III. HIPPOCRATES

The epochal event in the history of Greek science during the Periclean age was the rise of rational medicine. Even in the fifth century Greek medicine was in large measure bound up with religion, and the treatment of disease was still practiced by the temple priests of Asclepius. This temple therapy used a combination of empirical medicine with impressive ritual and charms that touched and released the imagination of the patient; possibly hypnosis and some form of anesthesia were also employed.⁴² Secular medicine competed with this ecclesiastical medicine. Though both groups ascribed their origin to Asclepius, the profane Asclepiads rejected religious aids, made no claim to miraculous cures, and gradually placed medicine upon a rational basis.

Secular medicine, in fifth-century Greece, took form in four great schools: at Cos and Cnidus in Asia Minor, at Crotona in Italy, and in Sicily. At Acragas Empedocles, half philosopher and half miracle man, shared medical honors with the rational practitioner Acron.⁴³ As far back as 520 we read of the physician Democedes, who, born at Crotona, practiced medicine in Aegina, Athens, Samos, and Susa, cured Darius and Queen Atossa, and returned to spend his last days in the city of his birth.⁴⁴ At Crotona, too, the Pythagorean school produced the most famous of Greek physicians before Hippocrates. Alcmaeon has been called the real father of Greek medicine,⁴⁵ but he is clearly a late name in a long line of secular medicos whose origin is lost beyond the horizons of history. Early in the fifth century he published a work On Nature (peri physeos)—the usual title, in Greece, for a general discussion of natural science. He, first of the Greeks, so far as we know, located the optic nerve and the Eustachian tubes, dissected animals, explained the physiology of sleep, recognized the brain as the central organ of thought, and defined health Pythagoreanly as a harmony of the parts of the body.⁴⁶ At Cnidus the dominating figure was Euryphron, who composed a medical summary known as theCnidian Sentences, explained pleurisy as a disease of the lungs, ascribed many illnesses to constipation, and became famous for his success as an obstetrician.⁴⁷ An unmerry war raged between the schools of Cos and Cnidus; for the Cnidians, disliking Hippocrates’ penchant for basing “prognosis” upon general pathology, insisted upon a careful classification of each ailment, and a treatment of it on specific lines. In the end, by a kind of philosophical justice, many of the Cnidian writings found their way into the Hippocratic Collection.

As we see Hippocrates in Suidas’ thumbnail biography, he appears as the outstanding physician of his time. He was born in Cos in the same year as Democritus; despite their far-separated homes the two became great friends, and perhaps the “laughing philosopher” had some share in the secularization of medicine. Hippocrates was the son of a physician, and grew up and practiced among the thousands of invalids and tourists who came to “take the waters” in the hot springs of Cos. His teacher, Herodicus of Selymbria, formed his art by accustoming him to rely upon diet and exercise rather than upon drugs. Hippocrates won such repute that rulers like Perdiccas of Macedon and Artaxerxes I of Persia were among his patients; and in 430 Athens sent for him to try his hand at staying the great plague. His friend Democritus shamed him by completing a century, while the great physician died at the age of eighty-three.

Nothing in medical literature could be more heterogeneous than the collection of treatises anciently ascribed to Hippocrates. Here are textbooks for physicians, counsels for laymen, lectures for students, reports of researches and observations, clinical records of interesting cases, and essays by Sophists interested in the scientific or philosophical aspects of medicine. The forty-two clinical records are the only examples of their kind for the next seventeen hundred years; and they set a high standard of honesty by confessing that in sixty per cent of the cases the disease, or the treatment, proved fatal.⁴⁸ Of all these compositions only four are by general consent from the pen of Hippocrates—the “Aphorisms,” the “Prognostic,” the “Regimen in Acute Diseases,” and the monograph “On Wounds in the Head”; the remainder of the Corpus Hippocraticum is by a variety of authors ranging from the fifth to the second century B.C.⁴⁹ There is a fair amount of nonsense in the assortment, but probably not more than the future will find in the treatises and histories of the present day. Much of the material is fragmentary, and takes a loose aphoristic form verging now and then upon Heracleitean obscurity. Among the “Aphorisms” is the famous remark that “Art is long, but time is fleeting.”⁵⁰

The historical role of Hippocrates and his successors was the liberation of medicine from both religion and philosophy. Occasionally, as in the treatise on “Regimen,” prayer is advised as an aid; but the page-by-page tone of the Collection is a resolute reliance upon rational therapy. The essay on “The Sacred Disease” directly attacks the theory that ailments are caused by the gods; all diseases, says the author, have natural causes. Epilepsy, which the people explained as possession by a demon, is not excepted: “Men continue to believe in its divine origin because they are at a loss to understand it. . . . Charlatans and quacks, having no treatment that would help, concealed and sheltered themselves behind superstition, and called this illness sacred in order that their complete ignorance might not be revealed.”⁵¹ The mind of Hippocrates was typical of the Periclean time spirit—imaginative but realistic, averse to mystery and weary of myth, recognizing the value of religion, but struggling to understand the world in rational terms. The influence of the Sophists can be felt in this move for the emancipation of medicine; and indeed, philosophy so powerfully affected Greek therapy that the science had to fight against philosophical as well as theological impediments. Hippocrates insists that philosophical theories have no place in medicine, and that treatment must proceed by careful observation and accurate recording of specific cases and facts. He does not quite realize the value of experiment; but he is resolved to be guided by experience.⁵²

The natal infection of Hippocratic medicine with philosophy appears in the once famous doctrine of “humors.” The body, says Hippocrates, is compounded of blood, phlegm, yellow bile, and black bile; that man enjoys the most perfect health in whom these elements are duly proportioned and mingled; pain is the defect or excess of one “humor,” or its isolation from the rest.⁵³ This theory outlived all the other medical hypotheses of antiquity; it was abandoned only in the last century, and perhaps survives by transmigration in the doctrine of hormones or glandular secretions today. Since the behavior of the “humors” was considered subject to climate and diet, and the most prevalent ailments in Greece were colds, pneumonia, and malaria, Hippocrates (?) wrote a brief treatise on “Airs, Waters, Places” in relation to health. “One may expose oneself confidently to cold,” we are told, “except after eating or exercise. . . . It is not good for the body not to be exposed to the cold of winter.”⁵⁴ The scientific physician, wherever he settles, will study the effects, upon the local population, of the winds and the seasons, the water supply and the nature of the soil.

