Over many centuries, the warrior heroes, the medical craftsmen, and the gymnasts of ancient Greece had accumulated a store of pragmatic information on maintaining health; the philosopher-scientists had championed secular causation in the cosmos and had developed rational theories and methods of treatment. In the fifth century B.C. this lengthy development of Greek medicine was capped by and epitomized in Hippocrates. From then on into modern times, medicine in the Western world and in parts of the East would be continually under the influence of the teachings of the man (or men) referred to as Hippocrates.
Who was Hippocrates?
Some facts have been generally accepted. Hippocrates did exist (although some scholars dispute even this) and was well known in the Greek world. Apparently born about 460 B.C. on the island of Cos, he died about 370 in Thessaly. He was a teacher on Cos, an itinerant practitioner of medicine, and the presumed author of a number of treatises. Precisely which parts of the Hippocratic Collection were actually written by him is not altogether established, but some reasonable attributions have been made on the basis of style, content, and what is known of attitudes and practices of rival teachers.
There were other prominent physicians of the time who were probably as well known. Chrysippos (whose statue was long thought to represent Hippocrates) was a later philosopher-physician of great reputation. Euryphon of Cnidos, a contemporary, seems to have been at least as famous and has often been considered an important contributor to the "Cnidian Sentences." Another famous physician of Cos, but later than Hippocrates, was Praxagoras, whose student Herophilos became an outstanding, influential figure as an anatomist and author in the Alexandrian school of the late fourth century B.C. Hippocrates, Chrysippos, and Praxagoras have sometimes been grouped as proponents and innovators of dietetics as a method of treatment.
But it was Hippocrates whose name shone ever brighter in subsequent years. Facts were embellished, stories told, and legends created. Some may have been true, some may have contained germs of truth, but others were wholly fabricated. A few of these legends may be worth mentioning because they indicate the types of achievement that appealed to the minds of the centuries following Hippocrates.
In Macedonia he cured the king of what had been diagnosed as phthisis (a progressively debilitating condition) but was perceived by Hippocrates as psychological in origin, a situation missed by Euryphon, the leading physician of Cnidos.
In Abdera, Hippocrates was asked to cure Democritos of presumed madness—thus illustrating his prowess but also enhancing his image as a philosopher to have communicated with the great Democritos, who introduced the atom into science. Invited to Asia Minor to stop the plague, he chose to remain home and help his own people. His patriotism was similarly shown by the tale of his rejecting a request from King Artaxerxes because the Persians were enemies of Greece. (The wars with Persia occurred just before the decades in which Hippocrates lived.)
Even fantastic legends arose. For example, on his tomb a beehive produced honey which had exceptional curative powers. Despite proof that there were no Asclepieian temples on Cos at the time, a rumor once started that Hippocrates had set fire to the temple to preserve his own primacy there.
Concerning his appearance, there have been many attempts to present to the world a noble face and impressive body to go with the physician's other attributes. However, very few Greek statues of the period have survived, so our view of Greek sculpture rests principally on Roman copies. Various dignified antique busts have been said to represent Hippocrates at different times, and likenesses painted and drawn from imagination have also perpetuated a belief in his impressive appearance. Aristotle indicated that Hippocrates was of short stature, so there was all the more reason to seek a handsome, outstanding face to portray the greatest physician of all time. Recent studies have yielded coins from Cos with profiles bearing the name of Hippocrates, which a sculpted head found in a cemetery in Ostia seems to resemble. These are now accepted by almost all as the likely appearance of Hippocrates.
What Did He Write?
