Hippocrates and History
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00:00
Lecture/ConferenceMeeting/Interview
Transcript: English(auto-generated)
00:11
Thank you very much. Count Benidot, Nobel laureates, ladies and gentlemen, it is a great pleasure to be present on this occasion
00:23
and an honor to have received an invitation to participate. That someone who is only a physician with severely limited classical as well as scientific background should venture to bring once more to your attention
00:43
the time-honored theme of Hippocrates and history is the result not so much of new discoveries concerning Hippocrates as it is of certain new and massive and to some extent rather frightening trends
01:01
that we find in present-day physical and biological affairs, including medicine. What I shall try to show is, first, the position originally taken by Hippocrates regarding man and nature. Second, how this position has waxed and waned
01:20
in its validity and acceptability over vast centuries of time. And third, the urgency now for a new consideration of what may fairly be called Hippocratic doctrine. We need to know about Hippocrates himself as well as his ideas and must first establish
01:41
that he was a man and not a fable. Like every great man, all kinds of fables gathered around and about him, but these must be recognized and discarded. There are two clear references by Plato, Hippocrates' contemporary. In the Protagoras, one of Plato's characters,
02:01
also named Hippocrates, is going to Hippocrates, of course, the Asclepiad, to be instructed in medicine. An Asclepiad was a term apparently used to describe the general guild of physicians. In the Phaedrus of Plato, it is recorded that Hippocrates, the Asclepiad, teaches
02:21
that an understanding of natural events is the necessary approach, not only to medicine, but to all knowledge. Aristotle, in his politics, has an interesting comment. When one says, the great Hippocrates, he writes, one means not the man, but the physician.
02:41
From this brief but authoritative statement, one can deduce that Hippocrates was a man, that he was well known to Aristotle, and that then, a generation after his death, he was already a great figure. Some have even thought that there is here an implication that Hippocrates was a man of small stature,
03:01
but this seems debatable. The pertinent question is raised, however, what indeed did Hippocrates look like? This question has occupied archaeologists for more than three centuries. The first evidence that was found, early in the 17th century, was a Roman coin of the first century AD, on which were depicted
03:22
a head in profile, the Greek letters, Iota Pi, hip, and a serpent's staff. Could I have my first slide, please? He begins to show. The head was rounded, bald, with a short beard, the nose large, with broad nares.
03:41
The design is, of course, crude, but gives a definite idea of the kind of head and countenance the man had. There was much interest through the latter 18th and 19th centuries in finding an antique sculptured head or other portrait, which would be sufficiently like that on the coin so as to call the head Hippocrates.
04:03
On the next slide, I might have the next slide, is one familiar in the Capitoline Museum in Rome, and the next slide, please, here of the same person that in the British Museum. The fit, as you will see, is not good,
04:21
the face being much narrower than that on the coin. Half a century or so ago, with much additional evidence, this head was identified as that of the stoic philosopher Chrysippus, and not Hippocrates. There was then, at this point, no accepted representation of Hippocrates except the coin.
04:42
In 1940, in the excavation of a burying ground near Ostia Antica, the ancient seaport of Imperial Rome, there was found within the family tomb of a distinguished Greco-Roman physician of the first century AD, a pedestal on which was an inscription, beginning, life is short.
05:02
Near the pedestal on the ground was the sculptured head or herm of an elderly bearded man, the right side with a face much damaged. The contour of the head and details of the face were found to correspond closely with those on the old Roman coin of Kars.
05:21
This with the inscription, life is short. Could I have the next slide, please? This with the inscription, life is short, and other evidence have led most archaeologists to believe, with some confidence, that the head is indeed an ancient representation of Hippocrates, a fine Roman copy
05:40
of an earlier Greek original. This is the side view. Could I have the next slide? This is from one side and the next, and this from the other. It is seen to be a head and confidence of great power. Its expression a curious blend of strength and sorrow.
