Hippocrates of Cos
Hippocrates of Cos, or simply Hippocrates (from Greek Ἱπποκράτης Hippokrátês), born around 460 BC on the island of Cos and died in 377 BC in Larissa, was a Greek physician of the century of Pericles, but also a philosopher, traditionally considered the “father of medicine”.
He founded the Hippocratic school that intellectually revolutionized medicine in ancient Greece. He made medicine distinct and autonomous from other fields of knowledge, such as theurgy and philosophy, to make it a profession in its own right.
Very little is known about Hippocrates” life, thought and writings. Nevertheless, Hippocrates is commonly described as the paragon of the ancient physician. He is the originator of a style and method of clinical observation, and the founder of ethical rules for physicians, through the Hippocratic Oath and other texts of the Hippocratic Corpus.
According to most historians, Hippocrates was born in 460 BC on the Greek island of Cos, which was part of the Athenian confederation. He was a renowned physician and a famous master of medicine. His family, of aristocratic origin, passed on medical knowledge and claimed, like other Asclepiades families, to be descended from Asclepius through his son Podalire.
The first part of his career is carried out in Cos, which is not the current city of Cos, the ancient city was located at another end of the island, on the current site of a small seaside resort, Kamari.
Then his life takes place in northern Greece, in Thessaly and Thrace, in particular in Abdere and the island of Thasos. According to the Hippocratic texts mentioning the geographical location of the patients, the most distant city towards the north is Odessos (Varna in Bulgaria today), and towards the south Athens and the islands of the Aegean Sea, Syros and Delos.
Many biographical elements are apocryphal and subject to discussion. In general, historians give more weight, as a matter of principle, to testimonies from Hippocrates” lifetime, notably those of Plato (in Protagoras, Phaedrus) and Aristotle (in Politics). According to these testimonies, Hippocrates was already in his lifetime a physician of great reputation, whose logical method and precise use of terms were exemplary.
Then come Greek and Roman texts about their own past. The Greco-Romans used to compose, as exercises or lectures, imaginary letters and speeches attributed to their celebrities of the past, of which it is difficult to disentangle the true from the false.
Galen refers to Hippocrates, and makes numerous allusions to his life. Soranos of Ephesus, a Greek gynecologist of the second century, was the first biographer of Hippocrates and his writings, including these letters and speeches, are the source of the main information we have on his person. These sources therefore date from nearly five centuries after Hippocrates” death in 377 BC.
The collection of Hippocratic texts (authentic, anonymous, and hypothetical) took place progressively during the first millennium, until 1526, date of the first printed edition of Hippocrates” complete works in Greek. On the basis of the information contained in these different texts, many authors have tried to reconstitute, or imagine, a biography of Hippocrates. Starting with the 10th century Souda (article “Hippocrates”), and the scholar John Tzetes who wrote a biography of Hippocrates in his Chiliades in the 12th century AD.
“Hippocrates is the greatest of physicians and founder of medicine.”
– Seneca, Letters to Lucilius 95.20
According to Aristotle”s account, Hippocrates is known as “the Great Hippocrates”. Regarding his appearance, Hippocrates was first described as a “dignified and compassionate old country doctor”, then as “arrogant and unapproachable”. He is certainly considered a wise man, a man of great intelligence and, above all, a good practitioner. Francis Adams, a physician and translator of Greek, describes him as a true “physician, a man of experience and good sense”.
This image of a wise, old doctor is reinforced by the busts that we have of him and which represent him with a wrinkled face and a large beard. Many physicians of the time had their hair cut short in the style of Jupiter and Asclepius. Therefore, the surviving busts of Hippocrates may be just another version of the portraits of these deities.
Hippocrates and the beliefs attributed to him are considered to be those of the medical ideal. Fielding Garrison, an authority on the history of medicine, said, “He is, above all, an example of that attitude of critical thinking, always looking for sources of error, which is the essence of the scientific mind.” “His figure…stands for future times as that of the ideal physician,” according to A Short History of Medicine, which has inspired the medical profession since his death.
According to Vivian Nutton, “In the 21st century, with the exception of the Bible, no text or author from antiquity surpasses the authority of Hippocrates of Cos and the Hippocratic Oath. Regularly quoted in scholarly journals and the popular press, Hippocrates remains a familiar figure, considered by all, physicians and non-physicians alike, as the Father of Western medicine, dictating the ethical conduct of physicians.
Realities or legends
There are several historical currents approaching the life of Hippocrates. A skeptical and positivist current, inaugurated by Émile Littré in the 19th century, rejects most of the texts on this subject as legends. In the 21st century, Vivian Nutton points out that almost nothing is known about Hippocrates himself, and that it is even unlikely that he was the author of the Oath.
Others, like Jacques Jouanna, consider “that one must beware of too much credulity, but also of too much skepticism”. Thus hypothetical literary data have been confirmed by new epigraphic discoveries. These data remain controversial, and other historians also study the formation and evolution of the Hippocratic legend as historical objects in their own right, whose different social role must be understood according to the periods and civilizations (Roman Empire, medieval Islam, European Renaissance…).
Most of the stories that are told about the life of Hippocrates are probably false because they are inconsistent with historical data, and similar or identical stories are told about other figures such as Avicenna and Socrates, which suggests that they are legends. The two most famous anecdotes, because they have been retold by writers and painters, are the meeting of Hippocrates and Democritus, and Hippocrates” refusal of the invitation of the Persian king Artaxerxes I. These two events would have taken place in the first period of Hippocrates” life, when he was still in Cos.
