William Osler.

Aequanimitas : with other addresses to medical students, nurses and practitioners of medicine online

. (page 4 of 26)
Online LibraryWilliam OslerAequanimitas : with other addresses to medical students, nurses and practitioners of medicine → online text (page 4 of 26)
Font size
QR-code for this ebook


able 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 pro-
fession in the latter part of the sixteenth century. So also
the satire of Molidre, 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 every-day 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 pre-
decessors, 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

as. 49 E



Digitized by



Google



PHYSIC AND PHYSICIANS

to what I have culled from the Dialogues of Plato. I
shall first speak of his physiological and pathological specu-
lations ; 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. 1

I

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 Timasus he con-
ceived 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. Mar-
row 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 proportions with one another, made the mar-

1 The Dialogues of Plato, translated into English by B. Jowett,
M.A., Master of Balliol College, Oxford. At the Clarendon Press,
first edition, 1871 ; third edition, 1892.

50



Digitized by



Google



AS DEPICTED IN PLATO

row 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 mar-
row 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 elon-
gated, 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 frame-
work of our body, constructing for the marrow, first of aft,
a complete covering of bone." '

The account of the structure of bone and flesh, and of
functions of respiration, digestion, and circulation is un-
intelligible 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 oon-
du#." * A complete circulation was unknown ; but Plato

i Dialogues, iii. 403. » Ibid. ilL 001.

51



Digitized by



Google



PHYSIC AND PHYSICIANS

understood folly that the blood was the source of nourish-
ment, — "the liquid itself we call blood, which nourishes
the flesh and the whole body, whence all parts are watered
and empty spaces filled." l 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 deli-
cate 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 com-
posed, 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 " Sym-
posium " Socrates makes Diotima say, " A man is called
the same, and yet in the short interval which elapses be-
tween youth and age, and in which every animal is said to
have life and identity, he is undergoing a perpetual pro-
cess 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

1 Dialogues, iii. 503. » Ibid. i. 578.

62



Digitized by



Google



AS DEPICTED IN PLATO

hold, and are parted by the. strain of existence, they in
torn loosen the bonds oi the soul, and she, obtaining a
natural release, flies away with joy. For that which takes
place according to nature is pleasant, bat that which is
contrary to nature is painful. 4nd 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 accom-
panied with pleasure rather than with pain." l

The mode of origin and the nature of disease, as de-
scribed in the Tim&us, are in keeping with this primitive
and imperfect science. The diseases of the body arise
when anyone of the four elements is out of place, or when
the blood, sinewB 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 meet. 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.*

1 Dialogue*, iii 003-4. » Ibid, til 007*4.

88



Digitized by



Google



PHYSIC AND PHYSICIANS

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 recog-
nized by students of the present day. The rational, im-
mortal 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 con-
sists 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. 9 ' '

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 Phcedrus 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 Thecetetus

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.

i Dialogues, ui. 491-2. * Ibid. i. 452..

54



Digitized by



Google



AS DEPICTED IN PLATO

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 that we remember and know what is im-
printed as long as the image lasts ; but when the image*
is effaced, or cannot be taken, then we forget and do not
know." l

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. 9

Plato recognized, in the Timceus, 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, how-
ever, 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 moat out of their wits we call " madmen," while we
term those who are less far gone "stupid," or "idiotic," or if we

i Dialogues, iv. 254-6. * Ibid. iv. 2S2. * Ibid. iii. 609.
65



Digitized by



Google



PHYSIC AND PHYSICIANS

prefer gentle language, describe them as " romantio " or " simple-
minded," or again as " innocent," or " inexperienced," or " foolish."
Ton may even find other names if yon seek for them, bnt by aU 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
pre-eminenetly 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." l

In the Phwdrus there is recognized a form of madness
" which is a divine gift and a source of the chiefest blessings
granted to man.' 9 Of this there are four kinds— prophecy,
inspiration, poetry and love. That indefinable something
which makes the poet as contrasted with th 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 recog-
nized as manifestations of insanity ; in the Laws the in-
curable 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

1 Dialogues, iii. 189.

2 Ibid. i. 450-1 ; " Not by wisdom do poets write poetry, bat by
a sort of inspiration and genius."— Apology.

66



Digitized by



Google



AS DEPICTED IN PLATO

which is begotten in man from ancient and unezpiated
crimes of his race. 9 ' 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 are increased by bad education. Re-
specting the care of the insane, it is stated that a wmdnMm
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. 1

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 power-
ful 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 pheno-
menon 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 pro-
tect 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 mathe-

1 DialogvUi v. 236, 923, 324.
67



Digitized by



Google



PHYSIC AND PHYSICIANS

matician to practise gymnastic, and the gymnast to culti-
vate music and philosophy. 1

The modes of treatment advised are simple, and it is
evident that Plato had not much faith in medicines. Pro-
fessor 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,
* every 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 (cp. Laws, VI. 761 G, 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 con-
demnation 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. Hay
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 (166, 7) he tells us
that the body cannot be cured without the soul, so in the
TimcBU8 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 in-
terdependence of mind and body will be more fully recog-

1 Dialogues, iii. 510-1.
68



Digitized by



Google



AS DEPICTED IN PLATO

nized, 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
iEsculapian temples. The comments upon physic and
physicians are made without allusion to these institutions.
Hippocrates and other practitioners at Athens were pro-
bably secular Asclepiads, but as Dyer remarks, " in spite
of the severance the doctors kept in touch with the wor-
ship of jEsculapius, and the priests in his temples did not
scorn such secular knowledge as they could gain from lay
practitioners. 2

II
So much for the general conception of the structure and
functions of the body, in order and disorder, as conceived
by Plato. Were nothing more to be gleaned, the thoughts
on these questions of one of the greatest minds of what
was intellectually the most brilliant period of the race,
would be of interest, but scattered throughout his writings
are innumerably little cbiter dicta, which indicate a pro-
found knowledge of that side of human nature which turns
* Dialogues, Hi. 413. * The Gods of Greece.

