of malarial poison infested the shores of Greece20 and Asia Minor 2,500 years ago. Nothing is more improbable than that they were always afflicted by the same forms with which we are familiar, or that malaria in any form was constant in any one locality, or that the malignity of the type was such as now fills the army hospitals at Salonica, but the evidence is indubitable that in the Greece of Hippocrates, in some of the islands of the Ægean and on the littoral of Asia Minor perhaps sometimes in one place, sometimes in another, varying from generation to generation, certainly from season to season-malaria was behind much of the confused picture of disease we find in the Hippocratic writings.

I see no evidence that such affections have ever permanently affected the course of empire, though it is always impossible to say what might have been the course of events if anyone of the innumerable cosmic factors which have shaped history in the abyss of time had been absent. We may be disposed to deprecate the importance of the factor of malaria, but it is impossible to ignore the fact that disease has often in specific instances halted the march of armies on the road to conquest and raised the siege of cities. It is not impossible that in the past, as at present, in some of the districts of central Africa, and in some of the medieval cities, epidemics may have desolated lands and somewhat altered permanently the course of human events; but for the most part the evidence in regard to the permanent influence of disease on empires and civilizations is dubious. Yet Hippocrates was dealing with this very problem when he noted the effect which airs, waters and localities had on the nature of man. The factors of this problem are not entirely clear in the light modern science has thrown on them, but they are dark indeed, and but a tangled skein of thread,

20 Jones, W. H. S., “Malaria and Greek History." Manchester: University Press, 1909.

as we gaze on them in the writings of Hippocrates, through the dimness of more than two thousand years. In the "Epidemics," we perceive easily, after reading Littré's masterly analysis of the first and third books, that the severest types of malarial fever prevailed on the mainland and the islands which fringed the shores of Greece and Asia Minor in the days of Hippocrates. We take note of the fact that he confused to some extent, as do modern biologists and ethnologists, the effect of "institutions" on men, and the effects of the malarial poison working through the lassitude of their bodies on their moral natures.

Many critics have noticed in Hippocrates the absence of any indication which they can plainly recognize of his appreciation of the infective nature of fevers arising from proximity to the stagnant waters of many of the Greek rivers and swamps. I think this can hardly be laid at the door of antiquity with justice since even in Hippocrates we find reference to the influence of locality on the type of disease in such connection that it can scarcely be doubted that he was familiar with pestilential varieties of swamp fever even if he did miss the plasmodium malariae and took no note of the anopheles fasciata. In this book we should not fail to notice in this connection his remark that:

XI... When a pestilence attacked the people of Selinus, by reason of the bad smells arising from the adjacent river, so that the men died and the women bore dead children, Empedocles contrived a plan, and brought into the same channel two other rivers at his own expense; and so, by mixing their waters with that of the other river, he sweetened the stream. And as the pestilence was removed in this way, when the people of Selinus were on one occasion holding a festival on the bank of the river, Empedocles appeared among them; and they rising up, offered him adoration, and prayed to him as to a God: And he, wishing to confirm this idea which they had adopted of him, leaped into the fire.

It is very evident that to Alcmaeon and to Empedocles the Hippocratic collection owes much of its physiology and anatomy; perhaps to the former a whole treatise, and it is improbable in the extreme that Hippocrates himself was not familiar with the influence of swamp land on the production of certain types of fever. Reference is made to those that accompany the prevalence of winds from marshy places in the second book on "The Diet" (38), but no classification or comprehension of them based on etiology can be found, conforming to the nosology which has resulted from the discovery of the plasmodium and its carrier, until well within the experience of living men. The comments of Adams and of Littré are scarcely less confusing to the recent graduate than those of Hippocrates. Indeed, in a way, Hippocrates and his immediate predecessors were more alive to all the factors entering into the etiology of malaria than were these gentlemen of the middle decades of the last century. As for us the plasmodium and the anopheles have all but eliminated from our thoughts the environment which makes their existence possible. For us a chain hangs down out of the sky and we only keep constantly in our visual focus these two links. What is the plasmodium to us but for the anopheles? What

would become of the anopheles, but for the swamp and and the heat, and so on ad infinitum. The literature which has grown up around the plasmodium and its carrier serves to alienate the mind, especially the mind uninstructed in the history of the medical art, from an attitude toward the intermittent and continued fevers with which Littré and his contemporaries two generations ago were familiar, and Hippocrates quite as intimately two thousand years ago and more, though the evidence of it is more convincing elsewhere than in this book on the "Airs, Waters and Places."