Accounts (notably that of Diogenes Laërce) affirm that Democritus, philosopher of the city of Abdere, was considered insane because he made fun of everything. The people of Abdera called upon Hippocrates to come and treat him. Hippocrates only diagnosed Democritus as having a happy disposition: far from being mad, he was in fact laughing at the madness of men. Democritus was later nicknamed “the laughing philosopher”. According to Jouanna, it is impossible to know the truth. “All that can be said is that Hippocrates and Democritus were contemporaries, and that Hippocrates or his disciples actually treated patients in Abdera.
This anecdote was taken up by La Fontaine in Démocrite et les Abdéritains, and by Stendhal in Vie de Henry Brulard. The painter Pieter Lastman, one of Rembrandt”s masters, represented the scene: Hippocrates visiting Democritus (1622).
Another legend concerns Hippocrates” refusal to accept gifts from Artaxerxes I, king of Persia, who wanted to hire his services. The validity of this anecdote is admitted by the most ancient sources, but refuted by more modern historians and is therefore questionable.
According to Jouanna, the invitation is likely, because the Persian kings traditionally called upon the best physicians from their known foreign world, notably Egyptians since the highest antiquity and Greeks since Darius, and the presence of several Greek physicians at the Persian court is attested. Similarly, the refusal of Hippocrates is plausible, given the political context of the period.
The anecdote was used in Roman circles as an invitation to distrust Greek physicians since they did not like the enemies of Greece (or on the contrary as an exemplary model of patriotism and disinterestedness (biographers of medieval Islam), and which will also be remembered in Europe. In 1792, the painter Girodet painted Hippocrates refusing the gifts of Artaxerxes, a painting noticed by Baudelaire during an exhibition in 1846.
The causes of Hippocrates” departure from Cos for Thessaly (around 420 BC) are subject to various interpretations according to the biographers.
There is a malicious tradition that Hippocrates fled after burning the library of the school of Knidos. Centuries later the Byzantine grammarian John Tzetes wrote that Hippocrates also burned down the temple of Asclepius in Cos, after he had learned medicine by studying the healing stories consecrated by the priests. He would have done this to destroy his sources, to hide his plagiarism and to ensure the exclusivity of a medical knowledge. This negative tradition, dating back to the Hellenistic period, testifies to the existence of an anti-Hippocratic current that would have manifested itself in the entourage of Herophilus, a great physician of Alexandria. It could also have been invented by the clergy of Asclepius itself, in order to make people believe in the great antiquity of the temple despite the absence of evidence before the fifth century.
According to Soranos of Ephesus, Hippocrates would have left following a dream telling him to settle in Thessaly. For Jouanna, the most likely explanation was his desire to enrich his experience, because one of the important ideas of Hippocratic medicine is the influence of the various natural environments (air, water, places) on health and disease.
Called to the new king of Macedonia, Perdiccas II, who was believed to be seriously ill, he would have diagnosed a love disease of the young king for the courtesan of his dead father.
A similar story is told about other ancient physicians like Erasistratus. In all cases, a great physician discovers in a young prince (by taking his pulse and making him parade in front of him, one by one, all the women of the palace) a hidden love disease for the wife (his stepmother) or the courtesan of his father, living or dead. The repetition of the plot raises doubts about the authenticity of the story, especially since pulse-taking is not mentioned in the Hippocratic texts.
This story remained famous, enriched with variants and innovations, and taken up by poets, such as Dracontius with Hippocrates (Aegritudo Perdicae “The disease of Perdiccas”), or painters, such as David with Erasistratus (Erasistratus discovering the cause of the disease of Antiochius, 1774)
Hippocrates is said to have contributed to the healing of the Athenians during the plague of Athens (430-429 BC) by burning large fires to purify the air (Roman period tradition), or even by having discovered an antidote (Byzantine period tradition). These events are unlikely to have actually occurred.
According to Jouanna, there would be confusion with another pestilence in northern Greece, notably at Delphi, in the years 419-416 BC. The arrival of Hippocrates would be confirmed at this time by dedicatory inscriptions.
He died in Larissa, in Thessaly, around 370 BC, at an advanced age (various biographers give a range of 85 to 109 years). His tomb was located north of Larissa; a swarm of bees located on his tomb provided a honey reputed for its healing powers. The local nurses used to go there to treat their children by rubbing them with this honey.
After his death, he became a healing hero who was worshipped. In his native island of Cos, annual sacrifices were made on the anniversary of his birth. Bronze coins with his effigy appear in Cos from the first century B.C. He is also the subject of private cults by doctors of antiquity (statuettes, busts, funerary inscriptions…).
A whole pseudo-Hippocratic literature developed in the Middle Ages. The forgery is distinguished by chronological impossibility. Thus, a letter by Hippocrates on the constitution of man is addressed to king Ptolemy Soter. It was a great success, since about thirty medieval manuscripts preserving this work are known.
In the French novel Lancelot-Graal (early 13th century), Hippocrates hears about the resurrection of Lazarus by Jesus Christ. He no longer treats the love disease of King Perdiccas, but that of the nephew of Augustus, the Roman emperor. The latter had two life-size golden statues of Hippocrates erected in the highest place in Rome in gratitude.
