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Medicine in Hippocratic Times

In the several centuries between the flourishing of Cretan-Mycenaean civilization and the time of the philosopher-scientists, a distinct change had come about in Greek attitudes toward the causes of disease: the teachers and medical practitioners of the time of Hippocrates no longer looked at illness as a punishment by the gods. Nevertheless, a sick person was thereby only a little better off. If the ill patient could be restored to a healthy state, all possible means were employed. But if he could not be cured or at least improved, he was virtually abandoned by the physician as well as his neighbors. Illness was indeed still a curse—of man if not of the gods.

The Stoics (in the fourth and third centuries B.C.), who preached virtue rather than health as the highest good, also considered illness an evil to be avoided at all costs. As a matter of fact, suicide was justified for illness under their code. Nevertheless, the position of the sick person was now better in that—unless his condition was considered hopeless—he was the focus of healers who looked upon him as a victim of natural causes within and outside his body, deserving, therefore, of rational methods of management.

Education

In his early years, a Greek youth was urged to be athletic, but at about the age of eighteen he was directed more to intellectual pursuits: philosophy, rhetoric, science, and—significantly—medicine. The educated man was expected to be acquainted with all fields of knowledge, and it was only natural for physicians to pursue all branches of medicine, both medical and surgical. Specialization had not yet appeared, although Herodotos had mentioned that a well-advanced system had already developed in Egypt.

By the time of Hippocrates the Greeks had developed a hypothetical system which explained the mechanism of illness in terms of four basic humors of the body. One can detect a clear progression of ideas in Greek metaphysics that led to this system: the teaching that four basic elements (water, air, fire, and earth), each with its specific quality (moist, dry, hot, and cold), comprise the entire universe; the concept that pairs of opposites (with concomitant emphasis on the number 4) were to be kept in equilibrium to achieve harmony in the cosmos and health in the microcosm of man; the special effects on the body and mind of the seasons, which were at first three and then four; the visible secretions of the body, also at first three (blood, phlegm, and bile) and then four by separating bile into yellow and black. Ultimately, some kind of hypothesis was required to organize these concepts, for as Peter Medawar, a Nobel Laureate of the twentieth century, has said, "Science without the underpinning of hypothesis is just kitchen arts."

The key principle was that all body fluids were composed of varying proportions of blood (warm and moist), phlegm (cold and moist), yellow bile (warm and dry), and black bile (cold and dry). When these "humors" were in balance the body was in health; excess or deficiency of one or more caused illness. There were three stages of disease: a change in humoral proportions caused by external or internal factors; the reaction of the body to this by fever or "boiling"; the resultant crisis when the disorder ended through discharge of the excess humor—or by death. The emanations or humors of the body were often seen during illness (blood, phlegm from the nose, vomit, fecal matter, urine, sweat), and frequently an illness did suddenly disappear after reaching a crisis—the discharge of one of the humors.

In attitudes toward mental disease, the Greeks like other peoples showed a gradual development from belief in supernatural or demoniac causes to more rational explanations. By the fifth century B.C. the mind and its derangements were clearly located in the brain. Yet even Plato, a contemporary of Hippocrates, classified madness mythologically into four main types: prophetic (mediated by Apollo); ritualistic (as in the Dionysian ceremonies); poetic (inspired by the Muses); erotic (under the influence of Aphrodite and Eros).

The Practitioners

As in Mycenaean days described in the Homeric epics, the physician of the sixth and fifth centuries B.C. was still of the class of craftsmen, although his status was enhanced because of the exceptional emphasis placed on health by the Greeks. An upper-class freeborn physician usually treated his own kind, for which he received fees. His assistants and slaves might attend to metics (resident aliens) and slaves, but there were no rules in this respect. Those who could afford to pay for treatment probably had access to experienced practitioners, but the poor had little open to them. This may account in part for the rise and extension of the Asclepieian temple as a doorway of medical treatment for all. Of course, magical medicine, which was respected by even the philosophers Plato and Theophrastos, was available to all—rich and poor, slave and free. In general, physicians cast a clinical rather than a political or economic eye on the patient, and treatment was the same for poor and rich. The physicians themselves came principally from the class of aristocratic citizens or from the metics, who also supplied the freedmen, traders, artisans, and farmers.

