The Evolution of Modern Medicine: Chapter II - HIPPOCRATES AND THE HIPPOCRATIC WRITINGS by@williamosler

The Evolution of Modern Medicine: Chapter II - HIPPOCRATES AND THE HIPPOCRATIC WRITINGS

The Evolution of Modern Medicine, by William Osler is part of HackerNoon’s Book Blog Post series.
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William Osler

The Evolution of Modern Medicine

The Evolution of Modern Medicine, by William Osler is part of HackerNoon’s Book Blog Post series. You can jump to any chapter in this book here.

HIPPOCRATES AND THE HIPPOCRATIC WRITINGS

DESERVEDLY the foundation of Greek Medicine is associated with the name of Hippocrates, a native of the island of Cos; and yet he is a shadowy personality, about whom we have little accurate first-hand information. This is in strong contrast to some of his distinguished contemporaries and successors, for example, Plato and Aristotle, about whom we have such full and accurate knowledge. You will, perhaps, be surprised to hear that the only contemporary mention of Hippocrates is made by Plato. In the "Protagoras," the young Hippocrates, son of Apollodorus has come to Protagoras, "that mighty wise man," to learn the science and knowledge of human life. Socrates asked him: "If . . . you had thought of going to Hippocrates of Cos, the Asclepiad, and were about to give him your money, and some one had said to you, 'You are paying money to your namesake Hippocrates, O Hippocrates; tell me, what is he that you give him money?' how would you have answered?" "I should say," he replied, "that I gave money to him as a physician." "And what will he make of you?" "A physician," he said. And in the Phaedrus, in reply to a question of Socrates whether the nature of the soul could be known intelligently without knowing the nature of the whole, Phaedrus replies: "Hippocrates, the Asclepiad, says that the nature, even of the body, can only be understood as a whole." (Plato, I, 311; III, 270—Jowett, I, 131, 479.)

Several lives of Hippocrates have been written. The one most frequently quoted is that of Soranus of Ephesus (not the famous physician of the time of Trajan), and the statements which he gives are usually accepted, viz., that he was born in the island of Cos in the year 460 B.C.; that he belonged to an Asklepiad family of distinction, that he travelled extensively, visiting Thrace, Thessaly, and various other parts of Greece; that he returned to Cos, where he became the most renowned physician of his period, and died about 375 B.C. Aristotle mentions him but once, calling him "the great Hippocrates." Busts of him are common; one of the earliest of which, and I am told the best, dating from Roman days and now in the British Museum, is here represented.

Of the numerous writings attributed to Hippocrates it cannot easily be determined which are really the work of the Father of Medicine himself. They were collected at the time of the Alexandrian School, and it became customary to write commentaries upon them; much of the most important information we have about them, we derive from Galen. The earliest manuscript is the "Codex Laurentianus" of Florence, dating from the ninth century, a specimen page of which (thanks to Commendatore Biagi) is annexed. Those of you who are interested, and wish to have full references to the various works attributed to Hippocrates, will find them in "Die Handschriften der antiken Aerzte" of the Prussian Academy, edited by Diels (Berlin, 1905). The Prussian Academy has undertaken the editorship of the "Corpus Medicorum Graecorum." There is no complete edition of them in English. In 1849 the Deeside physician, Adams, published (for the Old Sydenham Society) a translation of the most important works, a valuable edition and easily obtained. Littre's ten-volume edition "OEuvres completes d'Hippocrate," Paris, 1839-1861, is the most important for reference. Those of you who want a brief but very satisfactory account of the Hippocratic writings, with numerous extracts, will find the volume of Theodor Beck (Jena, 1907) very useful.

I can only indicate, in a very brief way, the special features of the Hippocratic writings that have influenced the evolution of the science and art of medicine.

