for the patient is to give nature a chance, to remove by regimen all that may hinder nature in her beneficent work.

It may be urged that this doctrine is as hypothetical as the thesis that all diseases come from air. In a sense it is. All judgments, however simple, attempting to explain sense-perceptions, are hypotheses. But hypotheses may be scientific or philosophic, the latter term being used to denote the

[p. xvii] character of early Greek philosophy. A scientific hypothesis is a generalization framed to explain the facts of experience ; it is not a foundation, but is in itself a superstructure ; it is constantly being tested by appeals to sense-experience, and is kept, modified or abandoned, according to the support, or want of support, that phenomena give to it. A "philosophic" hypothesis is a generalization framed with a view to unification rather than to accounting for all the facts ; it is a foundation for an unsubstantial superstructure ; no efforts are made to test it by appeals to experience, but its main support is a credulous faith.

Now the doctrine of the Epidemic group is certainly not of the philosophic kind. Some of it was undoubtedly derived from early philosophic medicine, but in this group of treatises observed phenomena are constantly appealed to ; nor must it be forgotten that in the then state of knowledge much that would now be styled inference was then considered fact, e. g. the "coction" of phlegm in a common cold. Throughout, theory is in the background, observation in the foreground. It is indeed most remarkable that Hippocratic theory is hard to disentangle from the three works on which my argument turns. It is a nebulous framework, implied in the technical phraseology--πέψις2, κρίς1ις2, κρᾶς1ις2--and often illustrated by appeal to data, but never obtrusively insisted upon.

In 1836 a French doctor, M. S. Houdart,18 violently attacked this medical doctrine on the ground that it

[p. xviii] neglected the physician's prime duty,19 which is to effect a cure. Diagnosis, he urges, is neglected in the cult of prognosis ; no attempt is made to localize the seat of disease ; the observations in the Epidemics are directed towards superficial symptoms without any attempt to trace them to their real cause. The writer is an interested but callous spectator who looks on unmoved while his patient dies.20

In this rather rabid criticism there is a morsel of truth. The centre of interest in these treatises is certainly the disease rather than the patient. The writer is a cold observer of morbid phenomena, who has for a moment detached himself from pity for suffering. But this restraint is in reality a virtue ; concentration on the subject under discussion is perhaps the first duty of a scientist. Moreover, we must not suppose that the fatally-stricken patients of the Epidemics received no treatment or nursing. Here and there the treatment is mentioned or hinted at,21 but the writer assumes that the usual methods

[p. xix] were followed, and does not mention them because they are irrelevant.

The charge of callousness may be dismissed. More serious is the attack on the fundamental principle of Hippocratic medicine, that " nature " alone can effect a cure, and that the only thing the physician can do is to allow nature a chance to work. Modern medical science has accepted this principle as an ultimate truth, but did the writer of the three treatises under discussion do his best to apply it ? Did he really try to serve nature, and, by so doing, to conquer her ? Houdart says that practically all the author of the Epidemics did was " to examine stools, urine, sweats, etc., to look therein for signs of coction, to announce crises and to pronounce sentences of death,"22 in other words that he looked on and did nothing. I have just pointed out that the silence of the Epidemics on the subject of treatment must not be taken to mean that no treatment was given, but it remains to be considered whether all was done that could have been done. What remedies were used by the author of Regimen in Acute Diseases ? They were :--

(1) Purgatives and, probably, emetics.

(2) Fomentations and baths.

(3) (a) Barley-water and barley-gruel, in the preparation and administering of which great care was to be taken.

b) Wine.

c) Hydromel, a mixture of honey and water ; and oxymel, a mixture of honey and vinegar.

[p. xx] (4) Venesection.

(5) Care was taken not to distress the patient.23

If we take into account the scientific knowledge of the time, it is difficult to see what more the physician could have done for the patient. Even nowadays a sufferer from measles or influenza can have no better advice than to keep warm and comfortable in bed, to take a purge, and to adopt a diet of slops. Within the last few years, indeed, chemistry has discovered febrifuges and anaesthetics, the microscope has put within our reach prophylactic vaccines, and the art of nursing has improved out of all recognition, but nearly all these things were as unknown to M. Houdart as they were in the fifth century B.C.

This criticism of Hippocratic medicine has been considered, not because it is in itself worthy of prolonged attention, but because it shows that underlying the three treatises I have mentioned there is a fundamental principle, a unity, a positive characteristic implying either a united school of thought or else a great personality. All antiquity agreed that they were written by the greatest physician of ancient times--Hippocrates. Within the last hundred years, however, doubts have been expressed whether Hippocrates wrote anything. Early in the nineteenth century a doctor of Lille published a thesis intitled Dubitationes de Hippocratis vita, patria, genealogia, forsan mythologicis, et de quibusdam eius libris multo

[p. xxi] antiquioribus quam vulgo creditur. Wellmann and Wilamowitz hold similar views nowadays. As the Hippocratic writings are all anonymous, such a hypothesis is not difficult to maintain. But it is a matter of merely antiquarian interest whether or not the shadowy " Hippocrates " of ancient tradition is really the writer of the Epidemics. The salient and important truth is that in the latter half of the fifth century works were written, probably by the same author, embodying a consistent doctrine of medical theory and practice, free from both superstition and philosophy, and setting forth rational empiricism of a strictly scientific character. If in future I call the spirit from which this doctrine emanated " Hippocrates " it is for the sake of convenience, and not because I identify the author with the shadowy physician of tradition.