The training system was by apprenticeship, and apparently for a fee the neophyte received instruction, participated in the care of patients, assisted and nursed as needed, and performed menial tasks in maintaining the equipment as required by the teacher. This may not have been much different from the practice in our recent past of a young physician's assisting an established practitioner in his office, staying in his place at the bedside of desperately ill patients as well as performing other tasks.

The office (iatreion) of a Greek physician was often in the vicinity of a temple of Asclepios in regions where they existed. Most often the office was a temporary location for medical activities because the majority of physicians were itinerant, traveling from city to city, carrying drugs and instruments, setting up in a suitable house near the market place where patients could even stay a day or longer for a procedure that required special attention. Most often, however, the physician went to the home of the patient, especially if he was rich. Even operations were often performed there—as was still customary in the nineteenth and early twentieth centuries in the West, when tonsillectomies were frequently performed in the home.

Payment was expected, but not necessarily for every service. Fees were often set and given in a lump sum in advance, a procedure advised in the Hippocratic writings but coupled with a precaution to avoid discussion of fees if the patient was acutely ill or worried about finances. "I advise making no excessive demands, but to take into account the means and income of the patient. In certain circumstances, the physician should give treatment for nothing. It is better to reproach those who escape than to bellow at those who are in danger."

By the time of Hippocrates in the mid-fifth century B.C., a multiplicity of practicing healers had come upon the scene. The question of who were charlatans and who were bona fide contributors is difficult to answer. There was no system of licensure or certification before 300 B.C., and anyone except a woman could take the title of physician.

That women did not qualify as medical practitioners would be expected in a culture which relegated them to secondary status. In Athens, wives rarely appeared in public, almost never showed themselves at feasts or social events, and were confined principally to household duties for all of their lives. In Sparta, presumably, they had a measure of greater freedom, but in that society in which everyone's function was to serve the state women were mainly breeders. One group of women in Greek society who did succeed in becoming relatively free spirits were the hetaeras who entertained men. Not exactly prostitutes, although their favors were for sale, they were like the "adventuresses" of more recent times who lived by their wits.

Methodology

The methods of treatment were general and local. Regimens consisted of diet, daily exercise, and temperate behavior in eating, drinking, sleeping, and sexual indulgence. This therapy was probably only suitable for the upper class, for the common workingman had neither the time nor financial security to embark on daily activities just to keep fit. During illness a sparse diet was the usual prescription. This restricted intake (sometimes consisting of only gruel, water, vinegar, and honey) has been evaluated in recent times as highly deficient and therefore probably harmful to the patients. Even the regular diet of the healthy Greek in those days may have been rather frugal.

Numbers in relation to the day of illness were important considerations. In the Pythagorean teachings of the sixth century B.C., the three- or four-day intervals between chills were significant. As in Mesopotamian cultures, the number 7 was also of medical interest: the menses occurred at four times seven intervals. Pregnancy lasted forty times seven days.

What we consider today branches of medicine (such as surgery, internal medicine, and obstetrics) were all combined as one in the healing art. Thus dental illnesses were also treated by the physician, who probably included among his methods the fixation of loose teeth with gold wire, an Etruscan practice.

Wounds and sores were cleansed and sprinkled with many kinds of mineral substances and mixtures of plant extracts, most of which included wine. The purposes were to soothe and presumably to hasten healing, but cloth stuffings placed within and around the open wound may have caused infection and pus. Since the sudden discharge of pus often is followed by the healing of a vexatious boil, sore, or wound, the encouragement of draining pus in a wound came to seem desirable. This belief, later memorialized in the Middle Ages as "laudable pus," represented a common attitude for centuries before and after the Greeks.