The first is undoubtedly the note of humanity. In his introduction to, "The Rise of the Greek Epic,"(21) Gilbert Murray emphasizes the idea of service to the community as more deeply rooted in the Greeks than in us. The question they asked about each writer was, "Does he help to make better men?" or "Does he make life a better thing?" Their aim was to be useful, to be helpful, to make better men in the cities, to correct life, "to make gentle the life of the world." In this brief phrase were summed up the aspirations of the Athenians, likewise illuminated in that remarkable saying of Prodicus (fifth century B.C.), "That which benefits human life is God." The Greek view of man was the very antithesis of that which St. Paul enforced upon the Christian world. One idea pervades thought from Homer to Lucian-like an aroma—pride in the body as a whole. In the strong conviction that "our soul in its rose mesh" is quite as much helped by flesh as flesh by the soul the Greek sang his song—"For pleasant is this flesh." Just so far as we appreciate the value of the fair mind in the fair body, so far do we apprehend ideals expressed by the Greek in every department of life. The beautiful soul harmonizing with the beautiful body was as much the glorious ideal of Plato as it was the end of the education of Aristotle. What a splendid picture in Book III of the "Republic," of the day when ". . . our youth will dwell in a land of health, amid fair sights and sounds and receive the good in everything; and beauty, the effluence of fair works, shall flow into the eye and ear like a health-giving breeze from a purer region, and insensibly draw the soul from earliest years into likeness and sympathy with the beauty of reason." The glory of this zeal for the enrichment of this present life was revealed to the Greeks as to no other people, but in respect to care for the body of the common man, we have only seen its fulfilment in our own day, as a direct result of the methods of research initiated by them. Everywhere throughout the Hippocratic writings we find this attitude towards life, which has never been better expressed than in the fine phrase, "Where there is love of humanity there will be love of the profession." This is well brought out in the qualifications laid down by Hippocrates for the study of medicine. "Whoever is to acquire a competent knowledge of medicine ought to be possessed of the following advantages: a natural disposition; instruction; a favourable position for the study; early tuition; love of labour; leisure. First of all, a natural talent is required, for when nature opposes, everything else is vain; but when nature leads the way to what is most excellent, instruction in the art takes place, which the student must try to appropriate to himself by reflection, becoming a nearly pupil in a place well adapted for instruction. He must also bring to the task a love of labour and perseverance, so that the instruction taking root may bring forth proper and abundant fruits." And the directions given for the conduct of life and for the relation which the physician should have with the public are those of our code of ethics today. Consultations in doubtful cases are advised, touting for fees is discouraged. "If two or more ways of medical treatment were possible, the physician was recommended to choose the least imposing or sensational; it was an act of 'deceit' to dazzle the patient's eye by brilliant exhibitions of skill which might very well be dispensed with. The practice of holding public lectures in order to increase his reputation was discouraged in the physician, and he was especially warned against lectures tricked out with quotations from the poets. Physicians who pretended to infallibility in detecting even the minutest departure from their prescriptions were laughed at; and finally, there were precise by-laws to regulate the personal behaviour of the physician. He was enjoined to observe the most scrupulous cleanliness, and was advised to cultivate an elegance removed from all signs of luxury, even down to the detail that he might use perfumes, but not in an immoderate degree."(22) But the high-water mark of professional morality is reached in the famous Hippocratic oath, which Gomperz calls "a monument of the highest rank in the history of civilization." It is of small matter whether this is of Hippocratic date or not, or whether it has in it Egyptian or Indian elements: its importance lies in the accuracy with which it represents the Greek spirit. For twenty-five centuries it has been the "credo" of the profession, and in many universities it is still the formula with which men are admitted to the doctorate.

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I swear by Apollo the physician and AEsculapius and Health (Hygieia) and All-Heal (Panacea) and all the gods and goddesses, that, according to my ability and judgment, I will keep this oath and this stipulation—to reckon him who taught me this art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of my art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.

I will give no deadly medicine to anyone if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion.

With purity and with holiness I will pass my life and practice my art.

(I will not cut persons labouring under the stone, but will leave this to be done by men who are practitioners of this work.)

Into whatsoever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption, and, further, from the abduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret.

While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!

(Adams, II, 779, cf. Littre, IV, 628.)

In his ideal republic, Plato put the physician low enough, in the last stratum, indeed, but he has never been more honorably placed than in the picture of Athenian society given by this author in the "Symposium." Here the physician is shown as a cultivated gentleman, mixing in the best, if not always the most sober, society. Eryximachus, the son of Acumenus, himself a physician, plays in this famous scene a typical Greek part(22a)—a strong advocate of temperance in mind and body, deprecating, as a physician, excess in drink, he urged that conversation should be the order of the day and he had the honor of naming the subject—"Praise of the God of Love." Incidentally Eryximachus gives his view of the nature of disease, and shows how deeply he was influenced by the views of Empedocles:". . . so too in the body the good and healthy elements are to be indulged, and the bad elements and the elements of disease are not to be indulged, but discouraged. And this is what the physician has to do, and in this the art of medicine consists: for medicine may be regarded generally as the knowledge of the loves and desires of the body and how to satisfy them or not; and the best physician is he who is able to separate fair love from foul, or to convert one into the other; and he who knows how to eradicate and how to implant love, whichever is required, and can reconcile the most hostile elements in the constitution and make them loving friends, is a skilful practitioner."