Hippocrate is also the victim of a Gaulish woman with whom he has fallen in love. Under the pretext of a gallant encounter, she manages to hang him from her window, trapped in a basket, where he is the laughing stock of passers-by. Medieval artists often depicted the scene on ivory tablets, the victim being either Hippocrates or Virgil.
According to an Arab legend, the wise man Lokman succeeded in wresting from Hippocrates his medical secrets, which he jealously guarded, and Hippocrates died of spite. According to another Arab legend, Hippocrates, feeling his death approaching, had his secrets engraved on a tablet and placed in an ivory cassette which he took to the grave. The short text that is supposed to be the transcription of this tablet is translated into Latin under the title Secreta Hippocratis or Capsula eburnea.
Legendary genealogy and family
The legendary genealogy of Hippocrates traces his paternal ancestry directly to Asclepius (Plato states that he is an “Asclepiad”) and his maternal ancestry to Heracles from the Greeks. According to the biographies, which overlap on the whole but differ in detail, Hippocrates is the 17th, 18th or 19th descendant from Asclepius.
The most complete family tree is that of Tzetzes. It is a filiation whose historicity is not controllable: Asclepios, Podalire, Hippolochus, Sostratos, Dardanos, Crisamis, Cleomyttades, Theodore, Sostratos II, Crisamis II, Theodore II, Sostratos III, Nebros, Gnosidicos, Hippocrates, Herakleidis, Phenaretus, Hippocrates II who is the great Hippocrates.
Biographers have not preserved the name of Hippocrates” wife, but her ancestor was Cadmos of Cos, tyrant of the island during the first medieval war. Three children were born from this marriage; two boys, Thessalos and Dracon, who were doctors, and a girl, wife of Polybius, another doctor. This Polybius, son-in-law and disciple of Hippocrates, is considered as the author of the Hippocratic treatise On the Nature of Man. This daughter of Hippocrates inspired a Byzantine legend, brought back by the crusaders, and which is found in a story by Jean de Mondeville. Transformed into a dragon by an enchantment, Hippocrates” daughter is locked up in a castle, where only the kiss of a knight will allow her to regain her original form. The treatise Nature of Man is attributed to Polybius, disciple and son-in-law of Hippocrates (and De la superfétation is attributed to Léophanès by Émile Littré.
Hippocrates is widely regarded as the “Father of Medicine”. His school gave great importance to the clinical doctrines of observation and documentation. These doctrines are supported by a clear and objective writing practice. This is the earliest surviving medical literature, presenting itself without a clear separation between technique and aesthetics.
It is the appearance of a medical style that is the foundation of clinical medicine: “the patient becomes the object of the gaze, the source of signs. Writing and semiology are absolutely linked. This medical style combines, among others, brachylogy (ellipsis or laconic style), parataxis (facts are recorded in successive accumulation), asyndeton (sublime style), metaphorical style, aphoristic style…
These procedures are not the result of a rhetorical intention, but of a conscious, reasoned, technical reflection. From then on, the name of Hippocrates has in fact two meanings: first of all, it is the historical figure, but also the work (the whole of the texts) bequeathed under his name, the Hippocratic collection or corpus.
The Hippocratic Corpus (from Latin: Corpus hippocraticum) is a collection of more than sixty medical treatises, written in Ionic (Ionian dialect). This collection poses numerous problems that have not been definitively resolved: problems of classification, dating, attribution…
It seems very likely that the vast majority of the treaties date from a period between 420 and 350 BC. The other treatises were written between the third century BC and the second century AD.
Because of writing styles and differences in vocabulary, contradictions in doctrines, and the apparent date of writing, scholars believe that the Hippocratic Corpus cannot have been written by a single person. As early as antiquity, Galen sought to determine the authentic texts from Hippocrates from others, written by his disciples or other physicians. The Hippocratic Corpus includes different types of texts or literary genres:
These texts were originally gathered in no particular order, several classifications were proposed in the course of history and none of them appeared satisfactory to reach a consensus.
Among the important texts, the most famous is the Hippocratic Oath, on the ethics of medical practice. Traditionally attributed to Hippocrates, but this attribution is questioned by most historians. Other significant and most often quoted texts are On the Sacred Disease; The Prognosis; Of Airs, Waters and Places; On Epidemics I and III; Aphorisms; On Ancient Medicine; On the Nature of Man; etc.
Beginning in the late twentieth century, many of the historical problems of the Hippocratic Corpus have become less important (attribution and classification of works). Instead of focusing on the authentication of writings, “scholars are now free to consider the Corpus in all its diversity of forms, doctrines, and purposes Together, these texts show the gradual creation of a form of medicine that would dominate Western medical thought and practice for centuries to come.”
In this sense, if the character Hippocrates has kept his image of Father or Hero, he has left his place to the anonymous “Hippocratic doctor”, but representative of a crucial period of antiquity.
Despite the divergences or contradictions that may exist in the Hippocratic corpus, historians have identified common and “revolutionary” constants that introduce a new vision of man and his place in the universe, where medicine must be defined by what it does and more importantly by what it does not do.
Natural causality: the setting aside of the divine
The treatise On the Sacred Disease is an emblematic text in the history of ideas, because it is the first text in which rational medicine is opposed to religious or magical medicine. Epilepsy was then called a “sacred disease” because it was seen as a divine sanction for an unspecified defilement. The author intends to show that this disease is not “more divine or more sacred than any other disease”.