06:04
The Hellenistic style places the Greek original at about 280 to 300 BC. Or somewhat less than 100 years after Hippocrates' death. Could I have the lights, please? What were the enduring creations
06:21
that came out of the life of this remarkable man? As in all history, there are not many certainties, and we must deal with records of greatly varying probability. One certainty is the Hippocratic corpus. The whole mass of medical treatises, some 70 or 80 of them still surviving, that were gathered over a period
06:41
probably of some 400 years, and that have survived over a period of 24 centuries. This in itself is an astonishing product. We have, of course, writings on religion collected over much longer periods, and still with us. But where else in either ancient or modern times
07:01
have we a collection of objective and interpretative writings in a scientific field assembled in one man's name, so sedulously protected and so earnestly studied and used over so great a span of time. Plato, Aristotle, and of course Galen
07:20
wrote more extensively, but within one or two generations they and their schools had completed their work. The Stoics continued teaching and writing for centuries, but their works were scattered, never held together by one dominating personality, and in great part, lost. It is fairly certain that there existed
07:42
a school of medicine at cost before Hippocrates the Great. His biographer, Siranus, mentions his grandfather, Hippocrates I, and at least two of the writings in the corpus have been dated before Hippocrates. What were the truly fundamental contributions
08:00
to medicine of Hippocrates himself? The evidence is largely internal, and authorities naturally vary as to which treatises are genuine, meaning by this, either written by himself or his immediate students or associates. I believe that by reference to a few of these,
08:20
one can reach the primary features of his teaching. One of the sevearer critics, Dichreiber, admits only one, The Epidemics, books one and three, as surely by Hippocrates himself. These, as I suppose everyone knows, are simple in form. They consist first of a brief discourse on constitution,
08:42
that is, the meteorological conditions and the kinds of disease occurring in a particular season. And second, three series of most detailed and exact descriptions of individual clinical cases. These are, moreover, complete.
09:00
They are no single visits to a prestigious patient by a prestigious consultant. The physician here sees every kind of patient, from the wealthy aristocrat to the artisan, the domestic, even the slave. And he follows the patient from the beginning of his disease to its end, whether recovery or death,
09:22
and whether the disease lasts two days or four months. He is concerned about the patient's mental and emotional state, as well as the physical strains or excesses that led up to his illness. I venture to state that this kind of exact description was new.
09:40
Here is an exact and accurate observer of natural events. Here is no philosopher proving a system. As Hippocrates himself insists over and over again, he is a practitioner of his technae, or craft. And craft is probably a better name for Hippocratic medicine than the traditional word art.
10:04
What further does he think and do in the broad field of medicine? There are a number of other works which are considered by most authorities to have been written by Hippocrates or one of his colleagues associated in contemporary practice and teaching.
10:20
The treatise, Regimen in Acute Diseases, indicates the broad principles of therapy, using the means then available, diets, purges, emetics, bleeding, and general daily regimen. The prognostics gives the evaluation of symptoms and signs favorable and unfavorable.
10:41
The surgical treatises on fractures, dislocations, and wounds of the head are an extraordinary group, detailing most accurately the anatomy and signs of these various injuries. When to use the knife, how to reduce the fracture or dislocation, precisely how to dress or bandage the injury,
11:01
what will happen on succeeding days, and how to deal with these events. Significant here is that Hippocrates included all branches of medicine and surgery on the same terms. There was no downgrading, for example, of surgery. This came centuries later. In the chapter on airs, waters, and places,
11:22
Hippocrates reaches out further and endeavors to place man in relation with his environment. Man and nature, as it were, together. What kind of human beings develop in such and such a climate or ecologic state, as well as what diseases they will have?
11:42
While he describes accurately malarial climates and the chronic malarial state in man, other sections are wide of the mark, as we would interpret them now. But the point here is the breadth of Hippocrates' conception of medicine and the identification of man, both in health and disease, as a part of nature.
12:03
Hippocrates' attitude, his philosophy, at the foundation of his medical art or craft, is perhaps best set forth in a very early chapter called Ancient Medicine. In this, he begins by stating that medicine has no need of hypotheses.
