An incredibly brief history of medicine
Medicine at the bedside
Hippocrates and all that
Hippocrates has become the favoured Father for healers of all stripes. Homoeopathists find in the Hippocratic writings the roots of their doctrines. Naturopaths, chiropractors, herbalists, and osteopaths invoke him as the founder of the ideals that underlie their own approaches to health, disease, and healing. So do modern hospital consultants, many of whom would have repeated his Oath, or a version of it, when they took their medical degrees.
The reasons for this curious state of affairs can be found in history. For one thing, the historical Hippocrates is sufficiently shadowy to allow a multiplicity of interpretations to be hung from him. He is shadowy but real. He lived on the island of Cos, off the coast of present-day Turkey, from about 460 BCE to 370 BCE. This makes him a bit older than Plato, Aristotle, and the other cosmopolitan creators of classical Greek culture, centred in Athens. His antiquity makes the survival of so many ‘Hippocratic’ works that much more remarkable; people save what they particularly value.
Besides where and approximately when he lived, we know only a little more. He practiced medicine, took pupils for a fee, and had a son. He also achieved a fair degree of fame, since Plato mentioned him. Whether he actually wrote any of the works attributed to him is less clear. He certainly did not write them all, for they were composed over about two centuries by various unknown hands. This means that the Hippocratic Corpus, the 60 or so works and fragments that survive, contain much inconsistency and many points of view. These ‘Hippocratic’ writings cover many aspects of medicine and surgery, as well as diagnostics, therapeutics, and disease prevention. The Hippocratics offered advice on diet and other aspects of healthy living, and there is a particularly influential treatise on the role of the environment in health and disease. There were thus many ‘Hippocratic’ stances, and our ‘Hippocratic medicine’ is a historical construct, achieved by picking out certain themes and theories, and putting them together in a framework that was unknown during the centuries of the composition of the treatises.
Amidst this multiplicity, however, there is one strand that runs through the whole corpus, and makes Hippocrates so attractive to so many modern healers. Hippocratic medicine is holistic. The Hippocratic approach is always to the whole patient and the modern yearning for a holistic medicine finds a natural resting place there. Despite its admirable, positive characteristics, this holism was also rooted in cultural values widespread in Greek society. The ancient Greeks disliked dissection of human bodies. They performed no autopsies to determine the cause of death, and Greek doctors taught no deep anatomy to their apprentices. There were no medical schools in the modern sense of the term.
Students learned through their masters, and what they knew was surface anatomy and a shrewd sense of looking carefully at their patients for signs suggesting the likely course of the disease, that is its prognosis, and, especially, whether the patient was likely to recover or not. That there were no hospitals meant that the bedside of this chapter’s title was literally the patient’s, in his or her own home.
These structures of ancient Greek medicine make it the prototype of modern primary care. The Hippocratic doctor needed to know his patient thoroughly: what his social, economic, and familial circumstances were, how he lived, what he usually ate and drank, whether he had travelled or not, whether he was a slave or free, and what his tendencies to disease were. The theoretical reasons for this were embedded in the Hippocratic writings.
If the holism attracts modern complementary healers to the Greek, there are other attributes to Hippocratic medicine that resonate within contemporary scientific medicine. The most important of these is its underlying naturalism. The medical systems of the ancient Near East – Egypt, Syria, Mesopotamia, and Babylonia – combine theology and healing. The priest-physician is a common trope.
Disease was widely assumed to be the result of divine displeasure, transgressions of various kinds, or magical forces. Diagnosis might involve prayer, interpreting animal entrails, or determining how the patient had transgressed. This mix of magico-religious medicine was also part of the Greek landscape during the Hippocratic period. Healing temples dedicated to the Greek god of medicine, Asclepius, were dotted all over the Greek sphere of influence, including, ironically, a famous one in Hippocrates’ own backyard, Cos itself. The most substantial one was on the mainland, at Epidaurus, the extensive remains of which are still extant. These temples were in the hands of resident priests who received patients and interpreted illness on the basis of dreams that patients reported to them. The dreams were probably affected by the presence of holy snakes, which undoubtedly disturbed sleep patterns. By sloughing its skin, the snake was an example of renewal, and a prominent part of the caduceus, symbol of the Greek god of healing (see Figure 4). Curiously, Asclepius and the caduceus, both redolent of magic and religion, have been naturalized as an emblem of modern medicine.