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The second great note in Greek medicine illustrates the directness with which they went to the very heart of the matter. Out of mysticism, superstition and religious ritual the Greek went directly to nature and was the first to grasp the conception of medicine as an art based on accurate observation, and an integral part of the science of man. What could be more striking than the phrase in "The Law," "There are, in effect, two things, to know and to believe one knows; to know is science; to believe one knows is ignorance"?(23) But no single phrase in the writings can compare for directness with the famous aphorism which has gone into the literature of all lands: "Life is short and Art is long; the Occasion fleeting, Experience fallacious, and Judgment difficult."

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Everywhere one finds a strong, clear common sense, which refuses to be entangled either in theological or philosophical speculations. What Socrates did for philosophy Hippocrates may be said to have done for medicine. As Socrates devoted himself to ethics, and the application of right thinking to good conduct, so Hippocrates insisted upon the practical nature of the art, and in placing its highest good in the benefit of the patient. Empiricism, experience, the collection of facts, the evidence of the senses, the avoidance of philosophical speculations, were the distinguishing features of Hippocratic medicine. One of the most striking contributions of Hippocrates is the recognition that diseases are only part of the processes of nature, that there is nothing divine or sacred about them. With reference to epilepsy, which was regarded as a sacred disease, he says, "It appears to me to be no wise more divine nor more sacred than other diseases, but has a natural cause from which it originates like other affections; men regard its nature and cause as divine from ignorance." And in another place he remarks that each disease has its own nature, and that no one arises without a natural cause. He seems to have been the first to grasp the conception of the great healing powers of nature. In his long experience with the cures in the temples, he must have seen scores of instances in which the god had worked the miracle through the vis medicatrix naturae; and to the shrewd wisdom of his practical suggestions in treatment may be attributed in large part the extraordinary vogue which the great Coan has enjoyed for twenty-five centuries. One may appreciate the veneration with which the Father of Medicine was regarded by the attribute "divine" which was usually attached to his name. Listen to this for directness and honesty of speech taken from the work on the joints characterized by Littre as "the great surgical monument of antiquity": "I have written this down deliberately, believing it is valuable to learn of unsuccessful experiments, and to know the causes of their non-success."

The note of freedom is not less remarkable throughout the Hippocratic writings, and it is not easy to understand how a man brought up and practicing within the precincts of a famous AEsculapian temple could have divorced himself so wholly from the superstitions and vagaries of the cult. There are probably grounds for Pliny's suggestion that he benefited by the receipts written in the temple, registered by the sick cured of any disease. "Afterwards," Pliny goes on to remark in his characteristic way, "hee professed that course of Physicke which is called Clinice Wherby physicians found such sweetnesse that afterwards there was no measure nor end of fees," ('Natural History,' XXIX, 1). There is no reference in the Hippocratic writings to divination; incubation sleep is not often mentioned, and charms, incantations or the practice of astrology but rarely. Here and there we do find practices which jar upon modern feeling, but on the whole we feel in reading the Hippocratic writings nearer to their spirit than to that of the Arabians or of the many writers of the fifteenth and sixteenth centuries A. D. And it is not only against the thaumaturgic powers that the Hippocratic writings protested, but they express an equally active reaction against the excesses and defects of the new philosophy, a point brought out very clearly by Gomperz.(24) He regards it as an undying glory of the school of Cos that after years of vague, restless speculation it introduces "steady sedentary habits into the intellectual life of mankind." 'Fiction to the right! Reality to the left!' was the battle-cry of this school in the war they were the first to wage against the excesses and defects of the nature-philosophy. Though the protest was effective in certain directions, we shall see that the authors of the Hippocratic writings could not entirely escape from the hypotheses of the older philosophers.