The works of Hippocrates compiled under the title "Hippocratic Collection" or Corpus Hippocraticum almost certainly include writings by many authors from Cos, Cnidos, Sicily, and perhaps elsewhere. The Collection was assembled in the fourth century B.C. at the great Library in Alexandria, where an extraordinary center of learning had been established by Ptolemy, one of Alexander's generals, who started a ruling Greek dynasty in Egypt that was ended when the Romans under Octavian overthrew Cleopatra VII in 30 B.C. The intention of the Ptolemies was to collect the entire sum of human knowledge in the Library, and the works of Hippocrates were undoubtedly sought out. As his name became increasingly famous it is likely that more and more medical contributions were assigned to his authorship. Since it is virtually impossible to determine which treatises were genuinely by Hippocrates, the custom has arisen to refer to the entire Collection as writings of the Hippocratists or Hippocratics, thus leaving the authorship undetermined. When we use the name Hippocrates we refer not only to the man but to any others who made important contributions to the Corpus Hippocraticum.
The total number of works in the Collection has been variously estimated, depending on how one counts the treatises and the books of which each treatise is composed. The books number about seventy-two and the treatises about fifty-nine, but the subject matter is not arranged in any coherent plan. Therefore, each summary of the Collection is forced to reassemble the works according to its perception of relatively similar topics. Although we cannot classify all the information under specific headings we would use today, we can extract and categorize a few general beliefs found in the collection.
Anatomy—Anatomical details are relatively sparse and there is no truly systematized presentation. Information on most of the viscera is scanty, but the heart is somewhat more completely dealt with. The pericardium, the muscular ventricles, the heart valves, the different contracting times of auricles and ventricles, and the great vessels are mentioned. Nerves are considered hollow and are confused with ligaments. Differences between arteries and veins are not understood.
Physiology—The innate heat of the body necessary for life comes from the pneuma of the air and is taken in by the lungs. Air along with blood fills the arteries. Sight depends on the lens and the vitreous humor (the gel that occupies the eyeball). The retina is not understood as the organ of sight. The four humors corresponding to the four elements are the physiological bases of body function. Harmony of all parts is necessary to health.
General Pathology—Causes of illness are either immediate due to internal difficulties or remote because of outside influences, especially climate, personal hygiene, diet, activity, and surroundings. Diseases have three stages: degeneration of the humors, coction (a cooking process), and crisis with the evacuation of offending humors. Over forty case histories are summarized in descriptions so superb that we can make good inferences even today on the type of illness presented.
Therapy—The repeated advice is to avoid interfering with the course of the illness except at the proper time indicated by natural signs. One must assist nature in doing the cure. "Timidity indicates incapacity; rashness is evidence of unskillfulness." Relatively few drugs are used, certainly not as many as were supposedly given on Cnidos or in the Western world in subsequent centuries. Laxatives and emetic herbs are the principal agents, as was the custom in Egypt. Narcotics, however, are also advised. Much emphasis is placed on regimens, including baths, inunction, and diet (usually quite simple and limited). Cupping, scarifications, and bleeding are also part of therapy, but they do not seem to be important.
Diagnosis—Very few names of diseases are mentioned and no special syndromes are presented. The condition of the patient is the important thing to the Hippocratists, and inquiry is made into details of his past and present behavior as well as his complaints. The patient's appearance is observed in detail, including his body makeup and excretions. Vaginal examination is practiced, and probes and speculums (instruments to hold open) are used to examine orifices. An ear is held against the chest to hear the breathing sounds, but the heart sounds seem not to have been well described. Palpation discloses the temperature as well as characteristics of parts of the body. The pulse is noted but not made much of, in contrast to the great emphasis on describing the pulse in later times. Even smelling and tasting are advised to give the doctor a complete picture of the patient's condition.
Prognosis—Almost all the information obtained from questioning the patient and examining him is considered. "In order to prognosticate correctly who will recover and who will die, in whom the days will be long, in whom short, one must know all the symptoms, and must weigh their relative value." The traveling physician could gain the patient's confidence and make his reputation by accurately predicting the outcome of an illness.
