XIII

GREEK MEDICINE OF THE FIFTH CENTURY, CHIEFLY HIPPOCRATIC

Though this book is not a history of medicine, many references have already been made to medical topics. Strangely enough, the peak of ancient medicine before this time had been reached more than a millennium earlier, by the Egyptians in the seventeenth century and before. The fame of Egyptian medicine had reached Greece: witness the Odyssey⁸⁴⁶ and Herodotos⁸⁴⁷ and the Hippocratic writings.⁸⁴⁸ True, by the time of Darios (king of Persia and Egypt from 521 to 485), the Egyptian physicians were no longer what they had been in their golden age and those attending to him would have been impaled but for Democedes’ intercession.⁸⁴⁹ In spite of that, we hear that Darios restored the Egyptian college of medicine at Sais.⁸⁵⁰ It is possible that the Greeks derived a certain amount of medical knowledge also from Babylonia. At any rate, since the days of Homer they had obtained much knowledge of their own, and by the second half or the end of the fifth century medicine had been raised to a new level, a much higher level than had ever been attained in Egypt or Mesopotamia. In order to explain that revolution, the Hippocratic revolution, we must briefly relate the long evolution that led up to it.

FROM HOMER TO HIPPOCRATES

The Iliad reveals a good deal of medical (chiefly surgical) knowledge, and two early physicians are named,⁸⁵¹ Podaleirios and Machaon, two good doctors, two sons of Asclepios, himself son of Apollo. This brings us back to the religious origin of medical teaching. In Homer’s time Asclepios was not a god, but a blameless physician; later the cult of Asclepios flourished in a large number of temples.⁸⁵² Some 320 places have been listed in the Greek world where the cult was celebrated. The rites included lustral bathing and incubation during which the patient experienced dreams, which, being interpreted, helped their healing. The patients who had been cured made gifts to the temple (ex voto), many of which have been preserved. After his apotheosis, Asclepios was represented with a head like Zeus, bearing a staff with a single serpent twisted around it. The serpent is a symbol and witness of the ancient chthonic worship with which Asclepios himself was associated.⁸⁵³

The rite of incubation was already practiced in Egypt and the Greeks may have derived it from there, but they might have developed it independently, for it is natural enough. Patients all over the world would pray to their gods for health and fertility. In warm climates they would be tempted to sleep in the temple court. Whenever wise priests were in charge, they would do their best to make the circumstances of incubation as favorable as possible: sufficient rest and enthusiasm, complete peace and trust. In the following morning the patients would love to speak of their experience and to narrate the events of that wonderful night which they had been privileged to spend in the sanctuary. The main events were dreams, which the priests would explain and from which they would obtain a better knowledge of the patient’s needs. The details of the cult would vary from place to place, and its application to healing purposes would depend upon the wisdom of its attendants. The practice might be grossly superstitious in some temples,⁸⁵⁴ and almost scientific in others, for it is certain that the practice of incubation, at its best, was excellent: all the resources of suggestion and autosuggestion could be enlisted; one could hardly devise a better method to restore the patient’s morale and to invigorate his soul.

The cult was relatively late in developing. It began perhaps in Epidauros ⁸⁵⁵ (hardly before 500), which remained the main sanctuary for the worship of Asclepios. In addition to Epidauros, the outstanding temples were eventually those of Cnidos, Cos, Rhodes, and Cyrene. The importance of those temples for the development of early Greek medicine can hardly be exaggerated, for even if there were no medical attendants, intelligent priests would accumulate case histories and perhaps keep records of them. They might even begin to classify these cases, more or less consciously, and build up gradually a treasury of medical experience. The interpretation of dreams might be the opportunity for a heart-to-heart talk between priest and patient, something comparable to modern consultation with a religious or medical adviser, or with a psychoanalyst. We should never forget, however, that a rational treatment could be combined, and probably was, with a certain amount of irrational practices. Many patients need such practices, ask for them, and get them.

Moreover the temple treatment, however rational, was largely restricted to psychologic means. Some drugs might occasionally be prescribed, but no surgical or obstetric operations would be attempted, and minor physical means, such as bleeding, scarification, and massage, would be abandoned to lay hands working in other places. Therefore, the medical experience that might accumulate in certain temples would be almost exclusively in the psychologic field, an immense field, to which the Greek physicians always gave proper attention.

The medical teaching that has come down to us may have been influenced at first by temple practice, but it should be emphasized that the Hippocratic writings are almost exclusively lay and rational, with few traces of superstitions and hardly any reference to religion.⁸⁵⁶