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I can do no more than indicate in the briefest possible way some of the more important views ascribed to Hippocrates. We cannot touch upon the disputes between the Coan and Cnidian schools.(25) You must bear in mind that the Greeks at this time had no human anatomy. Dissections were impossible; their physiology was of the crudest character, strongly dominated by the philosophies. Empedocles regarded the four elements, fire, air, earth and water, as "the roots of all things," and this became the corner stone in the humoral pathology of Hippocrates. As in the Macrocosm—the world at large there were four elements, fire, air, earth, and water, so in the Microcosm—the world of man's body—there were four humors (elements), viz.,blood, phlegm, yellow bile (or choler) and black bile (or melancholy), and they corresponded to the four qualities of matter, heat, cold, dryness and moisture. For more than two thousand years these views prevailed. In his "Regiment of Life" (1546) Thomas Phaer says:". . . which humours are called ye sones of the Elements because they be complexioned like the foure Elements, for like as the Ayre is hot and moyst: so is the blooud, hote and moyste. And as Fyer is hote and dry: so is Cholere hote and dry. And as water is colde and moyst: so is fleume colde and moyste. And as the Earth is colde and dry: so Melancholy is colde and dry."(26)

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As the famous Regimen Sanitatis of Salernum, the popular family hand-book of the Middle Ages, says:

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According to Littre, there is nowhere so strong a statement of these views in the genuine works of Hippocrates, but they are found at large in the Hippocratic writings, and nothing can be clearer than the following statement from the work "The Nature of Man": "The body of man contains in itself blood and phlegm and yellow bile and black bile, which things are in the natural constitution of his body, and the cause of sickness and of health. He is healthy when they are in proper proportion between one another as regards mixture and force and quantity, and when they are well mingled together; he becomes sick when one of these is diminished or increased in amount, or is separated in the body from its proper mixture, and not properly mingled with all the others." No words could more clearly express the views of disease which, as I mentioned, prevailed until quite recent years. The black bile, melancholy, has given us a great word in the language, and that we have not yet escaped from the humoral pathology of Hippocrates is witnessed by the common expression of biliousness—"too much bile"—or "he has a touch of the liver." The humors, imperfectly mingled, prove irritant in the body. They are kept in due proportion by the innate heat which, by a sort of internal coction gradually changes the humors to their proper proportion. Whatever may be the primary cause of the change in the humors manifesting itself in disease, the innate heat, or as Hippocrates terms it, the nature of the body itself, tends to restore conditions to the norm; and this change occurring suddenly, or abruptly, he calls the "crisis," which is accomplished on some special day of the disease, and is often accompanied by a critical discharge, or by a drop in the body temperature. The evil, or superabundant, humors were discharged and this view of a special materies morbi, to be got rid of by a natural processor a crisis, dominated pathology until quite recently. Hippocrates had a great belief in the power of nature, the vis medicatrix naturae, to restore the normal state. A keen observer and an active practitioner, his views of disease, thus hastily sketched, dominated the profession for twenty-five centuries; indeed, echoes of his theories are still heard in the schools, and his very words are daily on our lips. If asked what was the great contribution to medicine of Hippocrates and his school we could answer—the art of careful observation.

In the Hippocratic writings is summed up the experience of Greece to the Golden Age of Pericles. Out of philosophy, out of abstract speculation, had come a way of looking at nature for which the physicians were mainly responsible, and which has changed forever men's views on disease. Medicine broke its leading strings to religion and philosophy—a tottering, though lusty, child whose fortunes we are to follow in these lectures. I have a feeling that, could we know more of the medical history of the older races of which I spoke in the first lecture, we might find that this was not the first-born of Asklepios, that there had been many premature births, many still-born offspring, even live-births—the products of the fertilization of nature by the human mind; but the record is dark, and the infant was cast out like Israel in the chapter of Isaiah. But the high-water mark of mental achievement had not been reached by the great generation in which Hippocrates had labored. Socrates had been dead sixteen years, and Plato was a man of forty-five, when far away in the north in the little town of Stagira, on the peninsula of Mount Athos in Macedoniawas, in 384 B.C., born a "man of men," the one above all others to whom the phrase of Milton may be applied. The child of an Asklepiad, Nicomachus, physician to the father of Philip, there must have been a rare conjunction of the planets at the birth of the great Stagirite. In the first circle of the "Inferno," Virgil leads Dante into a wonderful company, "star-seated" on the verdure (he says)—the philosophic family looking with reverence on "the Master of those who know"—il maestro di color che sanno.(28) And with justice has Aristotle been so regarded for these twenty-three centuries. No man has ever swayed such an intellectual empire—in logic, metaphysics, rhetoric, psychology, ethics, poetry, politics and natural history, in all a creator, and in all still a master. The history of the human mind—offers no parallel to his career. As the creator of the sciences of comparative anatomy, systematic zoology, embryology, teratology, botany and physiology, his writings have an eternal interest. They present an extraordinary accumulation of facts relating to the structure and functions of various parts of the body. It is an unceasing wonder how one man, even with a school of devoted students, could have done so much.