His last argument is of a “physiological” nature: the disease only affects “phlegmatics” (see: theory of humours), but if the disease were truly a divine visitation, everyone should be able to be affected. He adds that this disease comes from the brain. “All diseases are divine and all are human”, the author says, because if nature is divine, all diseases can be divine as well as natural and human. His conclusion is that it is necessary to “distinguish the opportunity of useful means, without purifications, magic tricks and all this charlatanism”.
In fact, there is no mention of a single mystical illness in the entire Hippocratic corpus. The physician distinguishes himself from the priest-healer by avoiding magical or sacred means, which would aim at appeasing the anger of the gods or purifying the patient. The Hippocratic author is not an atheist, he considers that if nature (physis or phusis) has a divine character, it is not the plaything of the gods” whims, it is subject to a logical process of causality that the gods themselves do not break, and that it is possible to know.
Jackie Pigeaud goes further by showing that De la maladie sacrée is also a theodicy, a “profound attempt to clear God of evil”. The Hippocratic author affirms “I do not think that the body of the man is soiled by the god, the most mortal by the purest”. According to Pigeaud, if Greek rationalism was constituted against the gods, it is in the name of a purer conception of the Divine. By removing the disease from any tragic, religious or moral causality, De la maladie sacrée definitively distinguishes the disease from the evil, and puts it back in the domain of a specialist, the physician.
Illness: a logical history of the body in its environment
Illness is a bodily process under the combined influence of environmental factors (air, water, places), diet and lifestyle. This is a new vision of man who is no longer in a more or less conflicting relationship with the gods, but in relation with his environment. Thus the changes of the body do not depend on a divine justice, but on the course of the seasons, the social, geographical and climatic environment. In solidarity with his environment, man enjoys the best health when the external influences are balanced and moderate.
This new perspective is presented in the treatise of Airs, Waters, Places, also considered as a first treatise of anthropology, because the author applies his analysis of sick individuals to the whole of the peoples, explaining their diversity by the differences of climate and laws (political regime).
However, Hippocrates worked clinically in an empirical way, based on his experience and observations, and on the basis of principles that would be challenged by modern medicine in anatomy and physiology (such is the case of the theory of humours). However, in addition to the ethical principles, what most often remains of Hippocrates in modern medicine, without having been forgotten, are the principles of observation and logical analysis (Greek logic) of illnesses understood in their history and their course through a chain of causalities.
Illness is thus a change (Des lieux dans l”homme, 45).
Medicine: a therapeutic relationship
It is defined in the treatise On the art, it is a question of “averting the suffering of the sick and diminishing the violence of illnesses”; in Epidemics I, we find the maxim “To have two things in view in illnesses: to be useful or at least not to harm”, which is the probable source of the famous Latin expression Primum non nocere “First do no harm”.
Here the Hippocratic physician states that the purpose of medicine is not the success of the physician, but the interest of the patient. In the Hippocratic treatises, the patient is designated by the term anthrôpos “human being”, all other distinctions (sex, social status, people or race) being secondary, which has led to talk of a Hippocratic humanism.
However, medicine remains an art technê, that is to say a trade, a technique that has its limits: “to ask art what is not art, or nature what is not nature, is to be ignorant” (On art). It is necessary to know not to intervene when any action is vain or harmful ” What the drugs do not cure, iron cures it; what iron does not cure, fire cures it; what fire does not cure must be regarded as incurable ” (Aphorism 7).
Thus, in Hippocratic medicine, there is also a refusal to treat in cases deemed hopeless, for fear of losing one”s reputation (for example, in Fractures, cases of open fractures of the femur or humerus on the inside of the limb). The theoretical basis of this refusal (the beyond resources of art cannot go against the natural course) has become alien to modern consciousness.
Closer to modern concerns are the avoidance of spectacular innovation, which benefits the doctor more than the patient (Fractures), or the probity of the doctor who recognizes his own mistakes to avoid their repetition (Epidemics V).
According to the author of Epidemics I, “The art of medicine consists of three terms: the disease, the patient and the physician. The physician is the servant of the art. The patient must oppose the disease with the help of the physician. This triad has been called “the Hippocratic triangle” because, according to Gourevitch, it is a geometric figure with three vertices that offers two points of view to observe the other two vertices: the doctor”s point of view and the patient”s point of view.
The therapeutic relationship is thought of in terms of an alliance strategy in a fight. The disease must be fought and this fight is led by the patient, the doctor is the patient”s ally, the one who helps him/her to fight. The doctor is the patient”s ally, the one who helps him to fight”. This dimension constitutes one of the original features of Hippocratic medicine.
According to Debru, the Hellenistic physician-historian Littré translated the last sentence backwards as follows: “It is necessary that the patient helps the doctor to fight the disease” so much Littré is persuaded, in the XIXth century, that it is the doctor to fight and the patient to help him. At the end of the XXth century, the strangeness of the original text disappeared, with the actuality making the point of view of the patient prevail.
The Hippocratic physician must therefore deploy a professional strategy to be accepted by the patient as an ally, firstly through his knowledge and know-how, but also through his appearance, attitude and behavior, speech and sense of dialogue. Aristotle, and especially Plato, transpose this medical reflection into rhetoric, politics and ethics. The legislator must be, like the physician, a man not only skilled in his art, but also a master of persuasion.