The main information concerning drugs had been accumulated for centuries by the collectors of herbs and the root diggers (rhizotomoi). Judging from the great mass of empirical knowledge available and the extreme slowness of empirical methods, the work must have been continued for untold generations. A great many plants had been tried, some of their virtues or powers (dynamis) recognized, and elaborate means devised for the collection of the most useful herbs. No rational explanation of their virtues could be given, and therefore this part of folklore was deeply impregnated with magic. We could not go into that without losing ourselves in the jungle growth of superstitions. It must suffice to state the fact that the phar-macodynamic properies of many plants were known to root diggers long before the beginning of scientific medicine. The Hippocratic physicians had received from their anonymous ancestors a treasury of drugs. The herbs that they needed were gathered for them by professional herbalists who observed all kinds of superstitious practices in their work. For example, they would have to be in a state of ceremonial purity, otherwise the plants collected by them would fail; some plants had to be plucked only in darkness, or at the time of the waxing (or waning) moon; various spells had to be intoned during the gathering, definite tools used, and the plants dealt with according to a ritual. The possibilities of variations are innumerable. Every part of the work was dominated by magical concepts. As Conway Zirkle amusingly put it, “The gathering of herbs or the digging of roots from the bosom of Mother Earth was considered vaguely analogous to pulling hairs from the back of a sleeping tiger, a dangerous occupation unless proper precautions were observed.” ⁸⁵⁷ At any rate, the new physicians did not have to discover the plants or the roots; they had them and their task was simply to reinvestigate their properties and to determine the proper use and dosage of each of them in a more scientific manner.

While the guardians of the Asclepieia were obtaining a better knowledge of men’s psychologic defense against disease, and while the rhizotomists were gathering and testing roots, stems, leaves, flowers, and fruits, various schools of philosophers were devising theories. Let us recall briefly the philosophic influences that might come and did come from four parts of the Greek world: South Italy (Magna Graecia), Sicily, Ionia, and Thrace.

From South Italy came the mystical teachings of Pythagoras and his school. The main physician of that school was Alcmaion of Croton who had some visions of genius; for example, he realized the importance of the brain as the center of sensations and that health was due to an equilibrium of forces. Democedes carried the experience of Croton to the court of Persia in Susa. Philolaos, though primarily concerned with astronomy, had also some physiologic ideas; he was the first to distinguish between sensory, animal, and vegetative functions, centralized respectively in the brain, the heart, and the navel (not so bad except for the third one!). More influential than the medical particularities were the general ideas, which have never completely ceased to flow and have colored more or less the thinking of physicians as well as of philosophers.

The Sicilian prophet was Empedocles, deeply interested in physiology and medicine, but too much of a poet and a seer (a kind of Greek Paracelsus). His main disciples were Acron of Agrigentum⁸⁵⁸ (V B.C.) and a little later Philistion of Locroi (IV-1 B.C.). Both attached special importance to air, inside the body and out. Acron distinguished between different currents of air, useful to man or not. According to Suidas he wrote a regimen for healthy people (peri troph s hygiein n); according to Plutarch he ordered fires to be lighted to purify the air during the plague of Athens. This seems doubtful because Thucydides does not refer either to the practice or to Acron. The idea that the plague was carried by the air and might be averted by purifying the air was a plausible one, however, and it reoccurred periodically apropos of each epidemic until the nineteenth century.

The third cradle of medical theory was Ionia (or Asia Minor). It must suffice to recall the names of Anaximenes of Miletos, Heracleitos of Ephesos, Anaxagoras of Clazomenai, Archelaos of Miletos (?), and finally, perhaps, Diogenes of Apollonia.⁸⁵⁹ These men were physiologists in the old sense, some of them in the new sense. Their cosmologic theories had physiologic applications. Anaxagoras and Diogenes made anatomic dissections.⁸⁶⁰ Diogenes accentuated the pneumatic tendencies of Anaximenes and of the Sicilians.

Finally, there were the Thracian influences, Democritos of Abdera, whom Hippocrates knew personally, and Herodicos of Selymbria,⁸⁶¹ who is said to have been his teacher. Herodicos attached great importance to gymnastics, and claimed that physical activity and diet must complete and balance each other (this was one of the central Hippocratic doctrines). As to Democritos, we have some curious letters exchanged by Hippocrates and him; ⁸⁶² these letters are apocryphal, yet they testify to the popularity of both men and are documents for the study of the Hippocratic legend, the formulation of which began very early. These letters deal with insanity and the use of hellebore, and it is a fact that Democritos was deeply interested in what might be called psychomedical problems or, to use an ugly modern term, psychosomatic medicine. The best Greek medicine was decidedly psychosomatic, which is not surprising considering the origins which we have described (incubation, philosophy). The encyclopedic tendencies of Democritos are illustrated by the scope of his medical studies, for various anatomic investigations are ascribed to him, he tried to account for inflammation, hydrophobia, epidemic contagion, and he approached many difficult questions, such as the nature of enthusiasm, artistic creation, genius, and folly. Apparently at that time efforts had already been made (perhaps in the healing temples) to cure patients by musical means, for Democritos tried to explain the cures that were thus obtained. Music was used mainly for the healing of psychologic troubles, but it was also used in other cases, such as intoxication caused by snake bites. It is probable that the psychologic symptoms accompanying such intoxication suggested the use of musical therapy.⁸⁶³ Democritos’ attempts to explain all the modalities and mysteries of psychologic life were perhaps premature — our ignorance of these matters is still deep today — but so were all the Greek scientific efforts of his time; it was easier to ask questions than to solve them, yet an unusual amount of wisdom and imagination was already required for the asking of them; it is typical of the Greek genius that it was ready and eager to ask difficult questions and did so.

