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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 anopbeles fasciata. In this book we should not fail to notice in this connection his remark that:
Such cities as lie well to the sun and winds, and use good waters, feel these changes less, but such as use marshy and pooly waters, and lie well both as regards the winds and the sun, these all feel them more. And if the summer be dry, those diseases soon cease, but if rainy, they are protracted.
It is interesting in this connection to read what Diogenes Laertius says of the wonders wrought by Empedocles. I give it as translated by Yonge. 21 | 21 Diogenes Laertius, “Lives and Opinions of Eminent Philosophers,” tr. by C. D. Yonge, London: Henry G. Bohn, 1853.
XI . . . When a pestilence attacked the would become of the anopbeles, but for the people of Selinus, by reason of the bad smells
swamp and and the heat, and so on ad arising from the adjacent river, so that the men
infinitum. The literature which has grown died and the women bore dead children, Empedocles contrived a plan, and brought into the
up around the plasmodium and its carrier same channel two other rivers at his own ex- serves to alienate the mind, especially the pense; and so, by mixing their waters with mind uninstructed in the history of the that of the other river, he sweetened the medical art, from an attitude toward the stream. And as the pestilence was removed
intermittent and continued fevers with in this way, when the people of Selinus were
which Littré and his contemporaries two on one occasion holding a festival on the bank of the river, Empedocles appeared among them;
generations ago were familiar, and Hippocand they rising up, offered him adoration, and rates quite as intimately two thousand prayed to him as to a God: And he, wishing to years ago and more, though the evidence confirm this idea which they had adopted of of it is more convincing elsewhere than in him, leaped into the fire.
this book on the “Airs, Waters and Places.” It is very evident that to Alcmaeon and In addition to the incidental interest to Empedocles the Hippocratic collection to be noted in an account of early attempts owes much of its physiology and anatomy; to eradicate malaria, and in the reference perhaps to the former a whole treatise, and a
I have made to early evolutionary doctrine, it is improbable in the extreme that Hippoc- I have especially striven in the foregoing rates himself was not familiar with the to show how intimately in the thought of influence of swamp land on the production Hippocrates was combined the influence of certain types of fever. Reference is made of the same environment on the corporeal to those that accompany the prevalence of and on the spiritual nature of man as well winds from marshy places in the second as on his social and political relations. book on “The Diet” (38), but no classifica- This catholicity of thought is entirely tion or comprehension of them based on foreign to our modern medical mentality etiology can be found, conforming to the and I cannot urge with too much emphasis nosology which has resulted from the dis- that we are thereby the losers. It is that covery of the plasmodium and its carrier, broadening of medical thought which should until well within the experience of living be the concern of all education, but it is men. The comments of Adams and of Littré nowhere so lacking in the liberal professions are scarcely less confusing to the recent grad- as in the curriculum of the student of mediuate than those of Hippocrates. Indeed, cine. Incoherent as it may appear to the in a way, Hippocrates and his immediate modern reader in the Hippocratic text, predecessors were more alive to all the which I fear I have not made much more factors entering into the etiology of malaria coherent in the foregoing, such defects must than were these gentlemen of the middle be charged to the reader and to the expositor decades of the last century. As for us the rather than to the author, to whom, obviplasmodium and the anopbeles have all but ously, there was no gap in the consecutiveeliminated from our thoughts the environ- ness of the reasoning in his apprehension ment which makes their existence possible. of the cosmic laws applying to the spiritual For us a chain hangs down out of the sky and the physical phenomena of human and we only keep constantly in our visual beings. To him, indeed, as to Terence, focus these two links. What is the plas- nothing which was of human interest was modium to us but for the anopbeles? What foreign.
THE RISE AND EARLY HISTORY OF CLINICAL TEACHING
By DAVID RIESMAN, M.D.