69



Digitized by



Google



fcHYSIC AND PHYSICIANS

uppermost when the machinery is out of gear. There are,
in addition, many charming analogies drawn from medicine,
and many acute suggestions, some of which have a modern
flavour. The noble pilot and the wise physician who, as
Nestor remarks, " is worth many another man," furnish
some of the most striking illustrations of the Dialogues.

One of the most admirable definitions of the Art of
Medicine I selected as a rubric with which to grace my
text-book, " And I said of medicine, that this is an Art
which considers the constitution of the patient, and has
principles of action and reasons in each case." Or, again,
the comprehensive view taken in the statement, "There
is one science of medicine which is concerned with the
inspection of health equally in all times, present, past and
future."

Plato gives a delicious account of the origin of the
modern medicine, as contrasted with the art of the guild
of Asclepius. *

Well, I said, and to require the help of medioine, not when a
wound has to be cured, or on occasion of an epidemic, but just
because by indolence and a habit of life such as we have been
describing, men fill themselves with waters and winds, as if their
bodies were a marsh, compelling the ingenious sons of Asclepius
to find more names for diseases, such as flatulenoe and catarrh ;
is not this, too, a disgrace ?

Tee, he said, they do certainly give very strange and new-fangled
names to diseases.

Yes, I said, and I do not believe there were any such diseases in
the days of Asclepius ; and this I infer from the circumstance that
the hero Eurypylus, after he has been wounded in Homer, drinks
a posset of Pramnian wine well besprinkled with barley-meal and
grated cheese, which are certainly inflammatory, and yet the sons of
Asclepius who were at the Trojan war do not blame the damsel

1 Dialogues, iii. 93.



Digitized by



Google



AS DEPICTED IN PLATO
who gives him the drink, or rebuke Patroclus, who is treating his



Well, he said, that was sorely an extraordinary drink to be given
to a person in his condition.

Not so extraordinary, I replied, if yon bear in mind that in former
days, as is commonly said, before the time of Herodious, thqguildof
Asolepius did not practise oar present system of medicine, which
may be said to educate diseases* Bat Herodieas, being a trainer,
and himself of a sickly constitution, by a combination of training
and doctoring found out a way of torturing first and ohiefly .himself,
and secondly the rest of the world.

How was that ? he said.

By the invention of lingering death ; for he had a mortal disease
which he perpetually tended, and as recovery was out of the ques-
tion, he passed his entire life as a valetudinarian; he oould do
nothing but attend upon himself, and he was in constant torment
whenever he departed in anything from his usual regimen, and so
dying hard, by the help of science he struggled on to old age.

A rare reward of his skill 1

He goes on to say that Asclepius did not instruct his
descendants in valetudinarian arts because he knew that
in well-ordered states individuals with occupations had
no time to be ill. If a carpenter falls sick, he asks the
doctor for a "rough and ready cure — an emetic, or a
purge, or a cautery, or the knife — these are his remedies."
Should any one prescribe for him a course of dietetics
and tell him to swathe and swaddle his head, and all that
sort of thing, he says, " he sees no good in a life spent in
nursing his disease to the neglect of his customary employ-
ment; and therefore bidding good-bye to this sort of
physician, he resumes his ordinary habits, and either gets
well and lives and does his business, or, if his constitution
fails, he dies and has no more trouble.' 9 '

He is more in earnest in another place (Oorgias) in an

1 Dialogue* in. 03-4.
61



Digitized by



Google



PHYSIC AND PHYSICIANS

account of the relations of the arts of medicine and gym-
nastics: "The soul and the body being two, have two
arts corresponding to them: there is the art of politics
attending on the soul ; and another art attending on the
body, of which I know no specific name, but which may
be described as having two divisions, one of them gym-
nastic, and the other medicine. And in politics there is
a legislative part, which answers to gymnastic, as justice
does to medicine ; and the two parts run into one another,
justice having to do with the same subject as legislation,
and medicine with the same subject as gymnastic, but
with a difference. . . . Cookery simulates the disguise of
medicine, and pretends to know what food is the best for
the body ; and if the physician and the cook had to enter
into a competition in which children were the judges, or
men who had no more sense than children, as to which of
them best understands the goodness or badness of food,
the physician would be starved to death." l

And later in the same dialogue Socrates claims to be the
only true politician of his time who speaks, not with any
view of pleasing, but for the good of the State, and is un-
willing to practise the graces of rhetoric — and so would
make a bad figure in a court of justice. He says : " I
shall be tried just as a physician would be tried in a court
of little boys at the indictment of the cook. What would
he reply under such circumstances, if some one were to
accuse him, saying, '0 my boyB, many evil things has
this man done to you ; he is the death of you, especially of
the younger ones among you, cutting and burning and
starving and suffocating you, until you know not what to

1 Dialogues, iL 345-6.
62



Digitized by



Google



AS DEPICTED IN PLATO

do ; he gives yon the bitterest potions, and compels yon



Online LibraryWilliam OslerAequanimitas : with other addresses to medical students, nurses and practitioners of medicine → online text (page 4 of 26)