We may now speak of the two places where medical thought matured, Cnidos and Cos, both in the same region, Caria, in the southwest corner of Asia Minor.⁸⁶⁴ The occurrence of the two main medical schools in that little corner is not accidental. A look at the map will show that if one were to sail northwest from Cos, one would review the Ionian islands, or southward a short run would take one to Rhodes. From Rhodes one can sail in a circle to Cypros, Phoenicia, Egypt, Cyrenaica, and back to Crete. The Cyclades take one step by step to Greece. One can sail across the Aegean almost without ever losing sight of land. The main point is that Caria, with its back to Asia, was relatively near to Crete, Cypros, and Egypt, and hence was a strategic location for intellectual exchanges. Of course, Cnidos and Cos need not have been as close to each other as they were, and this we cannot explain. It may be that one was the offshoot of the other. We cannot know; both schools appear over the horizon at about the same time, after a period of obscure preparation, which may have taken two or three generations in each case but which we have no means of measuring.

As this and the following chapters will be chiefly devoted to the school of Cos, let us speak first of its contemporary rival.

THE SCHOOL OF CNIDOS

The main difference between the school of Cnidos and that of Cos lies in the fact that the latter was more interested in disease in general and the former in particular diseases. To use modern terms, we might say that the doctors of Cos dealt chiefly with general pathology and their Cnidian colleagues with special pathology. Both tendencies were justifiable, and one might argue that the second was at least as necessary as the former, but even so it was premature. According to Galen, Cnidian doctors recognized seven diseases of the bile and twelve of the bladder; that was obviously artificial. The means of exact diagnosis were utterly insufficient to discover characteristic symptoms, that is, to distinguish between symptoms that have differential value and those that have not. The Cnidians were not able to make such distinctions; they attached too much importance to unessential details and thus created nosologic ghosts (this summarizes the Coan criticism of them).

We have already become acquainted with one Cnidian physician, the historian Ctesias, who flourished at the court of Persia. Their main physician, however, was Euryphon of Cnidos, who may have been the author or editor of a collection of aphorisms, the Cnidian sentences (Cnidiai gn mai), and of other Cnidian treatises which are preserved in the Hippocratic corpus.⁸⁶⁵ The Sentences are unfortunately lost and thus we lack what could have been an excellent tool for distinguishing between the two schools. The distinction is not easy, because it is quantitative rather than qualitative. Rival medical schools can never be mutually exclusive and their points of agreement must necessarily be far more numerous than their points of disagreement. It would seem, for example, that the Cnidians paid more attention than the Coans to obstetrics and gynecology, yet it is obvious that the latter could not completely abandon the care of women.⁸⁶⁶

Euryphon had made anatomic studies and had written a book on the “livid fever” (peli nosos); he explained pleurisy as an affection of the lungs and treated consumption with milk and a red-hot iron. A third Cnidian physician, Chrysippos of Cnidos, flourished somewhat later; as he was a pupil of Philistion as well as of Eudoxos,⁸⁶⁷ he combined in himself the doctrines of Cos and of Sicily.

Cnidos gave birth not only to the physicians Euryphon, Ctesias, and Chrysippos, but also to the architect Sostratos (III–1 B.C.), builder of the lighthouse of Alexandria, and to the geographer Agatharchides (II–1 B.C.). Her most illustrious son, however, was Eudoxos (IV–1 B.C.). In the second half of the fourth century, many pilgrims thronged to the temple of Cnidos to see the statue of Aphrodite, one of Praxiteles’ masterpieces.

THE SCHOOL OF COS

While the Cnidian physicians were practicing and meditating on their promontory, another school was developing in an island of their immediate neighborhood. Another look at the map will show that the island of Cos is situated at the entrance of a gulf (Ceramicus Sinus), and the sailor entering that gulf or bay has Halicarnassos to his left and Cnidos to his right. Thus Herodotos, Euryphon, and Hippocrates were at some time close neighbors. Cos is a small island (111 mi²), but fertile and beautiful, admirably situated; it produced vines, ointments, and silk. The bombyx of Cos lived on the leaves of oak, ash, and cypress, not on mulberry like the true silkworms. The silk obtained was different from the Chinese silk. A Coan woman called Pamphila, daughter of Plateus,⁸⁶⁸ invented means of producing and weaving the local silk, out of which were made very thin and almost transparent fabrics, which became one of the great luxuries of the Augustan age.⁸⁶⁹ Cos, rich in grapes and silk, was blessed also in her men, for she was the birthplace (or main residence) of three poets of the third century B.C., Philetas, Herodas, and Theocritos, and of the great artist Apelles (fl. 336-306), who had painted for her temple a famous picture of Aphrodite rising out of the sea (h anadyomen Aphrodit ). It is pleasant to think of Hippocrates and his disciples in the middle of vineyards and mulberry groves, and to associate with his memory that of an illustrious painter and of poets; it is pleasant to think of Asclepios vying with Aphrodite to attract pilgrims to the island.⁸⁷⁰ For us, of course, Cos is primarily the home of the greatest medical school of antiquity. Hippocrates was not its founder, but he towered so high above the other physicians of that island that Coan medicine and Hippocratic medicine are now interchangeable expressions. Who was Hippocrates?