12:21
Here, one must distinguish, as WHS Jones notes, the ancient from the modern notion of hypothesis. In the modern, an hypothesis is a postulate which, once stated, can be investigated. Not so in ancient times. Then, an hypothesis was a thesis,
12:40
a declaration of underlying truth, to be accepted and thereafter used to explain phenomena but never questioned. To such an hypothesis, Hippocrates was opposed. He does not accept, for example, empedocles' proposition that in order to know nature, one must first know the origin of man,
13:01
how he came into being and out of what elements. Medicine is concerned, says Hippocrates, with the sufferings of ordinary folk and does not require ultimate cosmologic theory. He admits of certain general processes and forces which can be derived from the study and observation of man himself.
13:21
As one would expect, these are not especially original but relate to a number of philosophic generalities current in the fifth century B.C. The state of health is one of harmony or balance of forces. An acute disease, for example, with sharp acrid discharges is caused by an imbalance of forces
13:42
to be restored by coction, the Greek word pepsis, into thicker, more purulent secretions that lead to healing, and this through mixture or blending, the Greek word crassus. The so-called humors in this early era were recognized but numerous and of various kinds. The fixed doctrine came later.
14:01
In all cases, the basis of medical care is to understand nature, the Greek word phusis, that is the natural order. The function of medicine is to assist nature, to restore this balance of forces which is the state of health. It is necessary now to define our terms
14:20
even more precisely if we are to know what Hippocrates is talking about. The Greek word phusis, or nature, comes from phuo, to grow, spring forth, come into being. And so phusis as Hippocrates uses it means both nature and the natural order in the large, and also the nature or constitution of man himself.
14:43
The term differs from the Aristotelian episteme, which is to know how or understand and thus denotes man's own definition of scientific knowledge. Neither one includes the notion of experimentation as a planned action to demonstrate a process. It should be noted, however, that Hippocrates
15:03
was very much aware of the experimental aspect of medicine. The word pera, or trial, which he uses in the first aphorism, shows that for him, every therapeutic effort in medicine is an experiment, as indeed it is. The other word of importance is iatricae,
15:22
medicine or the art of healing, and this too is very broad. In Hippocrates' conception, it signifies the guidance of man by the physician in health and disease, and in all man's relations with nature. In this same treatise, that is ancient medicine, Hippocrates makes the boldest
15:42
and most inclusive statement of all. I hold, says he, that clear knowledge about nature can be obtained from medicine and from no other source. This is presumptuous indeed. It may be no more than a naive statement by a craftsman trying to advance the prestige
16:01
of his own trade, perhaps. But I believe that it is more than this. Since man and nature are one, we must seek this knowledge through the study of man and man in nature. This is medicine or iatricae in its broadest sense. It is in fact humanism also in the broadest sense.
16:23
I am inclined to think that Hippocrates had this large concept in mind, though the language was not then available to give it more precise expression. I should mention the Hippocratic aphorisms. These terse statements, some 400 of them, are of variable quality and origin,
16:43
many brilliant clinical observations, many obscure and hard to interpret, many of post-Hippocratic and some of pre-Hippocratic origin. They were revered and memorized in later ages by scores of generations of Greek, Roman, Hebrew, Arabic, and medieval physicians.
17:03
We must examine one more Hippocratic or early post-Hippocratic treatise, that on the sacred disease or epilepsy in which he contrasts medicine with religion and magic. The name sacred disease for epilepsy came out of the tradition of some past age.
17:21
But why this, asks Hippocrates, more than any other. All diseases are divine, he insists, and all are human. Each has a nature and proceeds according to its natural order. Hippocrates is opposed to non-rational magic, but not at all opposed to religion in and for itself.
17:42
Bring the sick man to the sanctuary, he says. At least it is Godhead that purifies and cleanses us from the greatest of our sins. While thus not denying religion, he holds as absolutely to the mechanical order in his description of nature as Democritus himself.
18:01
Incidentally, while there is multiple evidence that Hippocrates and Democritus of Abdera were friends over many years, Hippocrates did not use or appear to need atomistic theory in all its detail. He might have been interested in Aristotle's biology, but not his cosmogony.
18:21
Plato's idealism was the opposite of Hippocrates' primary concern with objective living events. Least of all would he have accepted the Judaic belief of man under a beneficent Jehovah as lord and master of created beings, both living and non-living.
