Medicine - Physic and Physicians As Depicted in Plato Part 1
( Originally Published 1905 )
OUR Historical Club had under consideration last winter the subject of Greek Medicine. After introductory remarks and a description of the Esculapian temples and worship by Dr. Welch, we proceeded to a systematic study of the Hippocratic writings, taking up in order, as found in them, medicine, hygiene, surgery, and gynecology. Among much of interest which we gleaned, not the least important was the knowledge that as an art, medicine had made, even before Hippocrates, great progress, as much almost as was possible without a basis in the sciences of anatomy and physiology. Minds inquisitive, acute, and independent had been studying the problems of nature and of man; and several among the pre-Socratic philsophers had been distinguished physicians, notably, Pythagoras, Empedocles, and Democritus. Unfortunately we know but little of their views, or even of the subjects in medicine on which they wrote. In the case of Democritus, however, Diogenes Laertius has preserved a list of his medical writings, which intensifies the regret at the loss of the works of this great man, the title of one of whose essays, "On Those who are Attacked with Cough after Illness," indicates a critical observation of disease, which Daremberg seems unwilling to allow to the pre-Hippocratic philosopher-physicians.
We gathered also that in the golden age of Greece, medicine had, as to-day, a triple relationship, with science, with gymnastics, and with theology. We can imagine an Athenian father of the early fourth century worried about the enfeebled health of one of his growing lads, asking the advice of Hippocrates about a suspicious cough, or sending him to the palaestra of Taureas for a systematic course in gymnastics; or, as Socrates advised, "when human skill was exhausted," asking the assistance of the divine Apollo, through his son, the "hero-physician," Esculapius, at his temple in Epidaurus or at Athens itself. Could the Greek live over his parental troubles at the end of the nineteenth century, he would get a more exact diagnosis and a more rational treatment; but he might travel far to find so eminent a "professor" of gymnastic as Miccus for his boy, and in Christian science or faith-healing he would find our bastard substitute for the stately and gracious worship of the AEsculapian temple.'
From the Hippocratic writings alone we have a very imperfect knowledge of the state of medicine in the most brilliant period of Grecian history; and many details relating to the character and to the life of physicians are gleaned only from secular authors. So much of the daily life of a civilized community relates to problems of health and disease that the great writers of every age of necessity throw an important side-light, not only on the opinions of the people on these questions, but often on the condition of special knowledge in various branches. Thus a considerable literature already illustrates the medical knowledge of Shakespeare, from whose doctors, apothecaries, and mad-folk much may be gathered as to the state of the profession in the latter part of the sixteenth century. So also the satire of Moliere, malicious though it be, has preserved for us phases of medical life in the seventeenth century, for which we scan in vain the strictly medical writings of that period; and writers of our times, like George Eliot, have told for future generations in a character such as Lydgate, the little everyday details of the struggles and aspirations of the profession of the nineteenth century, of which we find no account whatever in the files of the Lancet.
We are fortunate in having had preserved the writings of the two most famous of the Greek philosophers—the great idealist, Plato, whose "contemplation of all time and all existence" was more searching than that of his predecessors, fuller than that of any of his disciples, and the great realist, Aristotle, to whose memory every department of knowledge still pays homage, and who has swayed the master-minds of twenty-two centuries. From the writings of both much may be gathered about Greek physic and physicians; but I propose in this essay to restrict myself to what I have culled from the Dialogues of Plato. I shall first speak of his physiological and pathological speculations; then I shall refer to the many interesting allusions to, and analogies drawn from, medicine and physicians; and, lastly, I shall try to estimate from the Dialogues the social standing of the Greek doctor, and shall speak on other points which bear upon the general condition of the profession. The quotations are made in every instance from Professor Jowett's translation, the third edition, 1892.
To our enlightened minds the anatomy and physiology of Plato are crude and imperfect; as much or even more so than those of Hippocrates. In the Timm-us he conceived the elements to be made up of bodies in the form of triangles, the different varieties and combinations of which accounted for the existence of the four elementary bodies of Empedocles—fire, earth, water, and air. The differences in the elementary bodies are due to differences in the size and arrangement of the elementary triangles, which, like the atoms of the atomist, are too small to be visible. Marrow had the most perfect of the elementary triangles, and from it bone, flesh, and the other structures of the body were made. "God took such of the primary triangles as were straight and smooth, and were adapted by their perfection to produce fire and water, and air and earth; these, I say, he separated from their kinds, and mingling them in due pro-portions with one another, made the marrow out of them to be a universal seed of the whole race of mankind; and in this seed he then planted and enclosed the souls, and in the original distribution gave to the marrow as many and various forms as the different kinds of souls were hereafter to receive. That which, like a field, was to receive the divine seed, he made round every way, and called that portion of the marrow brain, intending that, when an animal was perfected, the vessel containing this substance should be the head; but that which was intended to contain the remaining and mortal part of the soul he distributed into figures at once round and elongated, and he called them all by the name `marrow'; and to these, as to anchors, fastening the bonds of the whole soul, he proceeded to fashion around them the entire framework of our body, constructing for the marrow, first of all, a complete covering of bone."'