HIPPOCRATES OF COS

It does not take very long to recite all that we know about Hippocrates. He was born in Cos c. 460 and was taught the art by his father Heraclides and by Herodicos of Selymbria. He traveled considerably in Greece. For example, the cases related in Epidemics I, III refer to the island Thasos, to Larissa in Thessaly, Abdera in Thrace (it was probably there, or in Athens (?) that he became acquainted with Democritos), Maliboea in Magnesia (east of Thessaly), Cyzicos, south of the sea of Marmara, and elsewhere. He was consulted by Perdicas II (king of Macedonia c. 450–413) and by Artaxerxes II Mnemon (king of Persia 405–359) and lived to a very old age; he died in Larissa. If the date of birth c. 460 is correct, and he lived until the age of almost eighty-five, his date of death would be c. 375, that is, well into the fourth century.⁸⁷¹

There are three ancient biographies of Hippocrates, the earliest being that of Soranos (II–1), but his existence was attested long before that, in the first place by his younger contemporary Plato. In the Protagoras⁸⁷² Plato speaks of a young man who goes to visit Hippocrates the Asclepiad of Cos to learn medicine, and in Phaidros⁸⁷³ he discusses one aspect of Hippocratic doctrine, the need to understand nature if we would understand the body and the soul of man. We may conclude from these two references that Hippocrates of Cos belonged to a family of Asclepiads (we shall explain the meaning of this presently), that he taught the medical art, and that he was already enjoying some amount of fame within his own lifetime.

In the Politica⁸⁷⁴ Aristotle speaks of Hippocrates’ greatness as a physician. Why should one want other testimonies than those of Plato and Aristotle?

It is paradoxical, however, that no early reference is made to his writings,⁸⁷⁵ so much so that Wilamowitz Moellendorff could speak of him as “a name without writings.” Nevertheless, there is no doubt about the existence of a good many Hippocratic writings. Their genuineness will be discussed in the next chapter.

Hippocrates belonged to an Asclepiad (medical) family; both his grandfather, Hippocrates, and his father, Heraclides, had practiced medicine before him; the latter was naturally his first teacher. Hippocrates II was succeeded by his sons, Thessalos and Dracon of Cos, and by his son-in-law, Polybos of Cos.

The surgical treatises on Fractures and Joints which are one of the glories of Hippocratic medicine were once ascribed to his grandfather, Hippocrates son of Gnosidicos;⁸⁷⁶ this ascription is generally rejected, but it proves that the grandfather was a physician of some distinction.

Thessalos flourished at the court of Archelaos, king of Macedonia from 413 to 399; he was one of the founders of the Dogmatic school. The edition of Epidemics II, VI, and even IV was ascribed to him without any proof. Galen called him the most eminent of Hippocrates’ sons.

Polybos (IV-1 B.C.) was the greatest of Hippocrates’ successors; he may be the author of the treatise on the Nature of Man, as was suggested by Aristotle.

The only thing we know about Hippocrates’ physical appearance is that, like many other great men, he was of small stature.

HIPPOCRATIC MEDICINE

It is best to proceed with the Hippocratic writings as we did with the Iliad and the Odyssey, that is, to study their contents and tendencies, and postpone the consideration of their authorship. Indeed, the main reality for us is constituted by these writings, which are of their nature eternal while the authors, whoever they were, have passed away like shadows.

For the sake of clearness, let us consider the Hippocratic ideas under a series of definite topics.

1. Anatomy and physiology. Anatomy was rudimentary. The Hippocratic physicians might have had a sufficient knowledge of the bones, especially if they were surgeons, but their knowledge of the internal organs, of the vessels, sinews, and nerves, was exceedingly vague. Yet they needed some anatomic and physiologic guidance; therefore, they did what other learned physicians did under the same circumstances — they invented or postulated a system of general physiology. Happily, their path along that dangerous slope was braked by a few careful observations and their fantasies restrained by Greek common sense and moderation. What would have happened without such restraints is well illustrated by the development of Hindu and Chinese medicine.⁸⁷⁷

Their general physiology was the so-called theory of humors, which had been adumbrated many centuries before. It is obvious that the bodies of men (or of other animals, which it was easier to observe) include various liquids of considerable importance, such as blood, watery phlegms, biles. Some distempers are evidenced by the appearance of liquid excretions, for example, the slimy mucus running from one’s nose when one has a cold in the head, expectorations, diarrhetic stools. The Pythagorean Alcmaion of Croton (VI B.C.) was the first to think of health as an equilibrium of the body, and of disease as an upsetting of that equilibrium (isonomia as against monarchia). Now, such thinking would naturally be centered on the fluid and variable parts of the body rather than on the fixed organs. These views were repeated by Empedocles, who made them more precise by stating that health (or disease) is conditional on the equilibrium (or disequilibrium) of the four elements (fire, air, water, earth) of which human bodies (as well as everything else) are composed. The theory of four elements evoked the complementary theory of four qualities⁸⁷⁸ (dry and moist, hot and cold) which is referred to in Ancient medicine⁸⁷⁹ and Sacred disease.⁸⁸⁰ Later still, it evoked the theory of four humors (phlegm, blood, black bile, yellow bile). The first explanation of the theory of four humors (implying the four elements, the four qualities, and even the four seasons) is found in the treatise on the Nature of man, which Aristotle ascribed to Polybos. Curiously enough, the theory of humors is not explained in the Hippocratic treatise on humors (Peri chym n). To complete this pyramid of quaternions, the theory of four temperaments was developed and explained for the first time by Galen (II–2);⁸⁸¹ it remained the central theory of post-Galenic medicine until the nineteenth century; it is still alive today, at least, in the nonmedical world, as is witnessed by many expressions in almost every language.