In addition to the incidental interest to be noted in an account of early attempts to eradicate malaria, and in the reference I have made to early evolutionary doctrine, I have especially striven in the foregoing to show how intimately in the thought of Hippocrates was combined the influence of the same environment on the corporeal and on the spiritual nature of man as well as on his social and political relations. This catholicity of thought is entirely foreign to our modern medical mentality and I cannot urge with too much emphasis that we are thereby the losers. It is that broadening of medical thought which should be the concern of all education, but it is nowhere so lacking in the liberal professions as in the curriculum of the student of medicine. Incoherent as it may appear to the modern reader in the Hippocratic text, which I fear I have not made much more coherent in the foregoing, such defects must be charged to the reader and to the expositor rather than to the author, to whom, obviously, there was no gap in the consecutiveness of the reasoning in his apprehension of the cosmic laws applying to the spiritual and the physical phenomena of human beings. To him, indeed, as to Terence, nothing which was of human interest was foreign.

T

HE history of medicine is in a sense the history of civilization. Among a given people, ancient or modern, the state of medicine

is as much an index of its culture as are its art and its literature. The world is, however, too busy to study medical history in order to find out what level a nation has attained at any particular time. This applies not only to the non-medical world but also to medical men themselves. Only a few have an interest in the history of their calling; and yet nothing is more instructive or inspiring, whether viewed from the narrower standpoint of the physician or from the broader one of the student of the race, than is the development of medicine throughout the ages. At the present day the lay public knows a great deal about medicines, but very little about medicine. If the people knew more concerning it they would have a greater respect for what medicine has accomplished.

From the vast and inexhaustible mine of the history of medicine I have extracted a single chapter, in itself large and fascinating, yet, strange as it may seem, few have written upon it. There are tomes upon tomes of medical history, some dealing with the doctrines and practices in vogue at different epochs or periods-Hindoo, Greek, Egyptian, Arabic, Talmudic medicine, for example. Few, however, concern themselves with the history of medical teaching, with the ways in which the accumulated knowledge has been transmitted from generation to generation. It is a consideration of that phase of medical history that I have made my task in this essay.

The medical students of to-day, who are virtually living in the wards of hospitals for the greater part of their last year in medicine, and in that way coming into direct personal

contact with patients, cannot realize what the teaching of medicine was a few genera

tions ago. In my student days we saw only a

few medical cases close at hand. Most of them were seen from the benches in the amphitheatre and I do not think that we ever had an opportunity of making a complete physical examination of a single patient. Yet we were better off than the men who were our teachers; and if we go back but a little farther, we come to a time when there were no clinical facilities whatever. J. Marion Sims was graduated in Philadelphia in 1835 and immediately went to his home in South Carolina to practise. His sign, which was a very big one, had not been out long before he was called on to treat a child of the leading citizen of the town. He had never until then been in contact with a patient and had never made a physical examination. In consequence, he felt himself helpless, and when the child died he was profoundly depressed. Then when a second child in the same family died shortly afterward under his ministrations, he quietly took down his sign, dropped it into a well, and migrated to Alabama. Fortunately for American surgery he did not carry out his intention of giving up the practice of medicine for good.

The first teacher of medicine was necessity. When primitive man received a wound during the chase or in combat, another member of his tribe or of his family applied soothing herbs, the virtues of which he knew as the result of some happy accident. After having obtained success with this treatment, he would initiate his son or some one else into the secret of the preparation and use of the soothing lotion. Thus arose surgery. In the case of internal diseases, and especially those of epidemic character,

the causes of which were to him unfathomable and mysterious, man sought the help of his gods and naturally applied to those who knew the wishes of the gods, the priests. These tried to appease the wrathful deity with prayers and incantations—a survival of which we see to-day in public prayers for the sick. The priests were always the ablest and shrewdest men in the community and by experience through the ages gained considerable practical knowledge in the treatment of disease. In that way there came to be added to the religious ceremonies methods of therapy of more or less value. The religious practices and therapeutic methods were handed down in the priestly castes by oral tradition.

Among the Greeks, however, the priesthood never had a very strong influence; and the practice of medicine was rather a secret in certain families or social groups. The first teacher of medicine among the Greeks was the legendary Esculapius, who taught his son Machaon to bind up the wounds of the Trojan warriors, and his other son, Podalirius, to attend to their internal ills.

Eventually the common experience of the medical families was written down; and a study of the written works was added to oral tradition. The actual teaching was carried out in the so-called iatria, which may be compared to our out-patient departments or dispensaries, and which were usually built in close proximity to an Esculapian temple. In the iatria, the physician received and examined the patients, prescribed and distributed medicines, performed surgical operations and gave instruction to pupils. The most famous iatria or schools, were those of Cnidos and of Cos. The latter was the birth place of Hippocrates, under whom, at about 400 B.C., Greek medicine reached its zenith. As teachers of medicine Hippocrates and his contemporaries, for the most part unknown to us, were not excelled for a thousand years; indeed, for nearly two thousand.