The account of the structure of bone and flesh, and of functions of respiration, digestion, and circulation is unintelligible to our modern notions. Plato knew that the blood was in constant motion; in speaking of inspiration and expiration, and the network of fire which interpenetrates the body, he says: "For when the respiration is going in and out, and the fire, which is fast bound within, follows it, and ever and anon moving to and fro, enters the belly and reaches the meat and drink, it dissolves them, and dividing them into small portions, and guiding them through the passages where it goes, pumps them as from a fountain into the channels of the veins, and makes the stream of the veins flow through the body as through a conduit." A complete circulation was unknown; but Plato understood fully that the blood was the source of nourishment,—" the liquid itself we call blood, which nourishes the flesh and the whole body, whence all parts are watered and empty spaces filled." In the young, the triangles, or in modern parlance we would say the atoms, are new, and are compared to the keel of a vessel just off the stocks. They are locked firmly together, but form a soft and delicate mass freshly made of marrow and nourished on milk. The process of digestion is described as a struggle between the triangles out of which the meats and drinks are composed, and those of the bodily frame; and as the former are older and weaker the newer triangles of the body cut them up, and in this way the animal grows great, being nourished by a multitude of similar particles. The triangles are in constant fluctuation and change, and in the "Symposium" Socrates makes Diotima say, "A man is called the same, and yet in the short interval which elapses between youth and age, and in which every animal is said to have life and identity, he is under-going a perpetual process of loss and reparation—hair, flesh, bones, and the whole body are always changing.""
The description of senility, euthanasia, and death is worth quoting: "But when the roots of the triangles are loosened by having undergone many conflicts with many things in the course of time, they are no longer able to cut or assimilate the food which enters, but are themselves easily divided by the bodies which come in from without. In this way every animal is overcome and decays, and this affection is called old age. And at last, when the bonds by which the triangles of the marrow are united no longer hold, and are parted by the strain of existence, they in turn loosen the bonds of the soul, and she, obtaining a natural release, flies away with joy. For that which takes place according to nature is pleasant, but that which is contrary to nature is painful. And thus death, if caused by disease or produced by wounds, is painful and violent; but that sort of death which comes with old age and fulfils the debt of nature is the easiest of deaths, and is accompanied with pleasure rather than with pain."
The mode of origin and the nature of disease, as described in the Timaeus, are in keeping with this primitive and imperfect science. The diseases of the body arise when any one of the four elements is out of place, or when the blood, sinews and, flesh are produced in a wrong order. Much influence is attributed to the various kinds of bile. The worst of all diseases, he thinks, are those of the spinal marrow, in which the whole course of the body is reversed. Other diseases are produced by disorders of respiration; as by phlegm "when detained within by reason of the air bubbles." This, if mingled with black bile and dispersed about the courses of the head produces epilepsy, attacks of which during sleep, he says, are not so severe, but when it assails those who are awake it is hard to be got rid of, and "being an affection of a sacred part, is most justly called sacred" morbus sacer. Of other disorders, excess of fire causes a continuous fever; of air, quotidian fever; of water, which is a more sluggish element than either fire or air, tertian fever; of earth, the most sluggish element of the four, is only purged away in a four-fold period, that is in a quartan fever.
The psychology of Plato, in contrast to his anatomy and physiology, has a strangely modern savour, and the three-fold divisions of the mind into reason, spirit and appetite, represents very much the mental types recognized by students of the present day. The rational, immortal principle of the soul "the golden cord of reason" dwells in the brain "and inasmuch as we are a plant not of earthly but of heavenly growth, raises us from earth to our kindred who are in heaven." The mortal soul consists of two parts; the one with which man "loves and hungers and thirsts, and feels the flutterings of any other desire," is placed between the midriff and the boundary of the navel; the other, passion or spirit, is situated in the breast between the midriff and the neck, "in order that it might be under the rule of reason and might join with it in controlling and restraining the desires when they are no longer willing of their own accord to obey the word of command issuing from the citadel."
No more graphic picture of the struggle between the rational and appetitive parts of the soul has ever been given than in the comparison of man in the Phaedrus to a charioteer driving a pair of winged horses, one of which is noble and of noble breed; the other ignoble and of ignoble breed, so that "the driving of them of necessity gives a great deal of trouble to him.
The comparison of the mind of man in the Theaetetus to a block of wax, "which is of different sizes in different men; harder, moister, and having more or less of purity in one than another, and in some of an intermediate quality," is one of the happiest of Plato's conceptions. This wax tablet is a gift of Memory, the mother of the Muses; "and when we wish to remember anything which we have seen, or heard or thought in our own minds, we hold the wax to the perceptions and thoughts, and in that material receive the impression of them as from the seal of a ring; and we remember and know what is imprinted as long as the image lasts; but when the image is effaced, or cannot be taken, then we forget and do not know.
Another especially fortunate comparison is that of the mind to an aviary which is gradually occupied by different kinds of birds, which correspond to the varieties of know-ledge. When we were children the aviary was empty, and as we grow up we go about "catching" the various kinds of knowledge.