Hippocratic medicine was distinguished by its strict professionalism, its discipline and the rigor of its practice. The treatises devoted to these issues are in particular On the physician, On propriety, and On the physician”s dispensary. These texts recommend that doctors should always be rigorous, honest, calm, understanding and serious. Particular attention is paid to all aspects of practice: detailed prescriptions for lighting, the personnel assisting the practitioner, the positioning of instruments and the patient, the techniques of bandaging and restraint in the operating room. Even keeping fingernails short to make the best use of fingertip touch is important.
“The rule of the doctor should be to be of good color and stoutness, according to his nature. Then he should be very clean, with a decent dress, pleasant perfumes and a smell that is not suspicious; He will have a thoughtful face, without austerity; otherwise he will appear arrogant and harsh; on the other hand, he who lets himself go to laughter and excessive merriment is considered as foreign to propriety; and this must be carefully preserved. Justice will preside over all his relations, for justice must often intervene; the doctor”s relations with the sick are not small; the sick submit to the doctor, and he, at all hours, is in contact with women, with young girls, with precious objects; with regard to all this, one must keep one”s hands pure” (Du médecin, 1, Littré translation).
Finally, the difficulties of the profession are summed up in the first aphorism of the Aphorisms, better known by the Latin expression Ars longa vita brevis (art is long and life is short), but whose complete original text is :
“Life is short, science is long, opportunity is fleeting, experience is deceptive, judgment is difficult. It is necessary not only to do oneself what is appropriate, but also to make the patient, the assistants and the external things contribute to it” (Aphorismes, I, 1, Littré translation).
The purpose of the Hippocratic examination of the patient is to determine the difference between his present state and his usual state, when he was close to the state of healthy people. To do this, the physician uses his five senses in a systematic way (starting with sight) and progressively (first from a distance and then from a close-up, going from an overall approach to minute details). Having gathered these elements, he questions the patient or his entourage to evaluate them in relation to a previous state.
He then uses his “reason” to determine the changes in progress, going back to the past, and “calculating” the future. It is then that he can judge whether to treat, by what means and at what times.
This approach is different from modern diagnosis, which aims to distinguish more and more precisely a particular disease. The Hippocratic physician looked for visible symptoms indicating internal (invisible) changes taking place in a patient. “He was interested in the individual disposition and not in the singular cause. For him, differentiation occurred at the level of the patient, not the disease.
The treatise Prognosis recommends the main observations to be made: examination of the face and eyes, the position of the patient on his bed (placement of the legs and movements of the hands), breathing (rhythm, warmth and moisture of the breath), wounds or abscesses if any, hot or cold sweats, touching of the hypochondria (hardness and sensitivity), warmth or coldness of the parts of the body, sleep disturbances, examinations of the bodily fluids (color, density, odor. . of stools, urine, sputum…).
The treatise Epidemics I and III adds: the diet already prescribed and who prescribed it, the constitution of the atmosphere and the situation of the place, the habits of life and age, the speech, the behavior, the silence and the thoughts, etc. In this treatise, the clinical observations are very detailed accounts, noting the evolution of the illness, day by day, of a particular patient (name, geographical location, social condition), a total of 42 patients in all. There is nothing comparable to these daily reports in all medical texts until the 16th century. Among the first to use this model of detailed observations was Guillaume de Baillou (1538-1616).
The collection of data obtained by the senses (“experience”) is completed by the use of reason or more exactly the faculty of calculating logismos or logizesthai. From there, the author of the treatise On art proposes to pass from the visible to the invisible, i.e. to perceive not only the apparent diseases on the surface of the body, but also those which hide inside. “For what escapes the eyes, all that is overcome by the glance of the intelligence”.
This ability to calculate also allows a prognosis prognosis or “Greek prognosis” which is a distinct prediction from the divinatory or mantic prediction. The role of the Hippocratic prognosis has been variously interpreted by specialists. It could be a way of showing one”s competence by distinguishing oneself from the diviners (Greek prognosis is a “divination” by the “walking” body), while at the same time protecting oneself from accusations of negligence, by indicating the most predictable outcome. “In this way, the physician will be justly admired, and he will exercise his art skillfully; for those whose recovery is possible, he will be even more capable of preserving from peril (…) and, foreseeing and predicting which are those who must perish and which must escape, he will be free from blame” (The Prognosis, 1).” According to A. According to A. Debru, one of the avowed aims of Hippocratic prognosis is also to seduce and to be admired: “they were as anxious to be cured as to escape blame”.
According to Pigeaud, the Hippocratic grasp of the temporal unfolding of illness is “one of the great ancient experiences of time, which contributed to the awareness of duration, as well as of oriented time”. Illness is also a historical process. Analogies have been noted between the historical method of Thucydides and the Hippocratic method, notably the notion of “human nature” as a way of explaining predictable repetitions with a view to future usefulness, for other times or for other cases.
The “Greek prognosis” is also a way of controlling the disease, so that the treatment can be modified at the time of expected events to intervene quickly even in the most dangerous acute diseases. Thus, Hippocratic medicine uses terms such as “exacerbation”, “relapse”, “resolution”, “crisis or paroxysm”, “peak” and “convalescence”.