HE history of medicine is in a contact with patients, cannot realize what
sense the history of civilization. the teaching of medicine was a few genera-
student days we saw only a or modern, the state of medicine few medical cases close at hand. Most of them is as much an index of its culture as are its were seen from the benches in the amphitheaart and its literature. The world is, how- tre and I do not think that we ever had an ever, too busy to study medical history in opportunity of making a complete physical order to find out what level a nation has examination of a single patient. Yet we attained at any particular time. This applies were better off than the men who were our not only to the non-medical world but also teachers; and if we go back but a little farto medical men themselves. Only a few have ther, we come to a time when there were no an interest in the history of their calling; and clinical facilities whatever. J. Marion Sims yet nothing is more instructive or inspiring, was graduated in Philadelphia in 1835 and whether viewed from the narrower stand- immediately went to his home in South point of the physician or from the broader Carolina to practise. His sign, which was a one of the student of the race, than is the very big one, had not been out long before development of medicine throughout the he was called on to treat a child of the ages. At the present day the lay public knows leading citizen of the town. He had never a great deal about medicines, but very little until then been in contact with a patient about medicine. If the people knew more and had never made a physical examination. concerning it they would have a greater In consequence, he felt himself helpless, respect for what medicine has accomplished. and when the child died he was profoundly
From the vast and inexhaustible mine of depressed. Then when a second child in the the history of medicine I have extracted a same family died shortly afterward under single chapter, in itself large and fascinating, his ministrations, he quietly took down yet, strange as it may seem, few have written his sign, dropped it into a well, and miupon it. There are tomes upon tomes of grated to Alabama. Fortunately for Amerimedical history, some dealing with the doc- can surgery he did not carry out his intrines and practices in vogue at different tention of giving up the practice of medicine epochs or periods—Hindoo, Greek, Egyp- for good. tian, Arabic, Talmudic medicine, for ex- The first teacher of medicine was necesample. Few, however, concern themselves sity. When primitive man received a wound with the history of medical teaching, with during the chase or in combat, another the ways in which the accumulated knowl- member of his tribe or of his family applied edge has been transmitted from generation soothing herbs, the virtues of which he to generation. It is a consideration of that knew as the result of some happy accident. phase of medical history that I have made After having obtained success with this my task in this essay.
treatment, he would initiate his son or some The medical students of to-day, who are one else into the secret of the preparation virtually living in the wards of hospitals for and use of the soothing lotion. Thus arose the greater part of their last year in medicine, surgery. In the case of internal diseases, and in that way coming into direct personal 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 supposed to cure disease. A few curative the Yajur Veda, in the Commentaries of herbs were employed. As stated by Seneca: Charaka and Suśruta, contains explicit in- “Medicina quondam paucarum fuit scientia structions as to the education of the physi- herbarum quibus sisteretur fluens sanguis, cian. Susruta recommends to the student vulnera coirent” (Medicine was the science of medicine both theoretical and practical of a few herbs by means of which the flowing training. “He who is only theoretically edu- blood was staunched and wounds were cated,” says Suśruta, "and is inexperienced united. Epis. 95). in the details of practical treatment, does not Under Greek influence, a higher type of know what he should do when he receives a medical practice gradually came into vogue; patient, and conducts himself as foolishly as yet medicine was for a long time looked a coward on the battle-field. On the other
upon as a despised trade. The Roman hand, a physician who is educated prac- nobles had it taught to their slaves; or sometically and not theoretically lacks the times, as in the case of M. Portius Cato,. esteem of better men.” This reminds one they acquired it themselves in order that of the dictum of Osler, “to study the phe- they might teach it to their slaves and keep nomena of disease without books is to sail a watch over the health of their own on an uncharted sea, while to study books families. But with the tremendous political without patients is not to go to sea at all.” and social development of imperial Rome, The Hindoo teacher was therefore advised to medicine could not long remain patriarchal. instruct his pupils in the use of salves and Probably the constant foreign wars, reremedies, in the performance of surgical quiring the services of skilled physicians, operations and in general medical practice, helped to bring about the downfall of the “since through hearing lectures no one can patriarchal system. For a long time, howbecome proficient in the medical calling. ever, medicine remained a private matter Suśruta taught that the sweet taste of urine or a free trade that could be followed by was a sign of disease. He advised that a anyone. Under Alexander Severus, special thorough history be taken of every patient, auditoriums were assigned to medical teachsaying that the patient should be asked ers, in return for which they had to instruct where he lives, the season of the year in
students free of charge. It is probable which his trouble arose, his position, his that the valetudinaria which rich Romans affairs, the nature of his pain, his general established for their slaves were used for strength, appetite, and the duration of his medical instruction. That this instruction illness. Operations were taught on inani- had a decidedly modern aspect is shown in a
a mate objects. No physician was allowed to sort of novel by Philostratus, in which have more than five or six pupils.
mention is made of two physicians who Hospitals existed in India not alone for visited the sick accompanied by thirty human beings, but even for animals as early pupils. Such visits were made in large conas 300 B.C. (There is one known to have sultation rooms, called taberna medicinæ, existed on the island of Ceylon in the fifth or simply medicinæ. As a further evidence century B.C.) In view of the fact that the that clinical teaching similar to our ward study of anatomy was totally neglected it visits existed, we have the famous lines of is remarkable that Indian medicine was Martial (Epigr. V. 9): able to reach such a high plane. This is one of the riddles of medical history.
Languebam, sed tu comitatus protinus ad me Among the Romans, medicine was on a Venisti centum, Symmache, discipulis, much lower level than among the Greeks. Centum me tetigere manus aquilone gelatæ, Sacrifices, magic formulas and oracles were Nec habui febrem; Symmache, nunc habeo.