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Two men leave the Agora. They are deep in discussion, though the conversation is periodically interrupted by enjoyment of the honey-and-apple pastries that the pair purchased at a stall as they were leaving. Passers-by glance curiously at the two, for the older man is clearly the student. He listens attentively, and periodically stops as he commits some detail to memory.
This surprises many, for Phoikos is a respected physician with students of his own. The younger man – a burly fellow in his mid-forties – is a stranger. His accent has the sing-song rhythm that marks citizens of the eastern Aegean. (In many eastern cities Attic Greek has mutated into different dialects. Indeed, so error-prone has become the speech of citizens of Soli in Asia Minor that serious grammatical errors will for evermore be called ‘solecisms’.) This is Hippocrates of Kos – a man who accepts his title as the world’s greatest doctor without false modesty, but as a simple statement of fact.
‘It’s the whole body,’ Hippocrates is saying. ‘When you think on it, when the lungs have a fever, is not the brain also somewhat disordered? A cut on the hand can lead to a bloody flux from the bowel. A fat belly is a sign that the person carrying that belly will die sooner, of whatever causes, than he would if he were slim.
‘That’s the issue, you understand, which I have with the school at Knidos. If there’s a problem with the liver, they treat the liver, as if the liver was not, one might say, part of a community of organs within the body. I have observed that problems with the liver can become problems with the skin, and also the kidneys. A tumour starts in one part of the body, but the roots go deep elsewhere. You have to treat the body as a whole.’
Phoikos digs a shred of apple from between his teeth. So a rogue tumour must be excised, before it spreads to and damages other organs – he must pass that analogy to his friend Nicias. An adept politician and orator, Nicias will enjoy working the words of Hippocrates into a speech condemning his rival, Alcibiades.
Phoikos shares Nicias’ opinion that young Alcibiades is their city’s tumour. A corruption of the body politic with his waywardness, his reckless behaviour, and his disrespect for his elders and for the gods.
Alcibiades is an outstanding candidate for ostracism. Athenians can vote to exile a politician for ten years. Not for anything illegal, but because the citizens judge him to be a danger to the body politic.
Nicias could argue that Alcibiades should be ostracized, just as doctors excise a tumour before it damages the rest of its host. The medical analogy might help explain this to the people. Phoikos is convinced that Alcibiades has to be exiled before he drags Athens into that dangerous and stupid Sicilian expedition.
It suddenly occurs to Phoikos that he has completely lost track of what Hippocrates has been saying for the last minute. He is saved from admitting this by a man in a dishevelled tunic who pushes through the crowd. ‘Phoikos! Has anyone seen the doctor? He left the Agora by this street. I seek Phoikos!’
‘I am he.’
‘Come, please, at once. There’s been an accident. A column drum fell on someone.’
The man seeking help is hopping from one foot to another in impatience. ‘It’s the temple of Hephaestion – we’re doing repairs. The drum slipped off a cart. Young Deculion, it’s lying on his leg. So you’ll help him?’
This question is addressed to the backs of the two doctors. They have already taken off down the street at a dead run and arrive just in time to stop the workmen from killing their patient.
The men have wedged wooden poles under the column drum and are preparing to lever it off an inert body on the cobblestones. Nearby, a pair of oxen hitched to a cart have been joined by a crowd who offer comment, prayer and advice in equal measure.
Phoikos pauses to suck in air. Meanwhile, Hippocrates unceremoniously shoves the workmen away from the poles and kicks aside the person bent over the victim, whose abdomen he then cautiously palpates.
‘Breathing shallow, pulse thready. Skin pallid and clammy. There’s a large contusion and swelling at the back of the skull. No depression and the bone is unbroken. Was this man hit on the head?’
‘I don’t know. He went down hard,’ says one of the workmen. ‘Must have caught his head a crack on the cobbles. He’s not moved or spoken since. But isn’t that column drum the main problem? We’ve got to get it off him.’
Columns such as those at the front of this temple are not carved from single blocks of stone. Most columns are two or three times the height of a man, and even finding suitable stone to make into such monoliths would be hard work. Instead, the average column is made of ‘drums’ – circular lumps of stone around a cubit high, and flat on the top and bottom. Some have holes in the flat surfaces where metal rods can be used to secure the stone to drums above and below. Mostly, though, the sheer weight of a column drum holds it in place.
BATTLEFIELD REPAIRS
Once all the drums have been joined into a column, workmen put cement paste mixed with powdered stone into the gaps and sand it down so that the joins are indistinguishable from the rest of the stone. The drum lying across young Deculion’s lower leg is intended for the base of one such column and is a hefty lump of marble.