18:40
Man belongs to nature according to Hippocrates, but nature does not belong to man. We shall come back to this later. So much for Hippocrates, the man and the physician and his teaching. It has been a long introduction. Now to pursue the adventures, misadventures, and distortions of himself and his doctrines
19:01
through the course of history. We must keep separate at all times two main features of this teaching. One is the actual clinical instruction in practical medicine. The other is the larger philosophical scheme of man in nature because they have very different histories. Let us examine first the course of Hippocratic medicine
19:23
within his school itself as more and more medical writings came to be added to the collection. These were from many sources and with many different philosophic backgrounds. Pythagorean, Aristotelian, Epicurean, and so forth. The whole as we have it now is actually probably a part of the library
19:43
of the Hippocratic school. As is so often the case with the leader of thought, the wide ranging philosophy of Hippocrates became increasingly restricted and dogmatized as time went on to end eventually and unhappily in that rigid rubric which continued down the ages
20:03
as the Hippocratic doctrine of the four humors combining these with the four elements and four forces or powers. These as we have noted Hippocrates himself had been at much pain to denounce as the wrong way by which to approach
20:21
the art and science of medicine. Could I have the last slide please? This figure familiar I suppose to all of you gives the pattern. We have the four elements, fire, earth, water, and air and associated with them the Hippocratic humors,
20:41
yellow bile, black bile, phlegm, and blood and acting upon them the four dunamis or forces or hot, dry, cold, and moist. Like so many theories it is so neat that it ought to be true even if it is not
21:02
and therefore was thought worthy to be perpetuated. Even more, could I have the lights slide off please? Even more perhaps than his scientific attitude, Hippocrates as a man was stripped of his human qualities and made into a figurehead if not a semi-deity.
21:20
He was solemnly pronounced 19th in lineal descent from Asclepius and 20th in lineal descent from Hercules. He was set up as an actual disciple of Asclepius as for example in the so-called Hippocratic actually post-Hippocratic oath when in his life he scorned the use of magic in medicine and in his own writings
21:42
never once mentioned Asclepius name. In the later works of the corpus if one leaves aside the medical philosophy and looks only at the medical and surgical observations one finds that there is much of value and of the widest range. This solid foundation of practical clinical medicine
22:02
is what continued to be valued by successive generations of physicians and what therefore held the corpus together as a sort of textbook on a grand scale. The long list of commentators provides abundant proof of this. Aristotle comments on one. His student Menon lists a number of the writings.
22:22
Herophilus, the anatomist of the Alexandrian school around 300 B.C. was a commentator and more extensively his student Pacius. Erotian in the time of Augustus listed the works known to him. To complete our story the Renaissance compiler and editor Annutius Phoecius assembled over 250
22:43
commentators on the works of Hippocrates most of them Greek, Roman, Hebrew or Arabic but it was of course Galen. At the end of the second century A.D. who truly and authoritatively brought to life again the major writings of the Hippocratic school.
23:02
It is extraordinary how absolute the devotion which this arrogant and overweening man paid to the father of medicine. To be sure if Galen did not agree with the Hippocratic writing he either reinterpreted it to suit himself or else discarded it as a miscopying or a later interpolation.
23:21
He wrote commentaries on or mentioned over 30 chapters including all but one of those that we now accept as genuinely Hippocratic. But Galen also accepted and made his own that same rigid humoral philosophy worked out in the post Hippocratic period and he successfully passed this on
23:41
to later Roman and medieval times. We can skip now over vast centuries with medical theory and philosophy fixed and with experimental inquiry as yet unborn practical medical knowledge was derived largely from the ancients and even this in fragmentary form.
24:00
Some of Galen's medicine and physiology survived much of his materia medica. Greek medicine was delivered largely through Arabic sources though Hippocrates aphorisms, prognostic and dietetics were available in Latin translation. These sources form the textbooks in the better schools for a thousand years.