Surgery—Probably the most thorough treatises in the Collection are on surgery. Many conditions are treated by operative, manipulative, and more conservative means. Fractures and dislocations of all types are given much attention, as are wounds of the skull, which come in for particularly detailed analysis and treatment. Wounds of all kinds are carefully described and treated by a variety of methods, including local drugs, applications, insertions, and bandages. The injuries of war figure prominently: "He who desires to practice surgery must go to war."
Hemorrhage is controlled by positioning the part, compression, and mere watching. Cauterization is mentioned a number of times. "What drugs fail to cure, that the knife cures; what the knife cures not, that the fire cures; but what fire fails to cure, this must be called incurable." This concept is actually more ancient than Hippocrates, appearing even in Indian medicine. Later, in the Middle Ages, it was to become an important principle of Arabic medicine. Ligation of blood vessels is not spoken of at all.
Operative techniques are reported in detail, including preparation of the patient, table, light, instruments, and assistants. Tumors, fistulas, ulcers, and hemorrhoids are among the diseases treated by surgery, but very little is said of hernias. Almost all of the writings on surgery have been attributed to Hippocrates the man because they are clear, consistent, and pragmatic.
Gynecology and Obstetrics—The treatises on gynecology and obstetrics are a diffuse mixture of accurate observations and inaccurate suppositions. The head presentation at birth is understood to be normal, and the breech (feet first) position is known to require turning of the baby before delivery; however, the fetus is thought to initiate its own delivery. Some diseases of the uterus are well described, but it is thought to wander about in the abdomen. Delivery is performed with the patient kneeling or on a stool, and gradual expulsion of the placenta is advised, although its anatomy is poorly understood. Newborns of a seventh-month delivery are more likely to survive than those of the eighth month (possibly another example of emphasis on the number 7). "Semen" that produces a female child comes from the left ovary, whereas male-producing "semen" comes from the right. Some of the information and advice is contradictory to that in other parts of the collection, but it is likely that a difference in authorship is responsible.
Mental Illness—Concerning the emotional state of the patient and mental illness in general, the writings are especially astute and accurate in terms of modern understanding. Assignment of the brain as organ of thought and sensation is an important indication of a high state of understanding. Organic diseases such as epilepsy and delirium tremens and the more subtle derangements such as depression and anxiety are discussed with perspicacity. Even the possible medical origin of dreams is considered.
Ethics—On the subject of behavior the writings are exceptional. They deal with who should enter the profession of medicine, how the physician should look and comport himself, and what one should say and do to comfort the patient. He must also observe the following rules for a temperate inner life: not only reticence, but an absolutely well-ordered life, for in that he has the greatest advantage for his good calling.
The physician must have a worthy appearance; he should look healthy and be well-nourished, appropriate to his physique; for most people are of the opinion that those physicians who are not tidy in their own persons cannot look after others well. Further, he must look to the cleanliness of his person; he must wear decent clothes and use perfumes with harmless smells.
The physician must have a certain degree of sociability, for a morose disposition is inaccessible both to those who are well and those who are sick.
I swear by Apollo Physician and Asclepios and Hygeia and Panacea and all the gods and goddesses, making them my witnesses, that I will fulfill according to my ability and judgment this oath and this covenant:
To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art—if they desire to learn it—without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but to no one else.
I will apply dietetic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.
I will neither give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect. Similarly I will not give to a woman an abortive remedy. In purity and holiness I will guard my life and my art.
I will not use the knife, not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.
Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief, and in particular of sexual relations with both female and male persons, be they free or slaves.
What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.
If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.
(Translation by Ludwig Edelstein)
In summary, this famous testament contains both affirmations and prohibitions. It begins with pledges to the gods and to teachers as well as future students. The prohibitions are against harm to the patient, deadly drugs, abortion, surgery, sexual congress with the patient or his household, and revelation of secrets discovered while ministering to the sick. The duties are to act with purity and holiness.
The Oath is the most widely known document associated with the name of Hippocrates. Graduating medical students for centuries have stood to swear to its provisions (either unaltered or with modifications). Yet it is probably not a part of the Hippocratic teachings, was not in all likelihood sworn by physicians on Cos, and is at variance with some of the principles and practices of Hippocrates.