Plato recognized, in the Timaeus, two kinds of mental disease, to wit, madness and ignorance. He has the notion advocated by advanced psychologists to-day, that much of the prevalent vice is due to an ill disposition of the body, and is involuntary; "for no man is voluntarily bad; but the bad become bad by reason of ill disposition of the body and bad education, things which are hateful to every man and happen to him against his will." A fuller discussion of the theorem that madness and the want of sense are the same is found in the Alcibiades (II.); which is not, however, one of the genuine Dialogues. The different kinds of want of sense are very graphically described:
Socrates. In like manner men differ in regard to want of sense. Those who are most out of their wits we call "madmen," while we term those who are less far gone " stupid," or "idiotic," or if we prefer gentle language, describe them as "romantic" or "simple-minded," or again as "innocent," or "inexperienced," or "foolish." You may even find other names if you seek for them, but by all of them lack of sense is intended. They only differ as one art appears to us to differ from another, or one disease from another.
There is a shrewd remark in the Republic "that the most gifted minds, when they are ill-educated, become preeminently bad. Do not great crimes and the spirit of pure evil spring out of a fulness of nature ruined by education rather than from any inferiority, whereas weak natures are scarcely capable of any very great good or very great evil.".
In the Phaedrus there is recognized a form of madness "which is a divine gift and a source of the chiefs blessings granted to man." Of this there are four kinds—prophecy, inspiration, poetry and love. That indefinable something which makes the poet as contrasted with the rhymster and which is above and beyond all art, is well characterized in the following sentence: "But he who, having no touch of the Muse's madness in his soul, comes to the door and thinks that he will get into the temple by the help of art—he, I say, and his poetry are not admitted. The sane man disappears and is nowhere when he enters into rivalry with a madman." Certain crimes, too, are definitely recognized as manifestations of insanity; in the Laws the incurable criminal is thus addressed: "Oh, sir, the impulse which moves you to rob temples is not an ordinary human malady, nor yet a visitation of heaven, but a madness which is begotten in man from ancient and unexpiated crimes of his race." In the Laws, too, it is stated that there are many sorts of madness, some arising out of disease, and others originating in an evil and passionate temperament, and increased by bad education. Respecting the care of the insane, it is stated that a madman shall not be at large in the city, but his relations shall keep him at home in any way they can, or if not, certain fines are mentioned.'
The greatest aid in the prevention of disease is to pre-serve the due proportion of mind and body, "for there is no proportion or disproportion more productive of health and disease, and virtue and vice, than that between soul and body." In the double nature of the living being if there is in this compound an impassioned soul more powerful than the body, "that soul, I say, convulses and fills with disorders the whole inner nature of man; and when eager in the pursuit of some sort of learning or study, causes wasting; or again, when teaching or disputing in private or in public, and considerations and controversies arise, inflames and dissolves the composite form of man and introduces rheums; and the nature of this phenomenon is not understood by most professors of medicine, who ascribe it to the opposite of the real cause." . . . Body and mind should both be equally exercised to protect against this disproportion, and "we should not move the body without the soul or the soul without the body. In this way they will be on their guard against each other, and be healthy and well balanced." He urges the mathematician to practise gymnastic, and the gymnast to cultivate music and philosophy.
The modes of treatment advised are simple, and it is evident that Plato had not much faith in medicines. Professor Jowett's commentary is here worth quoting: "Plato is still the enemy of the purgative treatment of physicians, which, except in extreme cases, no man of sense will ever adopt. For, as he adds, with an insight into the truth, ever disease is akin to the nature of the living being and is only irritated by stimulants.' He is of opinion that nature should be left to herself, and is inclined to think that physicians are in vain (cf. Laws, VI. 761 C., where he says that warm baths would be more beneficial to the limbs of the aged rustic than the prescriptions of a not overwise doctor). If he seems to be extreme in his condemnation of medicine and to rely too much on diet and exercise, he might appeal to nearly all the best physicians of our own age in support of his opinions, who often speak to their patients of the worthlessness of drugs. For we ourselves are sceptical about medicine, and very unwilling to submit to the purgative treatment of physicians. May we not claim for Plato an anticipation of modern ideas as about some questions of astronomy and physics, so also about medicine? As in the Charmides (156,7) he tells us that the body cannot be cured without the soul, so in the Timaeus he strongly asserts the sympathy of soul and body; any defect of either is the occasion of the greatest discord and disproportion in the other. Here too may be a presentiment that in the medicine of the future the interdependence of mind and body will be more fully recognized, and that the influence of the one over the other may be exerted in a manner which is not now thought possible."
The effect of the purgative method to which Plato was so opposed is probably referred to in the following passage.
"When a man goes of his own accord to a doctor's shop and takes medicine, is he not quite aware that soon and for many days afterwards, he will be in a state of body which he would rather die than accept as a permanent condition of his life?"
It is somewhat remarkable that nowhere in the Dialogues is any reference made to the method of healing at the,Esculapian temples. The comments upon physic and physicians are made without allusion to these institutions. Hippocrates and other practitioners at Athens were probably secular Asclepiads, but as Dyer remarks, "in spite of the severance the doctors kept in touch with the worship of Esculapius, and the priests in his temples did not scorn such secular knowledge as they could gain from lay practitioners."