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Dissection—already practiced by Alcmaeon, Democritus, Diogenes and others—was conducted on a large scale, but the human body was still taboo. Aristotle confesses that the "inward parts of man are known least of all," and he had never seen the human kidneys or uterus. In his physiology, I can refer to but one point—the pivotal question of the heart and blood vessels. To Aristotle the heart was the central organ controlling the circulation, the seat of vitality, the source of the blood, the place in which it received its final elaboration and impregnation with animal heat. The blood was contained in the heart and vessels as in a vase—hence the use of the term "vessel." "From the heart the blood-vessels extend throughout the body as in the anatomical diagrams which are represented on the walls, for the parts lie round these because they are formed out of them."(29) The nutriment oozes through the blood vessels and the passages in each of the parts "like water in unbaked pottery." He did not recognize any distinction between arteries and veins, calling both plebes (Littre); the vena cave is the great vessel, and the aorta the smaller; but both contain blood. He did not use the word "arteria" (arthria) for either of them. There was no movement from the heart to the vessels but the blood was incessantly drawn upon by the substance of the body and as unceasingly renewed by absorption of the products of digestion, the mesenteric vessels taking up nutriment very much as the plants take theirs by the roots from the soil. From the lungs was absorbed the pneuma, or spiritus, which was conveyed to the heart by the pulmonary vessels—one to the right, and one to the left side. These vessels in the lungs, "through mutual contact" with the branches of the trachea, took in the pneuma. A point of interest is that the windpipe, or trachea, is called "arteria," both by Aristotle and by Hippocrates ("Anatomy," Littre, VIII, 539). It was the air-tube, disseminating the breath through the lungs. We shall see in a few minutes how the term came to be applied to the arteries, as we know them. The pulsation of the heart and arteries was regarded by Aristotle as a sort of ebullition in which the liquids were inflated by the vital or innate heat, the fires of which were cooled by the pneuma taken in by the lungs and carried to the heart by the pulmonary vessels.

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In Vol. IV of Gomperz' "Greek Thinkers," you will find an admirable discussion on Aristotle as an investigator of nature, and those of you who wish to study his natural history works more closely may do so easily—in the new translation which is in process of publication by the Clarendon Press, Oxford. At the end of the chapter "De Respiratione" in the "Parva Naturalia" (Oxford edition, 1908), we have Aristotle's attitude towards medicine expressed in a way worthy of a son of the profession:

"But health and disease also claim the attention of the scientist, and not merely of the physician, in so far as an account of their causes is concerned. The extent to which these two differ and investigate diverse provinces must not escape us, since facts show that their inquiries are, at least to a certain extent, conterminous. For physicians of culture and refinement make some mention of natural science, and claim to derive their principles from it, while the most accomplished investigators into nature generally push their studies so far as to conclude with an account of medical principles." (Works, III,480 b.)

Theophrastus, a student of Aristotle and his successor, created the science of botany and made possible the pharmacologists of a few centuries later. Some of you doubtless know him in another guise—as the author of the golden booklet on "Characters," in which "the most eminent botanist of antiquity observes the doings of men with the keen and unerring vision of a natural historian" (Gomperz). In the Hippocratic writings, there are mentioned 236 plants; in the botany of Theophrastus, 455. To one trait of master and pupil I must refer—the human feeling, not alone of man for man, but a sympathy that even claims kinship with the animal world. "The spirit with which he (Theophrastus) regarded the animal world found no second expression till the present age" (Gomperz). Halliday, however, makes the statement that Porphyry(30) goes as far as any modern humanitarian in preaching our duty towards animals.

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Osler, William. 2006. The Evolution of Modern Medicine. Urbana, Illinois: Project Gutenberg. Retrieved April 2022 from https://www.gutenberg.org/files/1566/1566-h/1566-h.htm#link2H_4_0013

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