One immediate inconsistency is the Oath's prohibition against abortion and contraceptives; the Hippocratic Collection contains a number of allusions to the methods of abortion and the use of pessaries. The interdiction in the Oath against the knife is especially out of keeping with the several treatises that deal at length and in detail with surgical techniques and operating room procedures.
There are possible explanations. It is likely that the Oath was never part of the teachings on either Cos or Cnidos. One view is that it represents a testament of Pythagorean origin antedating Hippocrates but added to the Hippocratic Collection in later centuries. The Oath's main points concur with the Pythagorean prohibitions against taking life in any form within or outside the body; against surgical procedures of all kinds; indeed, against the shedding of blood, in which the soul was thought to reside.
The omission from surgical treatises in the Corpus Hippocraticum of any mention of operations for urinary tract stones may be variously interpreted. For instance, it may be that results were ordinarily sc unsuccessful that ethical physicians avoided such procedures, or cutters for the stone might have been lowly regarded, but there may be other explanations. Certainly the extensive involvement in many types of surgical activity by physicians on Cos would make untenable a pledge that forbade surgery.
If the Oath is so clearly a non-Hippocratic document, why has it remained steadfastly the symbol of the physician's pledge to his calling? For one thing, the prohibitions against abortion and contraceptives were in easy consonance with the principles of the Christian Church of later centuries. The earliest reference to the Oath is in the first century A.D., and it may have been taken up later to fit the religious ideals of the time. Substitution of God, Christ, and the saints for the names of Asclepios and his family in the invocation would be a simple matter. Furthermore, the principal parts of the Oath that stick in the memory are those in which the physician swears to act in purity and holiness and to conduct himself in a way that generations of people in many lands and different cultures consider ideal behavior for a physician.
The Hippocratic Method
The rational attitudes expressed in the collected writings, free of religious or supernatural explanations, represent a great advance in medical thinking, but they were only arrived at after centuries of gradual development. Furthermore, even in those lands where the religious and the rational were closely linked, as in Egypt, wholly secular, empiric systems of medicine were also practiced. Yet the consistency of the rational approach shown by the Hippocratic authors and by the philosopher-scientists before them is exceptional.
The principles of the Hippocratic method may be thus summarized:
1. Observe all.
"A great part, I believe, of the Art is to be able to observe." Taking an intensive history was stressed. "Leave nothing to chance, overlook nothing: combine contradictory observations and allow yourself enough time." Hippocrates indicated that a nonmedical person could take a history, but "much of what the physician should know besides, without the patient's telling him, would be omitted."
A particularly well-known description of pulmonary edema (failing circulation in the lung) and fluid in the chest shows close attention to detail, contains the first description of clubbing of the fingers (a sign of chronic disease), and illustrates the use of picturesque, clear phraseology: "Water accumulates; the patient has fever and cough; the respiration is fast; the feet become edematous [swollen]; the nails appear curved and the patient suffers as if he had pus inside, only less severe and more protracted. One can recognize that it is not pus but water... If you put your ear against the chest you can hear it seethe inside like sour wine."
The doctor employed all the senses: sight, hearing, smell, taste, and touch. No finding was too insignificant to be recorded; no emanation from the patient was ignored. Furthermore, the observations were collected without prejudice; that is, before attempting to explain or fit them into the physiological systems of the time. This intellectually unconfined examination lessened the tendency to see what wasn't there or to miss a finding that was not expected—a failing to which observers in all ages are susceptible.
2. Study the patient rather than the disease.
The emphasis was on how the patient reacted to his illness, not just on the type of disease. To Hippocrates, the patient's makeup, surroundings, and way of life were all important in evaluating his state of illness and likelihood Of recovery. "Observe the nature of each country; diet; customs; the age of the patient; speech; manners; fashion; even his silence; his thoughts; if he sleeps or is suffering from lack of sleep; the content and origin of his dreams... one has to study all these signs and to analyze what they portend."