For example, one of Hippocrates” contributions is his description and prognosis of thoracic empyema (purulent pleurisy), and his determination of the time and site of a pleural puncture with pleural drainage (Of Diseases, II). His basic principle is still valid at the beginning of the 21st century.
The “Hippocratic facies” is the change that occurs in the face as death approaches, or during a long illness. Shakespeare alludes to this description in his account of Falstaff”s death in Henry V Act II, Scene III.
In the treatise Le Pronostic, after saying that the danger is all the greater as the face departs from its usual appearance, the original description is as follows: “The features have reached the last degree of alteration when the nose is pinched, the eyes sunken, the temples sunken, the ears cold and contracted, the earlobes spread, the skin of the forehead dry, taut and arid, the skin of the whole face yellow-black, livid or leaden.” In the same text, the physician may approach to examine the eyes: “If the eyes flee from the light, if they deviate from their axis, if one becomes smaller than the other; if the white becomes colored red, if there appear livid or black veins, if there is chassia around the prunella, if they are agitated protruding from the orbit, or deeply sunken ; if the eyes are dry and dull, all these signs are a bad omen. It will be a bad omen if the lips are loose, hanging, cold and completely blanched. The prognosis (Littré translation).” The text specifies that the physician must confront these observations with interrogation data on causes such as insomnia, diarrhea or fasting. If so, the patient may recover in a day and night. In the absence of these causes, if the patient has not recovered within the same time interval, he or she is near death.
It is a deformity of the tips of the fingers or toes involving only the soft parts and the nails. This digital hippocrasis is also called the “drum stick fingers” sign. It was an important sign, present in cases called today chronic obstructive pulmonary disease, lung cancer, cyanogenic congenital heart disease, etc.
This was a historic clinical maneuver that involved shaking the patient by the shoulders, in order to perceive a possible “succussion sound”, a lapping or fluctuating sound produced by fluid in the pleura during a pleural effusion. The procedure is described in Des Maladies II, to detect which side the sound is on in order to determine the incision site for evacuation of fluid or pus.
This method of immediate auscultation was ignored for a long time, until Laennec, at the beginning of the 19th century, rediscovered it by reading Hippocrates. He tested the method himself to actually hear the fluctuation of the fluid. He paid tribute to the accuracy of Hippocrates, but reproached him for not having understood that the lapping noise implies a collision of air and liquid, and therefore also a presence of air in the pleural cavity (pneumothorax).
The “Hippocratic bench” which is a device for putting bones in traction and the “Hippocratic bandage” are two devices that were named after Hippocrates.
The “Hippocratic reduction” is a reduction of a shoulder dislocation by traction on the upper limb, accompanied by a counter traction in the armpit where the operator pushes with his foot.
The “Hippocratic corpus” and the “Hippocratic Oath” also bear his name.
The laughter or sardonic rictus, caused by the spasm of the muscles of the face, is also sometimes called the “Hippocratic smile”.
The “Hippocratic sock” is a rudimentary filter made of a fabric forming a kind of sock with a string.
A medicinal drink widely used in the Middle Ages, “hypocras”, is also said to have been invented by Hippocrates.
Hippocratic medicine and its philosophy (“Hippocratism”) constitute a medicine “without anatomy, nor physiology” from the modern point of view. It would be situated in the more general framework of the traditional medicines of other civilizations, closer to natural medicines than to modern academic medicine, which is mainly based on the anatomical method and biological sciences.
Hippocratic knowledge is conjectural, based on suppositions founded on appearances (phainomena). In Hippocratic texts (On ancient medicine, 9), the medical art is similar to navigation, it is the pilot of a ship that has to face many moving and changing forces. He must guide this ship to port, knowing how to anticipate the decisive maneuvers at a given moment, under specific circumstances. The physician is distinguished by his experience, for there is no way to reach the exact truth (akribes), the only accepted criterion is the correct (orthόn). The doctor is condemned to make his way, helping himself to all the signs, conjecturing it with opinions (dόxas).
Hippocratic theories are based on observation integrated into a vast set of familiar analogies. The constant moving back and forth within the body is compared to the tending of forests, the stomach is an oven, the uterus a suction cup, the processes of cheese making illustrate the coagulation or separation of liquids in the body, etc. According to Nutton, “it is difficult to judge how seriously to take these multiple analogies and it is perhaps best to interpret them only in their immediate context”, that is, as texts delivered in public to explain and convince.
Body and function
The distinction between anatomy and physiology is of modern origin; the medicine of antiquity included both under the term physis. The anatomical structure is inseparable from its presumed function (final cause or telos). The Hippocratic physician does not practice human dissection, he seeks to reconstruct the interior of the body from surface examination, or from observation of animal dissections. The Hippocratic vocabulary uses many “false friends” terms, still used today but in a completely different sense.
The main organs are distributed in two large cavities separated by the diaphragm.
The arrangement and shape of the bones is on the whole accurate. This precise knowledge can be explained by the study of dislocations and fractures, the main subject of surgical treatises, and the long resistance of bones to decomposition after death.
The muscles are known, but not their property to contract, so they are called “flesh”. It is the ligaments that have the function of holding the whole together and causing movement, these ligaments are called neura, a term that in the Hippocratic context designates both tendons and nerves. This ancient view remains anchored in popular language where the term “nerves” actually refers to ligaments and aponeuroses (all the white parts) in a red meat butcher”s shop.