There is a fundamental difference, however, between the late theory of four temperaments and the previous theories. The four elements, the four qualities, and the four humors are present in every body, and health implies their equilibrium in each of them. On the other hand, the theory of temperaments is an anthropologic theory, a means of classifying people: each man is characterized by a single temperament, and one cannot speak of an equilibrium of temperaments except in a social, political, sense.⁸⁸²

It would be interesting to compare these quaternions with other physiologic theories, the tridosha (three humors) or pañcabh ta (five elements) of Ayurveda, the Buddhist theory of four elements, the Chinese concept of yin and yang, all of which illustrate the intellectual need of symmetry, which has guided men of science all over the world and sometimes misguided them.

2. Prognosis versus diagnosis. As indicated above, while the Cnidian doctors tried to distinguish (or diagnose) special diseases, their rivals of Cos were more interested in general pathology. The tendency of the latter was to consider all diseases as belonging to one of two groups (see section 4 below), or even to one group. The important matter, then, is prognosis, the ability to foretell the development of the disease, and whether the issue is likely to be fatal or not. We must bear in mind that few, if any, diagnoses were possible in the fifth century and that the patients were more concerned with health than with medical labels. They appealed to the physician somewhat in the same spirit as they consulted the oracles. Would they live and be well? How long would the ailment last? These were the questions.

Prognosis enabled the doctor to recognize, and eventually, as his experience increased, to foretell, different stages that occurred in every disease. During the initial stage (what we would call today the period of incubation), the humors were gradually disturbed and their equilibrium upset. Hippocrates called that stage “coction” (pepsis), a homely metaphor derived from the experience of cooking food or brewing drinks. After a definite number of days the cooking was done and the crisis, that is, the determination or judgment, was manifested. That judgment was not always final; even when the crisis was favorable, it might be followed by a relapse (hypostroph ) or by the ejection or abscession (apostasis) of peccant matters (in the form of abscess or tumor). Moreover, many diseases that fell under the observation of the Greek physicians, being malarial fevers, had a rhythmic development that must have been recognized very early. That is, new crises recurred periodically on “critical days” (crisimos h mera).⁸⁸³ In Prognostic, the series of critical days is 4, 7, 11, 14, 17, 20, 34, 40, 60; in Epidemics,⁸⁸⁴ 4, 6, 8, 10, 14, 20, 24, 30, 40, 60, 80, 120 (all even days) or 3, 5, 7, 9, 11, 17, 21, 27, 31 (all odd days).

The good physician is one who can form a general opinion of the disease in its early stage and can foretell the dangers ahead (critical days) and thus strengthen the patient’s will against them.

3. What diseases did the Hippocratic physicians know? In the first place, they recognized the fundamental symptom of disequilibrium in human bodies: a state of fever. They could not measure the temperature as we do, but they could appreciate it and may have been subtler in that than we could be today. They could observe the skin, tongue, eyes, sweating, urine, and stool, and make many distinctions between various kinds of fevers. It is possible that some of these distinctions were artificial; it is probable that many had a real differential value. Did they notice the acceleration of the pulse? Apparently not yet, or not clearly; this is one of the main puzzles of the Hippocratic writings — there is hardly any mention of the pulse in them. We find it hard to believe that the early Greek physicians did not feel the pulse of their patients, for the observations of pulsations (in arm or leg) is one that an intelligent man could not help making sooner or later.

This matter is so strange that we must stop a moment to examine it more closely. The early Egyptian physicians were well aware of the pulse.⁸⁸⁵ How did that knowledge slip away? Democritos, it is true, refers to the beating of the pulse (phlebopalia), but there is only one mention of the pulse in the Hippocratic corpus, to wit in Nutriment: ⁸⁸⁶ “Pulsations of veins and breathing of the lungs according to age, harmonious and unharmonious, signs of disease and of health, and of health more than of disease, and of disease more than of health.” This is meager enough; the mixing of pulsation with respiration is confusing and the cryptic tone unpleasant.⁸⁸⁷ A study of the pulse was ascribed to a shadowy physician of the Hippocratic age, Aigimios of Elis,⁸⁸⁸ and to Praxagoras of Cos (IV–2 B.C.), but we are on solid ground only with the great Hellenistic anatomist, Herophilos of Chalcedon (III–1 B.C.). From that time on (but we are now in an altogether different world, the Hellenistic age focused on Alexandria), the Greek knowledge of the pulse advanced considerably. Its results as published by Galen (II–2), Synopsis peri sphygm n, were the basis of sphygmology until the modern age.⁸⁸⁹

To return to the Hippocratic physicians: they were aware of the occurrence of various fevers, even if they could not measure temperature and count pulses as we do. The fevers varied greatly from the point of view of prognosis, for each had its own evolution, its own rhythm and critical days. Consider this enumeration in Epidemics:

Some fevers are continuous, some have an access during the day and an intermission during the night, or an access during the night and an intermission during the day; there are semitertians, tertians, quartans, septans, nonans. The most acute diseases, the most severe, difficult and fatal, belong to the continuous fevers. The least fatal and least difficult of all, but the longest of all, is the quartan. Not only is it such in itself, but it also ends other, and serious, diseases. In the fever called semitertian, which is more fatal than any other, there occur also acute diseases, while it especially precedes the illness of consumptives, and of those who suffer from other and longer diseases. The nocturnal is not very fatal, but it is long. The diurnal is longer still and to some it also brings a tendency to consumption. The septan is long but not fatal. The nonan is longer still but not fatal. The exact tertian has a speedy crisis and is not fatal. But the quintan is the worst of all. For if it comes on before consumption or during consumption the patient dies.⁸⁹⁰

The meaning of all this has been very well explained by W. H. S. Jones in his books on malaria and Greek history.⁸⁹¹ The most common diseases in the Hippocratic times and places were chest troubles and malaria. In both cases the humors were much in evidence: phlegm (mucus, expectorations), blood (in hemorrhages), black and yellow bile (in the vomiting fits of remittent malaria). Malaria was the dominating factor. As Jones remarks,

In malarious countries, all diseases, and periodically; latent malaria, in fact, colors not malaria only, tend to grow more severe all other complaints.⁸⁹²

This helps to account for Hippocrates’ interest in prognosis (as against diagnosis), for an experienced physician would have recognized the essential alikeness of most ailments in spite of changing rhythms and other differences. Hippocrates was thus led to attach more importance to disease in general (versus health) than to varieties of it.

The fevers dealt with in the Hippocratic corpus were all of them malarial fevers,⁸⁹³ or such as are concomitant with pneumonia, pleurisy, consumption. There is no mention of smallpox, measles, scarlet fever, diphtheria, bubonic plague, syphilis. We are almost certain that syphilis was imported from America only at the end of the fifteenth century, but what about the other diseases: did they not exist in ancient days? And if they did, how is it that the old physicians failed to recognize some of their clear symptoms? It is very baffling, as is always the mixture of knowledge and wisdom with deep ignorance.

Another puzzle: considering the immense catastrophe caused by the plague of Athens, how is it that we find no clear description or even mention of it in any of the medical writings, and would not even know of its existence but for the book of a layman, Thucydides?

There are many references to ophthalmias, and that is not surprising, for various eye diseases have always prevailed in the Near East, but scarcely any technical knowledge of them appears. The malarial fevers are tolerably well described, as well as the state of general ill-health and despondency to which they occasionally lead, the so-called malarial cachexia, characterized by weakness, anemia, darkened complexion, and enlarged spleen. Cases of delirium and various mental troubles are also described; such diseases could not be ignored, for they advertise themselves.

4. Hygiene and therapeutics. The scientific nature of Hippocratic efforts appears clearly in their therapeutics. The main difference between a scientist and a nonscientist is often this: the former is fully aware of his ignorance while the latter “knows” (in that respect Socrates was a man of science). “Je sais tout” is the motto of crass ignorance. In the same way we might say that the main difference between an honest physician and a quacksalver is that the latter promises a cure while the former is more prudent. It is not true that all quacks are crooks who care for nothing but money, and some expert physicians are as greedy as quacks; the difference between them lies not so much in greediness as in lack of criticism. Quacks are often good-natured and benevolent people who wish to help as many of their neighbors as possible; their anxiety to cure is equal to the average man’s anxiety to know; in both cases the wish is father to the thought. Hippocrates was very prudent and very humble. The therapeutic means at his disposal were very few and weak and he was aware of it. He used purgatives, emetics, cordials, emmena-gogues, enemata and clysters, bloodletting,⁸⁹⁴ starvation diets in order to evacuate the body, fomentations and baths, frictions and massage, barley water and barley gruel (ptisan , hence the English ptisan and the French tisane, designating all kinds of infusions), wine, hydromel (honey with water), oxymel (honey with vinegar). Remember that the Greeks had no sugar but honey.⁸⁹⁵ The best thing that the physician could hope to do was to assuage pain whenever possible and to strengthen the patient’s body and soul.

The main Hippocratic idea is neatly expressed by the Latin words vis medicatrix naturae (the healing power of nature).⁸⁹⁶ To use the physical language of today, health is a condition of stable equilibrium, disease is a break in that equilibrium; if the break is not too deep, the equilibrium tends to reestablish itself automatically. The bodily and spiritual peace of the patient must be guarded in such a way that the healing power of nature may assert itself and function without hindrance and that health (the state of equilibrium) may be promptly regained. The physician’s main duty is to stand by and to help nature.

Therefore, therapeutics is much less a matter of drugs than of diet. The main guarantee of health is a proper regimen combining a moderate amount of nourishment with a moderate amount of exercise. Walking is one of the best forms of exercise for sedentary men. These views are explained in Regimen IIIIV and passim in other Hippocratic writings.

5. Medical climatology. One of the Hippocratic treatises, the genuineness of which has hardly ever been questioned, is the one entitled Airs waters places (Peri aer n hydat n top n). This is certainly the first treatise on medical climatology. It describes the effects of topography and climate upon health, and upon character.