The Hippocratists on Cos opposed the practice of classifying diseases according to the organs affected. Today, with our advanced physiological and anatomical knowledge, we can make such classifications and find them useful—even necessary. On the other hand, we may focus too much on disease and too little on the patient. Francis Adams, himself a nineteenth-century country doctor and a great translator of Hippocrates, expressed it this way: "The great superiority of the ancient savants [the Hippocratists] over the modern was that the former possessed a much greater talent for apprehending the general truth than the latter who confine their attention to particular facts, and neglect too much the observations of general appearances."
3. Evaluate honestly.
The courses of over forty patients were described in detail in the Collection. More than half of the patients died, but their case histories were reported faithfully, with accuracy and objectivity. The author did not hesitate to admit the lack of response to treatment, for his expectations (and the patient's) did not exceed the reality that some people get well and others die no matter what is done.
Also, the ancient physician traveling from place to place was interested mainly in prognosis. If he could say with accuracy which of the sick brought to him would survive and which would die, he would be answering what most people wanted to know, even now. "I hold that it is an excellent thing for a physician to practice forecasting. For if he discover and declare unaided by the side of his patients the present, the past, and the future, and fill in the gaps in the accounts given by the sick, he will be the more believed to understand the cases, so that men will confidently entrust themselves to him for treatment."
4. Assist nature.
The constant thread throughout the treatises is a reliance on nature. The physician's chief function is to make conditions propitious for the natural forces in the body to reach harmony and therefore health. Even in the surgical treatises the focus is always on restoring. The physician must do what he can do—that is, what has been proved by his past experiences. He must leave alone what he cannot help. "As to diseases, make a habit of two things; to help or at least not to harm."
To be sure, weaknesses may be found in many of the methods of the Hippocratists. For one thing, their anatomical knowledge was scanty and unsystematic. Yet the writings do contain astonishing anatomical detail, as in the sections on wounds, dislocations, fractures, and rectal diseases. Apparently the Hippocratists had sufficient information to deal with what was known of sickness and injury at the time.
A second limitation lay in the lack of specific diagnosis and a sort of nihilism in therapy. The great emphasis on nature taking its course often resulted in a wait-and-see approach. Yet, in addition to dietary and other regimens Hippocrates did use direct methods, as witnessed by the numerous surgical and mechanical techniques in the Collection. However, he recognized his limitations and did only what appeared to be useful.
Another weakness was espousal of the four humors theory. This doctrine, together with many ramifications which had origins long before Hippocrates, was to be a principal basis for medical speculation in subsequent centuries, but Hippocrates used the system chiefly to explain illness in current terms. However, his treatment was not based on that theory alone since extreme remedies were not employed. Furthermore, Hippocrates judged results not on how they fit the theory but only on the outcome. Yet, like Galen much later, Hippocrates had need of a base, a system, a theory, to underlie the knowledge of physiology and illness.
Paracelsus, who will appear in the chapters on the Renaissance, burned the works of Avicenna and Galen to symbolize the need to rely on one's own observations rather than authorities. That principle, however, is part of the Hippocratic method itself. Hippocrates relied on his own observations, while using the past experiences of others, for he recognized that knowledge did not begin with him. We hope that in our times people will realize that what we embrace securely may seem foolish in future centuries.
If the Hippocratic method is used today, the physician can observe objectively, avoid rigid postures, foreswear arrogance, and shun abject adherence to doctrines. Furthermore, we are just beginning to learn once again the Hippocratic doctrine of attending to the whole person in his own environment.
"Life is short; and the art long; and the right time an instant; and treatment precarious; and the crisis grievous. It is necessary for the physician not only to provide the needed treatment but to provide for the patient himself, and for those beside him, and to provide for his outside affairs." (Translation by Dickinson Richards)