Although medicaments were used most often for external application, some drugs were taken internally to produce purging or vomiting, to rid the body of the excess humors. Enemas were also used. These practices had been common in other regions of the world for centuries. Herodotos reported, for example, the Egyptian custom of regularly cleansing the intestinal tract to maintain health, not just when ill.

Injuries to the bones and joints must have made up a substantial part of medical practice. The manipulations to reduce dislocations and fractures achieved a high degree of sophistication, sometimes with the employment of mechanical devices. Effective and complex techniques of bandaging all parts of the body are also to be found in the works of Hippocrates and in the numerous later commentaries. The cautery evidently was effectively used by the Greeks to treat infections, wounds, and tumors. In addition, their careful and extensive use of operative surgery with the knife is most impressive. The juice of the opium poppy and of mandragora (hyoscyamus) for anesthesia and pain relief were probably also commonly available among the Greeks.

Human and veterinary medicine were separate, especially since man was the only creature with a soul, but the anatomic and physiologic information obtained from animals in the kitchen, the butcher shop, and the hunt were applied to the human body. Furthermore, it seems that regular physicians cared for animals too, especially horses.

It was apparently on Cos that physical examination was brought to a high art. No detail of a patient's appearance and function was to be omitted. Moreover, his way of life, his emotional state, surroundings, and behavior were carefully examined. The climate and customs of his city and country were also part of the medical examination.

When all the information had been obtained and the responses of the sick person evaluated, the Coan physician apparently made a judgment on whether the patient would get well (prognosis) and then on what should be done. The explanation for a sickness or the type of disease it represented was subordinate to the outlook. For in a society where the physician traveled from place to place, his reputation was doubtless based more on how he predicted the outcome of an illness than on diagnosing what was wrong. Furthermore, at a time when therapy was limited, the prognosis might be the only contribution a physician could make.

Public Health and Hygiene

The Hippocratic writings used the word "endemic" to cover those diseases which were always present in an area because of climate, water, agriculture, nutrition, and customs. Among them were what we would today call "colds," pneumonia, gout, cirrhosis, mumps, tuberculosis, malaria, and diarrheal diseases. From the reports available it is difficult to identify with certainty the acute diseases with skin rashes (exanthemata) such as smallpox, measles, chicken pox, and scarlet fever. Some other descriptions may be interpreted as representing diphtheria, although they may have referred merely to severe infections of the mouth and neck.

For the bulk of the population, the houses were cramped, closely packed, poorly ventilated, and little better than hovels. The homes of the rich, however, were built with consideration for health in the choice, if possible, of a location far from swamps, where the sun was warm and the breezes mild. But the cities for the most part were laid out in squares, with row on row of small, poor dwellings. The streets were narrow and mired in filth. Since most people walked about outside in sandals, it is not surprising to learn that each man, whenever possible, washed his feet on entering his home. Bathing was frequent in the public baths as well as at home, usually in tubs (somewhat resembling large washbasins) and in showers that were created by running water through holes or spigots in an elevated wooden tub.

Water was always precious in Greece, never reaching the abundance achieved in Rome, a fact that may account for the reputation of the Greeks as connoisseurs of water, which they drank as often as feasible and with gusto. They also drank wine (considered of high quality in antiquity) but it was most often diluted with water. Resins used to prevent stored wine from turning to vinegar added a unique taste that came to be appreciated and later preferred by some—even to this day. Drunkenness was apparently not a major health problem in a culture which accented moderation. Yet at feasts of aristocratic citizens great quantities of wine were apparently consumed.

Thus there was a marked contrast between personal hygiene and public sanitation; between lofty philosophic moralizing and oppressive social organization; but also between the limited knowledge of the time and the brilliant, rational application of sensible principles to healing the sick.





Albert S. Lyons

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