A Little History Of Science: The Father of Medicine: Hippocrates
The next time you have to see the doctor, ask if he or she took the Hippocratic Oath at their graduation ceremony. Not all modern medical schools require their students to recite it, but some do, and this oath, written more than 2,000 years ago, has something to say to us still. We shall see what that is shortly. Even though Hippocrates’ name is attached to this famous oath, he probably didn’t write it. In fact, he wrote only a few of the sixty or so treatises (short books on specific topics) that bear his name.
We know only a little about Hippocrates the man. He was born about 460 bc, on the island of Cos, not far from present-day Turkey. He practised as a doctor, taught medicine (for money) and probably had two sons and a son-in-law who all were doctors. There is a long history of medicine being a family tradition.
The Hippocratic Corpus (a corpus is a group of writings) was actually written by many individuals, over a long period of time, perhaps as long as 250 years. The various treatises in the Corpus argue different points of view, and they deal with lots of different matters. These include diagnosing and treating diseases, how to cope with broken bones and dislocated joints, epidemics, how to stay healthy, what to eat, and how the environment can influence our health. The treatises also help doctors know how to behave, both with their patients and with other doctors. In short, the Hippocratic writings cover just about the whole of medicine as it was practised at the time.
Just as remarkable as the range of subjects covered is how long ago the treatises were written. Hippocrates lived before Socrates, Plato and Aristotle, and on Cos, a small, remote island. It is amazing that anything written so long ago survives at all. There were no printing presses, and words had to be copied laboriously by hand on parchment, scrolls, clay and other surfaces, and then passed from person to person. Ink fades, wars lead to destruction, and insects and weather take their toll. We generally have only copies of those writings, made much later by generations of interested people. The more copies that were made, the greater the chance that some of them would survive.
The Hippocratic treatises laid the foundation of Western medicine, and therefore Hippocrates still occupies a special position. Three broad principles have guided medical practice for centuries.
The first still underpins our own medicine and medical science: the firm belief that people fall ill because of ‘natural’ causes that have rational explanations. Before the Hippocratics, in Greece and its neighbouring lands, disease was assumed to have a supernatural dimension. We fall ill because we have offended the gods, or because someone with unearthly powers cast a spell on us, or is displeased with us. And if witches, magicians and gods caused disease, it was best to leave priests or magicians to figure out why the disease had happened and how best to cure it. Many people, even today, use magical remedies, and faith-healers are still with us.
The Hippocratics were not priest-healers, they were doctors, who believed that disease was a natural, normal event. One treatise, On the Sacred Disease, shows this very clearly. This short work is about epilepsy, a common disorder then as now: we think both Alexander the Great and Julius Caesar suffered from the condition.
People with epilepsy have fits, during which they can become unconscious and experience muscle-twitching, and their bodies twist about. Sometimes, they wet themselves. Gradually, the fit subsides and they regain control of their bodies and mental functions. Those who suffer from epilepsy nowadays look upon it as a ‘normal’, if inconvenient, episode. But seeing someone during an epileptic fit can be pretty disturbing, and so dramatic and mysterious were the seizures that the ancient Greeks assumed the condition had a divine cause. So they called it the ‘Sacred Disease’.
The Hippocratic author of the treatise was having none of this. His famous opening sentence states bluntly, ‘I do not believe that the “Sacred Disease” is any more divine or sacred than any other disease, but, on the contrary, has specific characteristics and a definite cause. Nevertheless, because it is completely different from other diseases, it has been regarded as a divine visitation by those who, being only human, view it with ignorance and astonishment.’ The author’s theory was that epilepsy is caused by a blockage of phlegm in the brain. Like most theories in science and medicine, better ones have replaced it. But the firm statement – that you can’t say a disease has a supernatural cause simply because it is unusual or mysterious or hard to explain – might be said to be the guiding principle of science throughout the ages. We may not understand it now, but with patience and hard work, we can. This argument is one of the most lasting things handed down to us by the Hippocratics.