With the exception of balneologists and other physicians attached to watering places, modern physicians do not bother so much about the climate as did their ancient and medieval colleagues. This is partly because our distant ancestors were more completely at the mercy of the weather than we are, especially in the cities, where one lives, as it were, in an artificial climate. It may be due also to gradual neglect and ignorance of climatic factors because of the overwhelming attraction of other factors. We should perhaps attach more importance to climate than we do: it is highly probable that some patients would be more easily cured in certain localities than in others.⁸⁹⁷

The study of the relations of climate to health has always been of special concern to historians of medicine, partly because of the Hippocratic example, partly because of balneologic tradition,⁸⁹⁸ and chiefly because of the bearing of climatic and topographic factors on the spread of epidemics. On the other hand, the pedagogues of Europe considered history and geography two parallel disciplines, and continued to do so until yesterday. Therefore, it is not surprising that the same scholars were tempted to study the “geography of medicine” just as well as the history of medicine.⁸⁹⁹

6. Scientific aspects of Hippocratism. Some scientific aspects have already been evidenced in the previous sections, but we must come back to that because it is really the central point. If one were asked to characterize Hippocratic medicine in the briefest way, one would say: it is scientific medicine, the first in Greece, if not in the world.⁹⁰⁰

Hippocrates set himself the task of solving medical problems in a rational way. In fact, he has sometimes laid himself open to an accusation often made against modern experts, that he cared less for individual cures than for knowledge. There is nothing to prove his indifference to patients, except that his clinical stories are dispassionate, as they should be. The fact that these stories do not betray any irrelevant feelings does not prove that he did not have feelings and that he did not suffer when patients died. Examples of such clinical stories will be given in the next chapter. They are astounding. In Epidemics I and III Hippocrates describes cases just as one of our own physicians would do, giving what he considers the essential, nothing more and nothing less. Forty-two cases are described, twenty-five of which ended in death. Hippocrates, like a true scientist, realized that truth matters above everything else, and therefore he recorded his failures as accurately as his successes (a quacksalver would have hidden his failures, not necessarily because he was dishonest, but because the whole business of medical charlatanry implies overconfidence).

The scientific nature of Hippocrates’ genius appears in his careful observations, moderate judgments, love of truth, and also indirectly, in his rejection of superstitions, irrelevant philosophy, and rhetoric.⁹⁰¹

7. Psychologic healing. When Hippocrates explained the prime duty of favoring the healing power of nature, he was conscious that the means of favoring it were psychologic as well as physical. It is not enough that the body be allowed to rest as completely as possible (confinement to bed, very light diet), but the soul must rest (quietness) and be invigorated by good cheer and hope. The physician must deal very gently with his patients.

Here is a typical passage of the Precepts, a relatively late cento but derived from good Hippocratic sources:

I urge you not to be too unkind, but to consider carefully your patient’s superabundance or means. Sometimes give your services for nothing, calling to mind a previous benefaction or present satisfaction. And if there be an opportunity of serving one who is a stranger in financial straits, give full assistance to all such. For where there is love of man, there is also love of the art. For some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician. And it is well to superintend the sick to make them well, to care for the healthy to keep them well, but also care for one’s own self, so as to observe what is seemly.

Hippocrates’ interest in psychologic healing was natural enough if he had witnessed (as he probably had) the practice of incubation in the Asclepieia or other temples. If so, he had heard of the miraculous cures which the priests and pilgrims would be sure to advertise, and he could appreciate the therapeutic value of such methods. Body and soul are very closely interrelated; neither can be healthy if the other is not and the physician cannot heal the one while neglecting the other; therefore he must try to strengthen both.

It is very tempting to corroborate these views with an extract from Plato’s Charmides, wherein Socrates refers to one of the Thracian physicians of Zalmoxis who are said even to make one immortal. This Thracian said that the Greeks were right in advising as I told you just now: “but Zalmoxis,” he said, “our king, who is a god, says that as you ought not to attempt to cure eyes without head, or head without body, so you should not treat body without soul”; and this was the reason why most maladies evaded the physicians of Greece — that they neglected the whole, on which they ought to spend their pains, for if this were out of order it was impossible for the part to be in order. For all that was good and evil, he said, in the body and in man altogether was sprung from the soul, and flowed along from thence as it did from the head into the eyes. Wherefore that part was to be treated first and foremost, if all was to be well with the head and the rest of the body.⁹⁰²

The Zalmoxian criticism reported by Socrates might apply to certain Greek physicians; it certainly did not apply to Hippocrates.