Similar in style and in spirit to the three treatises discussed above are Aphorisms and Airs Waters Places, along with two surgical works, Fractures24 and Wounds in the Head. The severely practical character of the last is particularly noteworthy, and makes the reader wonder to what heights Greek surgery would have risen had antiseptics been known. Aphorisms is a compilation, but a great part shows a close relationship to the Hippocratic group. The least scientific of all the seven treatises is Airs Waters Places, which, in spite of its sagacity and rejection of the supernatural, shows a tendency to facile and unwarranted generalization.

[p. xxii]

1 The περὶ φυς1ῶν.

2 Histoire des sciences médicales, p. 82.

3 A young man in the old age of Pythagoras. See Aristotle Meta. A 986 a 30. Alcmaeon was more interested in medicine than in philosophy, but does not seem to have been a " general practitioner."

4 Ἀλκμαίων τῆς2 μὲν ὑγιείας2 εἰναι ς1υνεκτικὴν τὴν ἰς1ονομίαν τῶν δυνάμεων, ὑγροῦ, ξηροῦ, ψυχροῦ, θερμοῦ, πικροῦ, γλυκέος2, καὶ τῶν λοιπῶν, τὴν δ᾽ ἐν αὐτοῖς2 μοναρχίαν νός1ου ποιητικήν: φθοροποιὸν γὰρ ἑκατέρου μοναρχίαν.--Aétius V. 30. 1.

5 For the medical theories of Philolaus see the extracts from the recently discovered Iatrica of Menon, discussed by Diels in Hermes XXVIII., p. 417 foll.

6 Galen X. 5.

7 Hippocrates . . . ab studio sapientiae disciplinam hanc separavit, vir et arte et facundia insignis.

8 Grimm, Ermerins and Adams are convinced of the early date of these. Littré seems to have changed his mind. Contrast I. 351 with VIII. xxxix. The writer in Pauly-Wissowa is also uncertain. I hope to treat the question fully when I come to Prognostic in Vol. II.

9 There are several Cnidian treatises in the Corpus. See p. xxiii. The Cnidian point of view admits of defence, and their desire to classify was a really scientific instinct. I hope to treat of the Cnidians fully when I come to translate Regimen in Acute Diseases.

10 The Coan school, on the other hand, sought for a unity in diseases. Its followers tried to combine, the Cnidians to distinguish and to note differences. See Littré II. 202-204.

11 A possible exception is Decorum, which I hope to discuss in Vol. II.

12 The resemblance struck Littré. See Vol. I., pp. 474, 475.

13 Of course even in the greatest works of the Hippocratic Corpus there is, and could not help being, some theory. But the writer does not love the theory for its own sake. Rather he is constantly forgetting it in his eagerness to record observed fact.

14 There is a clear account of Hippocratic doctrine in Littré, Vol. L, pp. 440-464.

15 This knowledge is πρόγνως1ις2.

16 It is not clear whether this disturbance is regarded as quantitative, qualitative, or both.

17 This term will be explained later. Roughly speaking, it means the collection and expulsion of morbid elements at a fixed point in the body. I translate it " abscession," a term which suggests " abscess," perhaps the most common form of an " abscession."

18 Etudes historiques et critiques sur la vis et la doctrine d'Hippocrate, et sur l'état de la médecine avant lui. Paris and London.

19 " Attendre qu'il plaise é la nature de nous délivrer de nos maux, c'est laisser l'économie en proie é la douleur, c'est donner le temps aux altérations de dévorer nos viscéres, c'est, en un mot, nous conduire sérement é la mort."--Op. cit. p. 253. M. Houdart was but following the example of Asclepiades, the fashionable physician at Rome in the first century B.C., who called the Hippocratic treatment a "meditation upon death."

20 " Lisez les épidémies. Si votre coeur résiste é cette lecture, vous l'avez de bronze. Qui peut voir en effet de sang-froid cette foule d'infortunés conduits é pas lents sur les bords de la tombe, oé ils finissent la plupart par tomber, aprés avoir souffert durant trois ou quatre mois entiers les douleurs les plus variées et les plus aigués ?"--Op. cit. p. 246.

21 E.g. Epid. III. Case VIII. (second series) : θερμάς1ματα and ὸγδόη ἀγκῶνα ἔταμον.

22 Op. cit. p. 247.

23 It should be noticed that in all the Hippocratic collection no attention is paid to the pulse. The doctor judged whether a patient was feverish, and estimated the degree of fever, by the touch. I have not translated πυρετὸς2 ὀξύς2 by " high temperature," but by " acute fever," because I wish to introduce as few anachronisms as possible.

24 With this should be joined the work Articulations, which is very closely allied to Fractures, and is supposed by Galen to have been originally combined with it as a single work. Instruments of Reduction appears to be a compendium of Articulations.

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