The second Hippocratic principle was that both health and diseases are caused by the ‘humours’ in our bodies. (An old expression is that someone is in a good or bad humour, meaning in a good or bad mood.) This idea is most clearly set out in the treatise On the Nature of Man, which might have been written by Hippocrates’ son- in-law. Several other Hippocratic works mention two humours – phlegm and yellow bile – as the causes of disease. On the Nature of Man added two more: blood and black bile. The author argued that these four humours play essential roles in our health, and when they get out of balance (when there is too much or too little of one or the other) then disease occurs. You’ve probably seen your own bodily fluids when you’ve been ill. When we have a fever, we break out in a sweat; when we have a cold or chest infection, our noses run and we cough up phlegm. When we have upset tummies, we vomit, and diarrhoea expels fluids from the other end. A scrape or cut can cause the skin to bleed. Less common today is jaundice, when the skin turns yellow. Jaundice can be caused by many diseases affecting those organs that make the bodily fluids, including malaria, which was common in ancient Greece.
The Hippocratics associated each of these humours with an organ in the body: blood with the heart, yellow bile with the liver, black bile with the spleen, and phlegm with the brain. The author of On the Sacred Disease thought that epilepsy was caused by blocked phlegm in the brain. Other diseases, not just ones such as colds or diarrhoea with their obvious changes in fluids, were asso- ciated with changes in the humours. Each of the humours had its properties: blood is hot and moist; phlegm, cold and moist; yellow bile, hot and dry; black bile, cold and dry. These kinds of symp- toms can actually be seen in those who are ill: when a wound is inflamed with blood, it’s hot, and when we have a runny cold we feel cold and shiver. (Galen, who developed Hippocratic ideas about 600 years later, also gave these same characteristics of hot, cold, moist and dry to the foods we eat, or drugs we might take.) The cure for all illnesses was to restore whatever balance of humours was best for each patient. That meant that in practice Hippocratic medicine was more complicated than simply following instructions to return each humour back to its ‘natural’ state. Each individual patient had his or her own healthy balance of the humours, so the doctor had to know all about his patient: where they lived, what they ate, how they earned their living. Only by knowing his patient well could he tell the patient what was likely to happen, that is, give them a prognosis. When we are sick, we want most of all to know what to expect, and how we might get better.
Hippocratic doctors placed great store in being able to predict just what would happen. Getting that right increased their reputations and brought them more patients.
The medicine that the Hippocratics learned, and then taught to their pupils (often their sons or sons-in-law), was based on careful observation of diseases and the course they took. They wrote down their experiences, often in the form of short summaries called ‘aphorisms’. Aphorisms was one of the Hippocratic works most widely used by later doctors. The Hippocratics’ third important approach to health and disease was summarised by the Latin phrase vis medicatrix naturae, which means ‘the healing power of nature’. Hippocrates and his followers interpreted the movements of humours during disease as signs of the body’s attempt to heal itself. So sweating, bringing up phlegm, vomiting and the pus of abscesses were viewed as the body expelling – or ‘cooking’ (they used kitchen metaphors a lot) – the humours.
The body did this to get rid of excesses or modify or purify bad humours that had been changed by disease. The doctor’s job was therefore to assist nature in the natural healing process. The doctor was nature’s servant, not her master, and the processes of disease were to be learned by close observation of exactly what occurred during disease. Much later, one doctor coined the phrase ‘self-limited disease’ to describe this tendency, and we all know that many illnesses get better by themselves. Doctors sometimes joke among themselves that if they treat a disease it will be gone in a week, but if they don’t it will take seven days. The Hippocratics would have agreed.
Besides their many works on medicine and surgery, hygiene and epidemics, the Hippocratics left us the Oath, still a source of inspiration to doctors today. Some of this short document is concerned with the relationships between the young student and his master, and between doctors. Much of it, however, deals with the appropriate behaviour that doctors ought to adopt with their patients.
They ought never to take advantage of their patients, gossip about secrets they might hear from the sick, or administer a poison. All these issues are still vital in medical ethics today, but one Hippocratic statement in the Oath seems particularly timeless: I will use my power to help the sick to the best of my ability and judgement; I will abstain from harming or wrongdoing any man by it. ‘To do the sick no harm’ ought still to be every doctor’s aim.