These healing temples were an important part of Greek medical care but the values they embodied had little impact on the Hippocratic Corpus. The treatises that form it assume that disease has a natural cause, but only once does a Hippocratic author explicitly attack supernatural explanations of disease. This occurs at the beginning of a treatise on epilepsy, called ‘The Sacred Disease’ in common Greek parlance. It was deemed sacred because epileptic attacks were dramatic, causing as they do a loss of consciousness, foaming at the mouth, relaxation of muscle, bladder, and sphincter control, but also included psychological symptoms which sufferers could sometimes turn to their advantage.
Alexander the Great and (later) Julius Caesar were powerful epileptics in antiquity. The opening sentences of ‘The Sacred Disease’ have been interpreted as a clarion call for a complete naturalism within medicine. They are still compelling, written as they were more than two millennia ago: It is thus with regard to the disease called Sacred: it appears to me to be nowise more divine nor more sacred than other diseases, but has a natural cause from which it originates like other affections. Men regard its nature and cause as divine from ignorance and wonder, because it is not at all like to other diseases. And this notion of divinity is kept up by their inability to comprehend it, and the simplicity of the mode by which it is cured, for men are freed from it by purifications and incantations. But if it is reckoned divine because it is wonderful, instead of one there are many diseases which would be sacred.
It is significant that the stance is not irreligious (‘nowise more divine nor more sacred than other diseases’), but couched within a framework that could offer an explanation within naturalist terms of the origins of this so-called sacred disease. The Hippocratic author goes on to offer such an explanation: epilepsy is caused by blockage within the brain, so that the regular expulsion of phlegm is stopped, thereby producing malfunctioning of the brain, and the dramatic symptoms of the epileptic seizure. Two further implications are worth noting.
First, this Hippocratic author located consciousness and other mental functions to the brain. And men ought to know that from nothing else but the brain come joys, delights, laughter and sports, and sorrows, griefs, despondency, and lamentations. And by this, in an especial manner, we acquire wisdom and knowledge, and see and hear, and know what are foul and what are fair, what are bad and what are good, what are sweet, and what unsavoury; some we discriminate by habit, and some we perceive by their utility.
The centrality of the brain is of course now a commonplace in scientific thinking, but it was not so with the Greeks. Plato followed Hippocrates in viewing the brain as the seat of psychological activity, but Plato’s pupil Aristotle believed that the heart is the centre of emotion and other mental functions.
After all, when we are anxious or in love, it is in the breast, or heart, not the brain, that we experience such events. The heart, not the brain, beats faster when we are most alive. Besides, Aristotle, an experienced student of embryological development, noted that the first sign of life in the developing chick embryo was the motion within the primitive heart. Almost two millennia later, Shakespeare was to recall this old debate:
Tell me where is fancy bred.
Or in the heart or in the head?
Despite our language, which still attributes much to the ‘heart’, Hippocrates and Plato won that debate.
The second significant point to tease out of this treatise relates to the Hippocratic cause of epilepsy: blocked phlegm. Phlegm might seem the sign of a common cold to us, but it was for the Hippocratics one of four humours, which were constitutive of health and disease, and thus at the heart of Hippocratic physiology and pathology. Although humoral doctrine was not contained in all of the Hippocratic treatises, it can be pieced together and was interpreted by the other giant of ancient Greek medicine, Galen (AD 129-c. 210), as central to medical theory. Galen gave humoral medicine such prestige that it dominated medical thinking until the 18th century.