The weakest point in Hippocratic medicine was diagnosis. There was, apparently, no taking of the pulse; fever was judged by simple touch, and auscultation was direct. Infection was understood in the case of scabies, ophthalmia, and phthisis.⁵⁵ The Corpuscontains excellent clinical pictures of epilepsy, epidemic parotitis, puerperal septicemia, and quotidian, tertian, and quartan fevers. There is no mention in the Collection of smallpox, measles, diphtheria, scarlet fever, or syphilis; and no clear mention of typhoid fever.⁵⁶ The treatises on “Regimen” move towards preventive medicine by advocating “prodiagnosis”—an attempt to catch the first symptoms of a disease, and nip it in the bud.⁵⁷ Hippocrates was particularly fond of “prognosis”: the good physician, he believed, will learn by experience to foresee the effects of various bodily conditions, and be able to predict from the first stages of a disease the course that it will follow. Most diseases reach a crisis in which either the illness or the patient comes to an end; the almost Pythagorean calculation of the day on which the crisis should appear was a characteristic element of Hippocratic theory. If in these crises the natural heat of the body can overcome the morbid matter and discharge it, the patient is cured. In any cure nature—i.e., the powers and constitution of the body—is the principal healer; all that the physician can do is to remove or reduce the impediments to this natural defense and recuperation. Hence Hippocratic treatment makes little use of drugs, but depends chiefly upon fresh air, emetics, suppositories, enemas, cupping, bloodletting, fomentations, ointments, massage, and hydrotherapy. The Greek pharmacopoeia was reassuringly small, and consisted largely of purgatives. Skin troubles were treated with sulphur baths, and by administering the oil of dolphin livers.⁵⁸ “Live a healthy life,” Hippocrates advises, “and you are not likely to fall ill, except through epidemic or accident. If you do fall ill, proper regimen will give you the best chance of recovery.”⁵⁹ Fasting was often prescribed, if the strength of the patient allowed; for “the more we nourish unhealthy bodies the more we injure them.”⁶⁰ In general “a man should have only one meal a day, unless he have a very dry belly.”⁶¹

Anatomy and physiology made slow progress in Greece, and owed much of this to the examination of animal entrails in the practice of augury. A little brochure “On the Heart,” in the Hippocratic Collection, describes the ventricles, the great vessels, and their valves. Syennesis of Cyprus and Diogenes of Crete wrote descriptions of the vascular system, and Diogenes knew the significance of the pulse.⁶² Empedocles recognized that the heart is the center of the vascular system, and described it as the organ by which thepneuma, or vital breath (oxygen?), is carried through the blood vessels to every part of the body.⁶³ The Corpus, following Alcmaeon, makes the brain the seat of consciousness and thought; “Through it we think, see, hear, and distinguish the ugly from the beautiful, the bad from the good.”⁶⁴

Surgery was still for the most part an unspecialized activity of advanced general practitioners, though the armies had surgeons on their staffs.⁶⁵ The Hippocratic literature describes trephining operations, and its treatment for dislocations of shoulder or jaw are “modern” in everything except anesthesia.⁶⁶ A votive tablet from the temple of Asclepius at Athens shows a folding case containing scalpels of various forms.⁶⁷ The little museum at Epidaurus has preserved for us ancient forceps, probes, scalpels, catheters, and specula essentially like those that are used today; and certain statues there are apparently models illustrating methods for reducing dislocations of the hip.⁶⁸ The Hippocratic treatise “On the Physician” gives detailed directions for the preparation of the operating room, the arrangement of natural and artificial light, the cleanliness of the hands, the care and use of instruments, the position of the patient, the bandaging of wounds, etc.⁶⁹

It is clear from these and other passages that Greek medicine in Hippocrates’ days had made great advances, technically and socially. Heretofore Greek physicians had migrated from city to city as need called them, like the Sophists of their time or the preachers of our own. Now they settled down, opened iatreia—“healing places,” or offices—and treated patients there or at the patients’ homes.⁷⁰ Women physicians were numerous, and were usually employed for diseases of their sex; some of them wrote authoritative treatises on the care of the skin and the hair.⁷¹ The state exacted no public examination of prospective practitioners, but required satisfactory evidence of an apprenticeship or tutelage to a recognized physician.⁷² City governments reconciled socialized with private medicine by engaging doctors to attend to public health, and to give medical treatment to the poor; the best of’ such state physicians, like Democedes, received two talents ($12,000) a year.⁷³ There were, of course, many quacks and, as always, an inexhaustible supply of omniscient amateurs. The profession, as in all generations, suffered from its dishonest or incompetent minority;⁷⁴ and like other peoples the Greeks revenged themselves upon the uncertainties of medicine by jokes almost as endless as those that wreak their vengeance upon marriage.

Hippocrates raised the profession to a higher standing by his emphasis on medical ethics. He was a teacher as well as a practitioner, and the famous oath ascribed to him may have been designed to ensure the loyalty of the student to his instructor.*