The body is traversed by phlebic ducts, both veins and arteries without distinction. These ducts distribute blood, air or humours, separately or together. The modern term trachea is an abbreviation of the Hippocratic term trachea-arteria. The number and arrangement of these vessels is variable according to Hippocratic texts, showing that this vascular system or “protovascular” is much discussed during antiquity until Galen. Hippocratic authors can describe in the body the routes of air without involving the lungs, or of blood without mentioning the heart.
According to the texts, the starting point of the vascular system can be the head, the liver, the spleen, or the heart. The arterial pulse is not yet known and is not used for diagnosis. If arterial beats at the temples are well observed, they are seen as a pathological manifestation. This vascular knowledge can be used as a clue to date a Hippocratic text. These texts show the progressive reversal of a point of view: anatomical speculations are first made from medical practice, but the opposite approach tends to impose itself, it is the medical practice which must be based on the observable interior of the body.
The digestive organs are not well known. The stomach does not play an important role, the seat of digestion is the “belly” or “cavity” koiliè under the diaphragm. Digestion is seen as a kind of struggle where human nature triumphs over the nature of the food, or as a kind of cooking in a pot, or fermentation in a vat.
Chicken eggs serve as a model for understanding the development of the human fetus, and the description of the human uterus actually resembles what can be observed in animals. The female uterus is the organ that most stirs the imagination of the Hippocratic physician. The womb can travel suddenly through the whole body, dried up or heated up, it runs towards wetter or cooler organs, from the legs to the head, it is the “womb suffocation”. The matrix seems to have a life of its own, it is like a recalcitrant pet, which can be attracted by sweet flavors or repressed by bad smells.
Menstruation is seen as an absolutely necessary process of purification, of evacuation of bad blood. The fact of not having a normal period was considered very dangerous, and the beginning of the menopause was understood as a stagnation of poison or putrefaction in the woman”s body. These conceptions will have a deep influence until the 19th century.
The brain is seen as a double organ (the two hemispheres) separated by a membrane. The spinal cord remains also vague, according to the author of the treatise Of the Flesh, it is not similar to the marrow of the bones, because it is the only one to have envelopes while being joined to the brain. The author of The sacred disease makes of the brain the seat of the intelligence and the sensation, and refuses the heart or the diaphragm as seats of the emotions. The intelligence proceeds from the brain, receptacle of the sensations, by the intermediary of the air and the blood.
The brain also acts like a sponge, drawing the body”s humors to it to distribute them again. The Hippocratics attribute to the other organs of a spongy nature (lungs, spleen, liver…) a predominant role in the regulation of the humours.
Theory of moods
The Hippocratic texts present different theories on the role and function of the humours (liquid fluids of the body) corresponding to a phase of formation or discussion. This phase leads to an overall theory known as the theory of the four humours, clearly set out in the treatise On the Nature of Man. This treatise is attributed to Polybius, disciple and son-in-law of Hippocrates. This theory became the great Hippocratic theory par excellence, whereas at the time of Hippocrates, it was only a minority viewpoint, still contested by many later authors.
This theory of the four humors had the advantage of being “a system of perfect clarity to account for an entirely obscure inner world”. It links the four humors to the four elements and the four seasons, establishing four temperaments encompassing the body and the soul or spirit (soma and psyche). This last theory, completed and popularized by Galen, is the one that will dominate medical thought until modern times.
The theory(ies) of humours bring together medical empirical data and pre-Socratic philosophical elements. Historians differ on the interdependence of medicine and philosophy (whether one prepared or influenced the other, or vice versa), and there is a debate (in the epistemology of medicine) on the relationship between observation and theory (e.g. whether observation without theoretical pre-suppositions is possible).
Various fluids or liquids flow out of the body in a state of health or from illness and injury: urine, semen, blood, stool, pus, sputum, runoff from the nose or ear. This outward evacuation sets the stage for an inner representation where liquids flow (rhein) into the body. The body is the seat of hydraulics and hydrography, with springs, rivers and mouths, from top to bottom, according to the path of the least obstacle. This conception survives in the popular language “brain cold”, i.e. flow (rheuma) through the nose, coming from a source located higher, the brain.
The Hippocratic texts do not give a fixed number to the main humours, which are two, three or four. Most of them give pathological importance to two fluids, phlegm and bile. Later texts distinguish between yellow and black bile, and the last ones establish four humours (blood, phlegm, yellow and black bile).
Phlegm is a Greek term originally designating a substance associated with combustion or inflammation (it is found in old medical terms such as phlegmasia – inflammation – or anti-phlogistic – anti-inflammatory -, or still current as phlegmon ). In the 5th century B.C., it changed its meaning to designate a cold, white and sticky substance, such as that of the mucus of the nose, of sputum, of certain deposits in the urine… or present in body fluids (today lymph, cerebrospinal fluid, synovial fluid…). In this last sense, phlegm will be called pituitary from the 16th century.
Bile (which will be specified as yellow bile) is present in vomiting and diarrhea, it is an irritant that interferes with proper digestion. Many texts place the diseases between two poles: phlegm and bile with their opposite seasonal occurrences (winter cold and summer dysentery).