24:23
Surgery declined to the level of barber surgeon practitioners. Medicine as a practical healing art was reduced to empirical formulae mixed with astrology, superstition and magic. Its total impotence during the ravages of the Black Death from the mid 14th century on
24:41
diminished its standing still further. Medicine was late in joining the revival of learning slumbering on in Galenic tradition for nearly two centuries after the first flowering of art and literature in Italy. This was only partly because of the stubborn adherence of medical leaders to Galenic doctrine,
25:03
partly because other science was late in starting and partly also because the full texts of the medical knowledge of the ancients arrived from the east only toward the end of the 15th and early 16th centuries. The Hippocratic Corpus was a part of this new or newly restored knowledge.
25:22
The first editions of the Corpus with Latin translations were published in 1525. This was a time of great events in which as it turned out Hippocrates and his doctrines played a diminishing role. Let us consider again the two aspects of this doctrine.
25:40
On the one hand the clinical descriptions and teaching and on the other the broader ideas of medicine and philosophy. In the former, as one would expect, it was the clinicians who seized avidly upon the newly discovered writings whereas the anatomists and physiologists such as Vesalius and William Harvey stayed with Galen and Aristotle
26:02
at least as long as they could. Outstanding among the clinicians were Amberouis Parret of France in the 16th century, Thomas Sydenham of England in the 17th and Herman Burohaba of Holland in the early 18th. Parret the surgeon, contemporary of Vesalius
26:20
was a man of humble origin and no learning. He has been thought to have hired some assistant to put into his writings Hippocratic quotations but actually Parret did more than this. In his great textbook of surgery the section on fractures and dislocations is modeled exactly after the Hippocratic treatises
26:42
in fact reads like an extension of these. Parret was a true disciple of the father of medicine. Thomas Sydenham went further. Not only did he follow in his textbook Processus Integri the Hippocratic method of exact clinical description
27:01
but he accepted also his broader ideas of health and disease in the natural order and made explorations in the field of epidemiology. These however were not taken up by his successors and were soon forgotten. But these more or less isolated events in clinical medicine over this two century span
27:22
were small indeed beside the momentous discoveries and revolutions in the whole realm of science. I realize that these are familiar to all of you but I must look at them briefly in their relation to medicine both looking backward to the ancients
27:41
and also forward as they transformed all science, philosophy and society in the generations ahead. The dominant force of course was the discovery and elaboration of the methods of experiment which had been absent from the work of almost all in ancient times. In the physical sciences in this brave new world
28:03
man was all but overwhelmed by his own success. A.N. Whitehead has said that the Middle Ages were the age of faith based on reason. The 18th century the age of reason based on faith. It was faith in science and its limitless possibilities.
28:21
It was faith also in man and his limitless capability. There was a resurrection of the old Judaic and now Judeo-Christian doctrine of man under a beneficent deity as lord of creation. Sometimes the deity was called providence, sometimes he was dropped out but the principle was the same.
28:42
Man was the master, nature in its limitless profusion was his servant. There was something also of the crusader added to the conception. Man conquering the infidels of a baleful nature or at least of the baleful and anti-human features of man's environment. In any event the prospect was pleasing.
29:03
By taking thought and exerting himself man would soon learn to live forever in prosperity and peace. The immense achievements of science and technology through the 17th, 18th and 19th centuries could not but serve as proofs of the validity
29:21
of this conception. In the new scheme of things it is only fair to say that our friend Hippocrates lost out completely. As emphasized recently by Galston whatever was left of the Hippocratic idea of medicine assisting nature in the restoration of health gave way before the experimental approach
29:43
and his consequences. Diseases became specific entities with etiologic agents, cures and preventions and in the ever strengthening anthropocentric philosophy of our age they came to be looked upon as enemies to be put down and stamped out under the foot of the Lord of creation.
30:03
Each discovery was another battle won in man's total conquest of nature. One by one infections, deficiency states, metabolic defects have been brought under control by miracle drugs for other agents. Even persisting chronic diseases alleviated.