Hippocrates was a wonderful observer

and impressed upon his disciples the importance of bedside observation. In a sense, physical diagnosis originated with him; for he discovered the succussion splash, pleural friction and pulmonary râles. He advised that in order to hear these sounds the ear be laid upon the chest for a considerable length of time. This is the earliest mention of auscultation. The Hippocratic School also tested the temperature of the body with the hand, and by palpation determined the boundaries of the liver and spleen. It is scarcely believable, and yet it is a fact, that fifteen hundred years later these simple but valuable physical methods were thought to be of no importance and were scarcely taught anywhere.

After Alexander the Great's time, Alexandria became the center of Greek life and medical teaching. Under Herophilus and Erasistratus, the Alexandrian School attained great fame, so that it was a distinction to any physician to be able to say that he had studied at Alexandria.

Among the Egyptians, from whom the Greeks undoubtedly derived some of their knowledge, medicine was in the hands of the priests, who controlled all the learned occupations. The foundations of instruction were the Holy Books in which all Egyptian knowledge was contained. These books were an encyclopedic work of forty-two parts, of which the last six were devoted to medicine. The first of these treated of anatomy; the second, of diseases; the third, of surgery; the fourth, of drugs; the fifth, of diseases of the eye; and the sixth, of diseases of women. Only fragments have come down to us. They are contained in the "Book of the Dead," and in the "Ebers Papyrus." There are medical allusions in the cuneiform inscriptions of the Babylonians and the Assyrians; but in so far as they have been deciphered, they tell us little about the teaching of medicine, and are chiefly formulas or, as in the Code of Hammurabi, tables of fees and penalties.

Among the Hindoos, the teaching of

medicine early reached a high plane; and the Yajur Veda, in the Commentaries of Charaka and Suśruta, contains explicit instructions as to the education of the physician. Suśruta recommends to the student of medicine both theoretical and practical training. "He who is only theoretically educated," says Suśruta, "and is inexperienced in the details of practical treatment, does not know what he should do when he receives a patient, and conducts himself as foolishly as a coward on the battle-field. On the other hand, a physician who is educated practically and not theoretically lacks the esteem of better men." This reminds one of the dictum of Osler, "to study the phenomena of disease without books is to sail on an uncharted sea, while to study books without patients is not to go to sea at all.” The Hindoo teacher was therefore advised to instruct his pupils in the use of salves and remedies, in the performance of surgical operations and in general medical practice, "since through hearing lectures no one can become proficient in the medical calling." Suśruta taught that the sweet taste of urine was a sign of disease. He advised that a thorough history be taken of every patient, saying that the patient should be asked where he lives, the season of the year in which his trouble arose, his position, his affairs, the nature of his pain, his general strength, appetite, and the duration of his illness. Operations were taught on inanimate objects. No physician was allowed to have more than five or six pupils.

Hospitals existed in India not alone for human beings, but even for animals as early as 300 B.C. (There is one known to have existed on the island of Ceylon in the fifth century B.C.) In view of the fact that the study of anatomy was totally neglected it is remarkable that Indian medicine was able to reach such a high plane. This is one of the riddles of medical history.

Among the Romans, medicine was on a much lower level than among the Greeks. Sacrifices, magic formulas and oracles were

supposed to cure disease. A few curative herbs were employed. As stated by Seneca: “Medicina quondam paucarum fuit scientia herbarum quibus sisteretur fluens sanguis, vulnera coirent" (Medicine was the science of a few herbs by means of which the flowing blood was staunched and wounds were united. Epis. 95).

Under Greek influence, a higher type of medical practice gradually came into vogue; yet medicine was for a long time looked upon as a despised trade. The Roman nobles had it taught to their slaves; or sometimes, as in the case of M. Portius Cato,. they acquired it themselves in order that they might teach it to their slaves and keep a watch over the health of their own families. But with the tremendous political and social development of imperial Rome, medicine could not long remain patriarchal. Probably the constant foreign wars, requiring the services of skilled physicians, helped to bring about the downfall of the patriarchal system. For a long time, however, medicine remained a private matter or a free trade that could be followed by anyone. Under Alexander Severus, special auditoriums were assigned to medical teachers, in return for which they had to instruct poor students free of charge. It is probable that the valetudinaria which rich Romans established for their slaves were used for medical instruction. That this instruction had a decidedly modern aspect is shown in a sort of novel by Philostratus, in which mention is made of two physicians who visited the sick accompanied by thirty pupils. Such visits were made in large consultation rooms, called tabernæ medicinæ, or simply medicinæ. As a further evidence that clinical teaching similar to our ward visits existed, we have the famous lines of Martial (Epigr. V. 9):

Languebam, sed tu comitatus protinus ad me Venisti centum, Symmache, discipulis, Centum me tetigere manus aquilone gelatæ, Nec habui febrem; Symmache, nunc habeo.