THE HIPPOCRATIC ACHIEVEMENTS

The main achievement of Hippocrates was the introduction of a scientific point of view and scientific method in the cure of diseases, and the beginning of scientific medical literature and clinical archives. The importance of this can hardly be exaggerated. Hippocrates’ personality, however shadowy, symbolizes one of the greatest initiatives in the history of mankind. In praise of him it may suffice to say that he did whatever could be done in his time, with genius alone, without the drugs and instruments of a later age. It is remarkable that the idea of writing and collecting clinical cases, as he did in Epidemics, was not continued after him. The stories told by Galen are very inferior in spirit; they are more in the nature of self-advertisement than plain and honest reports in the Hippocratic manner. Galen was more interested in puffing his reputation than in publishing the truth. After Galen there are no clinical cases on record until the time of al-R z (IX–2), and after that I can think of nothing else but a few of the medieval regimina and consilia and the post-mortem analyses of the Florentine Antonio Benivieni (d. 1502) — but between Hippocrates and Benivieni almost two millennia have elapsed.⁹⁰³

Though Hippocrates was more concerned with general than with special pathology, he has left clinical pictures of phthisis, puerperal convulsions, and epilepsy, and has described the typical countenance of a dying or dead man, or of a man whose body has been exhausted by starvation, excessive evacuations, long sickness and suffering. This aspect is still called facies Hippocratica. One also speaks of Hippocratic fingers, which are symptomatic of some chronic heart diseases; on account of insufficient oxygenation the terminal joints are enlarged and clublike.

Or consider this case, described in Epidemics:

In Thasos the wife of Delearces, who lay sick on the plain, was seized after a grief with an acute fever with shivering. From the beginning she would wrap herself up, and throughout, without speaking a word, she would fumble, pluck, scratch, pick hairs, weep and then laugh, but she did not sleep; though stimulated, the bowels passed nothing. She drank a little when the attendants suggested it. Urine thin and scanty; fever slight to the touch; coldness of the extremities.

Ninth day. Much wandering followed by return to reason; silent.

Fourteenth day. Respiration rare and large with long intervals becoming afterwards short.⁹⁰⁴

The breathing described in the last lines is now generally called Cheyne-Stokes breathing, after two Dublin physicians (1818), or “changed-stroke” by medical students.⁹⁰⁵

Hippocrates’ common sense, wisdom, and modesty were sometimes forgotten and overshadowed by the excessive rationalization and the immoderate pride of the Galenic and Arabic physicians, but men of genius were always ready to pay tribute to the father of medicine and to try to imitate him. I am not thinking of the medical philologists like Anuce Foes (1528–1591) of Metz or the Dutchman Van der Linden, whose editions of Hippocrates (published respectively in 1595 and 1665) were much used by students and physicians, but rather of clinicians like Thomas Sydenham (1624–1689). A new wave of medical self-conceit was created at the end of the last century by the triumphs of bacteriology, and for a time many physicians were hypnotized by microbes to such an extent that they failed to consider the patient in his wholeness. In combination with other factors, this has caused a Hippocratic revival which has sometimes been carried too far.⁹⁰⁶ Yet intelligent physicians make a distinction between knowledge and wisdom, and recognize that, in spite of the immense and almost incredible medical progress, there is something in the Hippocratic achievement that cannot be superseded.

THE ASCLEPIADAI

One of the very few things that we know about Hippocrates is that he was an Asclepiad (Plato tells it), and on the other hand we know that there were temples dedicated to Asclepios, patron and god of medicine. Who were the Asclepiads? The first idea was that they were priests of such temples. The intelligent priests of healing temples might accumulate medical experience, without too much trouble, almost unconsciously. It is probable, however, that in addition to such men, half priest, half physician, there were in such centers as Cnidos and Cos professional physicians who were called Asclepiadai, either because they were supposed to be descendants of the god or hero Asclepios, or because their duties were inspired by that god.

Such a profession tended to be restricted to certain families, for it was natural for a father to train his son and to bequeath to him his experience and his practice. We have already become acquainted with two medical families — the family of Ctesias in Cnidos and that of Hippocrates in Cos. Hippocrates had been trained by his father Heraclides and his work was continued by his sons and his son-in-law.

These medical families were united by common interests and it is possible that in some places, at least, their union was expressed in the form of rules and regulations, written or unwritten. The Asclepiadai of a district may have formed a kind of guild,⁹⁰⁷ that is, a professional association, the structure of which might be as weak or as strong as you please, and the spirit of which might be purely economic, social, scientific, or religious, or it might be colored by various combinations of these influences.

The presence in the Hippocratic corpus of a number of deontologic books does not prove the existence of medical guilds, but if such guilds existed they would have favored the composition of books wherein the duties of physicians, their manners, and their customs would be defined and explained. The deontologic books are first of all the Oath, then the Law, Decorum, Precepts, and the Physician, chapter 1. Some of them are late, yet they embody earlier traditions and it is with such traditions that we are at present concerned.

The short text entitled the Oath includes a professional oath and a kind of indenture (syngraph ) binding medical students to their teachers. The constitution of every guild would imply both things, for it must hold the members together, and provide for the education and admission of new ones, and for the defense and continuation of their traditions. The guild might be secret; it would certainly be private; its regulations bind only the members and facilitate their protection against other bodies or against incompetent outsiders. We should beware, however, of thinking too much in terms of modern experience; all of the activities of a modern guild would exist in an ancient one in potentia yet unformulated and unformalized. For example, the guild might have a ritual and liturgy to be employed on special occasions, such as the admission of members or their funerals.

We know nothing definite; the absence of documents would seem to prove that even if the Asclepiadai were organized the importance of their guilds cannot have been considerable; if medical guilds existed in certain places, such as Cos, their importance was restricted to a small district and a short period.⁹⁰⁸

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