Hippocrates explains, ‘Remove that drum and the boy’s death will be quick and certain, instead of highly probable, as is now the case. The rush of blood into the damaged limb upsets the body humours, see? But act as you wish. A swift death might be doing the lad a favour, it’s true, but if you do it, he can’t be my patient. The fundamental principle of my school is, “First, do no harm.”’
The workman looks at Phoikos. ‘Who in Hades is this?’
‘Hippocrates of Kos. Only the greatest doctor of our age. He has travelled in Egypt and Babylon, and knows more of medicine than ten of me combined. I would call this the boy’s lucky day – except that it evidently isn’t. If you want to save him, do whatever Hippocrates says – and don’t take offence. He can be a bit abrupt.’
Hippocrates ignores the character reference given by his companion. ‘The leg has got to go.’ He indicates the mangled flesh between column drum and roadway. ‘Actually, it has gone already. We must treat it as though it is a case of gangrene and remove it below the joint. Phoikos, take notes – even if this patient dies, the documentation will be useful.’
‘That’s fairly heartless,’ remarks a spectator. Hippocrates looks up.
‘Life is brief, but the art of medicine endures. What would be heartless would be to stand by and do nothing to help this boy, nor learn so as to later help others. Standing by in ignorance is exactly what you are doing, you understand? Until you become no worse than useless, be still and hold your tongue.’
Hippocrates turns to his fellow doctor. ‘Phoikos, I shall cut here, where the nerves are already severed. It is living flesh, and cutting that is not advised. If the patient is awake, he will quickly pass out and probably never revive. Our patient is unconscious and probably going to die anyway, so we must attempt it. What is the main danger here?’
Hippocrates
When we talk of a person convalescing, or relapsing, or whether a disease is acute, chronic or an epidemic, we are using terms categorized by Hippocrates, the ‘Father of Medicine’.
Hippocrates firmly established medicine as a science apart from religion and theurgy. (Theurgy is the use of supernatural means to effect a cure, such as prayer, magical amulets and sacrifices.)
Hippocrates established scientific principles of observation, clinical diagnosis and protocols for medical procedures. The amputation described here is lifted directly from the ‘Hippocratic corpus’ – texts written by Hippocrates (allegedly) and his successors at the medical school that he founded on his birth island of Kos. ‘First, do no harm’ is still incorporated into the Hippocratic Oath taken by many modern doctors. Another quote – sometimes rendered as ‘Ars longa, vita brevis’ and translated along the lines of ‘Art endures, life is short’ – has been kidnapped by the literary types, but was first applied to the art of medicine.
Hippocrates was at least eighty years old when he died, and some accounts have him living past a hundred. His name means ‘the strength of horses’ and, metabolically speaking, that was the case.
‘Indeed. Large blood vessels have been severed, and the bone is crushed. Usually with a leg this mangled, I would wait and let gangrene separate the bone as a natural process. After all, suppurating flesh is harder to look at than to treat. Yet we can’t do that here, you understand, and some haemorrhage at the crisis is useful, for it flushes ill humours from the site of injury. What remedy for haemorrhage do you suggest?’
‘Burning?’
‘Possible, indeed possible. Desperate situations require desperate measures. Yet I shall first try compression. I have seen patients recover, even when gangrene takes a leg at the femur. I need …’ Hippocrates rolls up his eyes as he searches his memory. ‘Water. Clean water, mind you, some warm and some hot potfuls of water. Vinegar. Honey. Fig leaves. Pine resin. And I need cloth – clean linen. Get it from the market. A knife, as sharp as possible, the blade rust-free. And leather – about so.’ Hippocrates holds up two hands making a circle with a gap of about two inches between his fingertips. ‘Carthaginian leather, if you can find it. Otherwise any leather, stretched thin.’
‘For what do you intend the leather?’ asks Phoikos curiously.
‘I shall do a wedge resection here.’ Hippocrates traces an inverted ‘V’ just below the patient’s knee, having to dig his fingers under the drum at the tips of the V. ‘See the bump in the leg there? The bone is shattered, so the least flesh is that which we leave here at the point of the V. We pull the longer flaps of flesh together below the bone, cup the stump in the leather and compress with bandages. The leather causes the flesh to bind to itself and not to the cloth.’
Hippocrates prods the point just below the broken bone, and looks to see if the patient flinches. There is no movement.
‘We need that knife now!’ Hippocrates bellows, causing some in the crowd to start back in surprise. Looking down at the patient he mutters. ‘In the first place, diagnosis. What is right and what is out of place. What is obvious, and what is needed to be known. What may be learned by visual examination, then by touch, then by hearing. Even smell and taste can convey information. Then understanding the data, without which all the other observations are pointless. Done that.