Black bile or atrabile appears later, it is first present in the texts, not as a substance, but as a disease “melancholy”, considered as a physical state of transformation of blood or phlegm. Most scholars believe that “black bile only came into existence to explain black bile diseases” before becoming a distinct mood corroborated by the color of warts, nevi, wounds and scars, and hemorrhages of black venous blood.
Finally, this black bile can be opposed to the red blood which maintains and gives life.
If Hippocratic medicine is influenced by the pre-Socratic philosophers, it also seeks as medicine to assert its autonomy. It is here that the Hippocratic texts diverge, even appearing to polemicize among themselves.
Texts, known as philosophical medicine, are based on the primacy of natural philosophy to establish the nature of man in order to practice medicine. One would find there the various influences of Anaxagoras, Heraclitus, Empedocles, Democritus… Thus the treatise On the winds makes air the essential constituent element, which is close to Anaximene of Miletus. Other treatises are based on two elements (fire and water, Of the Regime) or on three (fire, earth and air, Chairs), etc.
De la nature de l”homme also rejects philosophical medicine based on a single, two or three constituent elements of the universe, insufficient systems to account for the totality of medical phenomena. The “true medicine” must be based on the bodily humors such as they can be observed according to the individual constitution idiosyncrasy, the diet, the places, the climate, the seasons… The author then presents his own model, using that of Empedocles (4 cosmic elements linked to 4 fundamental qualities) for its explanatory potential.
According to this model, “the human body is composed of four humours whose correct temperament is the condition of health”. Disease is considered to evolve in three phases:
The “crisis” is the precise and decisive moment when everything can change: either the disease begins to triumph, and the patient can succumb, or conversely, healing begins, and the patient can recover. These seizures are supposed to come back on regular “critical days”. If an attack occurs on a day far from a “critical day”, this attack is definitively decisive (Of Epidemics I, 3).
Thus are distinguished the affections of even and odd days, of different periods, as well as the fevers quartes, quintanes, septanes, nonantes… It is a kind of numerology, where the number plays a role of organizing principle, similar to that of Hesiod (good and bad days) or Pythagoras (proportions and harmony). It is a mysticism of numbers which, starting from the clinical reality of intermittent fevers, seeks to understand the course of all illnesses.
If there is a break with the magical and incantatory means, there is also a continuity with the other means already known, three in number: the remedies, the incisions (“the iron”), the cauterizations (“the fire”).
More than 380 names of plants (in great majority), animal and mineral substances are found in the Corpus. Most of them have been identified, at least generically. The dosage is approximate, and the prescriptions do not always correspond to modern data, for example flaxseed oil is not used as a common laxative, but to treat uterine diseases.
If the value of many remedies can be confirmed from the modern point of view, there are also uses of a magical or symbolic nature, particularly in the gynecological field.
These remedies aim essentially at evacuating bad humors by the top (vomiting, expectorants…), or by the bottom (purgatives, diuretics…). To this can be added fumigation, steam baths… One of the most powerful remedies, then discussed, was hellebore. Several Hippocratic texts warned against the harmful effects of “superpurgation”; these were the first texts to expose excesses, accidents and therapeutic errors, or iatrogenesis.
In general, Hippocratic medicine was very respectful of the patient, the treatment was gentle, while seeking to keep the patient clean and prevent any aggravation. For example, clean water or wine was used to prepare the incision sites. Soothing balms (emollients) were sometimes used.
They are intended to evacuate impure liquids, when remedies have not been sufficient. Bloodletting is the most frequently used method. The texts give a list of the many points where bleeding could be done, based on the state of the disease and the strength of the patient.
One method often used was scarified cupping, where a small incision is made followed by the application of a suction cup.
The incision is also used to evacuate pus from an abscess, effusion fluids or other suppurated collections.
In addition, hemorrhoids, thought to be caused by excess bile and phlegm, were treated by excision and cauterization. Other treatments such as the application of various balms were also proposed. The uses of the rectal speculum, a common medical device, are outlined in the Hippocratic Corpus. This constitutes the first known reference to endoscopy.
The surgical treaties are mainly joints, fractures, head wounds… There is advice on the reduction of dislocations and simple fractures. The author shows a good knowledge of typical injuries and all kinds of fractures. His technical mastery allows him to perform even trepanning (removing a piece of cranial bone). He distinguishes a simple crack of the apophysis of a vertebra (painful but not serious) from a fracture-luxation of the vertebral body, which is much more dangerous.
Dietetics holds a central place in Hippocratic therapeutics. According to texts such as On Diet (around 400 BC), On Food, On Diet in Acute Diseases, it is the surest way to treat the disease and this, from the beginning.
According to this approach, dietetics is based on four ideas:
Food and beverages
In Hippocratic dietetics, foods are classified according to their properties corresponding to the four humours. They can warm or cool, moisten or dry. Others relax the belly or tighten it, are nourishing or slimming, cause expulsion or wind. As in traditional Chinese medicine, to stay healthy throughout the seasons, one must have a balanced diet appropriate to the needs of the moment. The diet thus varies according to the place, the climate and the seasons which influence the moods.
After Hippocrates, the most remarkable physician of antiquity was Galen. In the second century AD, he wrote more than 25 works of commentary on Hippocrates in Greek. Galen presented Hippocrates as a model for his contemporaries, reproaching them for praising him in word, without imitating him in deed. Most of these commentaries have been preserved in Greek or Arabic.
The Aphorisms are the most studied Hippocratic text in medical schools until the 16th century.