30:21
In our environment pests unfavorable to our food products, animal or vegetable have been destroyed by powerful poisons. Predatory animals wiped out. Heredity in plants and animals have been rearranged to man's benefit and even in man heredity is about to be placed
30:41
under favorable control, at least in the minds of some. Man has in fact all but reached his goal as Lord of creation. Even two world wars with their insane and ghastly devastation did not disturb the dream, still resting in the confident scientific philosophy
31:01
of the 18th century. Then at first slowly, afterward with increasing momentum, something happened. God disappeared from his heaven and all was not right with the world. It began to be apparent that the world no longer has a physical frontier
31:20
and never again will have. It has changed or has been changed from an open to a closed system. One physical event can reach around the world. There is no place to hide. This is something altogether new in history, at least so far as the small species, Homo sapiens is concerned.
31:42
Some things have happened by slow degrees, others suddenly. One is reminded of the moment in the life of Niels Bohr, that great and good man, when he awoke to the somber realization that the true and the good are not the same, that the true in fact can be appallingly evil.
32:01
I refer obviously to the explosion of the first atomic bomb. There is no need to continue this story. The subsequent destruction, all the radiation that up to now has been loosed upon the world, the grim threat of annihilation, but the list piles up. We have the ravages upon our forests and mineral resources,
32:23
water pollution, air pollution from many sources, the most overwhelming from all the effluent of the burned carboniferous fuels produced by our flourishing industries. Pesticides with their lethal track down our streams into the sea, taken up into animal aquatic and bird life,
32:41
destroying countless millions, if not whole species, and so back into man himself. Most ironical has been the progress in medicine. Simultaneously with the conquest of disease has come the enormous increase in population. The statisticians telling us
33:00
that the world population, if not checked, will double in 35 years with its inevitable threat of increased starvation and the rest. Our death control, as someone has said recently, has been admirable. Our birth control, when looked at over the whole world, small indeed. In our vaunted conquest of nature,
33:21
it appears, as so often with other conquests, that the conquered, and even the means of conquest, return to plague the conquerors themselves. If one proposes to be lord of creation, one must think of everything and one must not forget. And the trouble with man is, he has not thought of everything and he does forget.
33:42
It is a sad reflection on our miscalculations to consider now, if we are to survive, how much of our time will have to be spent correcting our own mistakes. In all of this, where does Hippocrates come in? He comes in most vigorously. You will remember some 24 centuries ago
34:01
his general position that man belongs to nature, but nature does not belong to man. Although the context has changed, it seems reasonable to suppose that Hippocrates would argue that man must now abandon the notion of conquering nature and become once more nature's servant. Nature must be protected more than exploited
34:22
and this must be man's primary concern. This argument is set forth by Galston in his paper, which I've already referred to, in which he claims a resurgence, or perhaps one should say a hoped for resurgence, of Hippocratic medicine. There is nothing new to be sure.
34:42
In this general proposition about the world today, you will say, as Horatio said to Hamlet, there needs no ghost, my lord, come from the grave to tell us this. But the question is not one of novelty, but of urgency. It is true that remedial measures are at hand
35:00
if we will use them, and on a large enough scale. Birth control is possible and feasible. Mineral and forest sources can be conserved, fuel consumption reduced, air and water pollution controlled, metabolizable pesticides discovered and applied, the nuclear arms race stopped, and dangers from radiation curbed.
35:21
It is true also that in some countries, as in Europe and Japan, much of this control is exercised. But the world picture is disturbing. In the heavily industrialized United States, politics and industry are in command, and the military pressures by the one, and the primary urge for profits by the other,
35:42
prevent essential reform. Over the world at large, population control is, of course, the most urgent of all considerations. But the ignorance of the people, and the incapacity or unconcern of most governments, leave little to hope for, and everything to be done. Yet if man is to survive,
36:01
somehow these huge obstacles must be overcome. And soon, there is much to do, and not very much time. As I listened yesterday to my friend and colleague, Andre Cornyn, this remark, by the way, is not in my prepared text. As I listened to Dr. Cornyn, it occurred to me that I might at this point
36:22
call in the prophet Daniel, as he did, and invoke his aid. But then I realized that Daniel was a prophet, and this is not prophecy, but only history. So I shall rest with Hippocrates. Hippocrates also had the right word
36:41
to describe where we now are. The art is long, he said, and life is short.