‘Next we need clarity. About the patient, who is in charge of the operation, what instruments are available, what light. We must be clear how many things are to be done, what they are and in what order we will do them. I should be here, for the light is common sunlight, and it falls on the operating area so. My garment does not interfere with the operation. My fingernails are trimmed. My assistant is reasonably competent. We now need the instruments, laid out and in order of use. You, Phoikos, will pass them to me. Have them ready beforehand and do as I direct.’
Beyond Hippocrates the bystanders have leapt into action. If there has to be a crisis, Athens is a good venue to have it. Athenians react quickly and coolly in emergencies, perhaps because of their unfortunate habit of provoking such emergencies in the first place. Within minutes Hippocrates has his materials. A razor-sharp skinning knife is in his hands, and behind him the leader of the work gang bickers with the stallholder who provided the linen.
‘You two – hold the boy’s shoulders. He will probably stay unconscious, mind you, but I don’t want him jumping around like a landed trout if he feels the knife. Phoikos, we need temporary compression here, at the adductor magnus. There’s a major artery between the tibia and fibia, and when I cut that, you need to suppress the blood in the femoral artery. I have seen the Egyptians do this. It is like damming a river upstream before you breach a dyke below. It works, anyway. You press there and the bleeding here will be reduced until we have closed and compressed the wound.’
‘Why not simply leave the compression on the thigh, if it is so effective?’ enquires Phoikos.
‘Doesn’t work, you understand? Tie a bandage or ligature too tight and for some reason the lower part mortifies and eventually rots. That’s why even with compression below the knee, we will eventually do it with the weight of bandages rather than their tightness.’
Hippocrates works smoothly, occasionally flipping the knife to separate muscle fibres with the slender handle instead of slicing through them with the blade. He doesn’t really need Phoikos, which is just as well, because Phoikos is occupied with jamming a knuckle into the upper leg at the point Hippocrates has indicated.
When he stops to ease a cramped elbow, Phoikos causes a rush of blood over the surgical site and a string of irritated obscenities from Hippocrates. Phoikos now shifts so he can keep the pressure reassuringly constant. The other workmen have appointed themselves as human barriers against the press of a gathering crowd, straining for a closer look at the operation in progress.
‘Leather,’ demands Hippocrates. He examines with disgust the thin sheet he is handed. ‘Is this from the curtain of a privy door? While I irrigate the wound with vinegar, scrub that leather down, smear the cleanest side lightly with honey. It will have to do.
‘Now, this bandage we shape like a cup, and sit it over the leather-covered stump, so.11 The honey helps to prevent infection, though expect plentiful pus as the wound heals. It will need draining later.
‘Now we wrap the wound firmly, because you understand there should be absolutely no swelling at this point. We start here, and wrap so that the next layer of wrapping holds the lower one in place. The incisions are at the left and right, so the top and bottom of each circuit get a dab of resin – here and here. That stops the bandage slipping. Oh, and now remove that column drum. It’s in the way.’
Amputations
The ancient Athenians, like most ancient Greeks, forbade the practice of dissection. Most anatomical knowledge was obtained through examining human leftovers opened on the battlefield by enthusiastic amateurs with swords.
While it was understood that cleanliness helped to prevent infection, the Greeks were ignorant of what caused infection, and sterilization of medical instruments did not happen. Consequently, major limbs were seldom amputated unless in circumstances as exceptional as those described here. Usually, the limb was kept, no matter how damaged. Often the limb would become gangrenous and drop off of its own accord, which was the preferred option. How many survived this process is unknown.
Hippocrates stands and arches his back to get rid of the kinks. He turns to the leader of the workmen and explains that either the boy will wake within the hour or not at all. Until sundown, they are to give him only sips of water to drink. Thereafter, his usual doctor can treat him as he would any wounded hoplite after a battle. Hippocrates instructs them to change the bandages after three days, and repeat until the wound has stopped weeping. If it suppurates, they need to cut away any rotten flesh that appears above the knee, and eventually the bones below will separate from the knee. For the first five days the young man is to lie flat with the stump slightly raised. Once the bleeding has stopped and the swelling has subsided, he will be allowed to sit.
Hippocrates points to a vase, and Phoikos pours warm water over Hippocrates bloody hands. Hippocrates shrugs off the effusive thanks of the workers. ‘Obviously, my colleague needs to be paid for his time. As to mine, consider this a gift from me to one of the citizens of Athens.’ (Unlike Phoikos, Hippocrates is independently wealthy. For him, medicine really is a calling rather than a job.)
Hippocrates pauses, wiping down his arms with cloth left over from the linen bandages. ‘Mind you,’ he tells the foreman, ‘there is something you can do for us. While we clean up, send someone down to the pastry stall in the Agora, the one near the exit by the Mint. Our honey-and-apple pastries went missing somewhere along the way. Will you get us two more apiece?’