Humours: the complete system
The four humours were blood, yellow bile, black bile, and phlegm; they constituted a formidable framework for understanding health and disease, and much else besides. They eventually embodied a theory of temperaments, which provided a guide to human personality and susceptibility to disease. The properties of the humours – heat, cold, dryness, moistness – offered a parallel reading of the course of diseases, and of the stages of the individual life cycle. Each of the humours was also linked to one of the four elements – air, fire, earth, water – which Greek natural philosophy posited as the constituents of all the things in the sublunary world. Below the moon, in our world, things change, grow old, and die. Above the moon, perfect circular motion was postulated as the norm, with stars made of a fifth element, the ‘quintessence’.
Taken as a whole package, Greek humoralism was the most powerful explanatory framework of health and disease available to doctors and laymen until scientific medicine began gradually to replace it during the 19th century.
Bodily fluids and their effects are features that someone caring for a sick person notices. The skin becomes flushed when the sick person is febrile; people cough up phlegm or blood; eyes water and noses run; the urine turns dark if there is jaundice or dehydration; the skin can become clammy, sweaty, or pale; and diarrhoea or vomiting may be prominent features of illness. Greek cultural prohibitions against dissecting human bodies meant that the Hippocratics had relatively little knowledge of deep anatomy, or it was inferred from animal dissections or knowledge acquired through preparation of animals for eating. This did not seem to bother the Hippocratics very much, although Galen later tried very hard to provide anatomical knowledge, largely through dissecting animals.
Humoral medicine does not require all that much knowledge of anatomy, since the operative elements are the bodily fluids, not the solids. Each of the humours was identified with a bodily organ, however: phlegm with the brain, blood with the heart, yellow bile with the liver and black bile with the spleen. Further, in the surgical treatises of the Hippocratic writings, these doctors also discussed the setting of fractures, reduction of dislocated joints, wound treatment, and simple operations for various specific conditions. Surgical work, then as now, requires a much more focused orientation on a particular area of the body. But Hippocratic medicine remained holistic and preoccupied with interpreting the changes of the humours.
Humoralism brought with it two related and enduring themes within Western medicine: balance and moderation. The Hippocratics viewed health as the result of a sound balance of the humours. Imbalance, too much or too little of one or more of them, or an imperfect quality (often described as a corruption) of one of them produced disease. The body was sometimes regarded as a kind of oven, with cooking metaphors prominent in Hippocratic descriptions of disease. Excretions in disease – pus, sweat, expectorated phlegm, concentrated urine, vomitus, diarrhoea – were interpreted as the products of natural defence mechanisms. The body often cooked, or concocted, corrupt or excess humours, to enable the better removal of the surfeit or the peccant humours, and restore a balance.
The Hippocratics interpreted this bedside observation – of the body getting rid of humours – as evidence of what they called the vix medicatrix naturae, the healing power of nature. This doctrine has long been debated within medicine, and it was codified in the 19th century with the concept of ‘self-limited disease’. A powerful modern medicine is able easily to accommodate it: most disease, treated or untreated, is self-limited. Treating the symptoms of a cold, for example, may make one feel better, but it never really touches the cause, which in due course the body generally deals with. Every doctor knows this, but they also know that the prescription that makes the patient feel better is often interpreted as curative. Post hoc, ergo propter hoc: ‘after, therefore, because of’: a lot of clinical medicine has always relied on this logical fallacy.
The Hippocratics were more modest, and the doctrine of the healing power of nature gave rise to two of their most important aphorisms: ‘Natural forces are the healers of disease’, and ‘As to diseases, make a habit of two things – to help, or at least do no harm’. Therapy was thus aimed primarily at assisting the patient’s body do its ‘natural’ work. Some of their procedures jar with modern sentiment.
Bloodletting, for example, had a rational basis, since local inflammation, or the flush of fever, was easily interpreted as evidence that the body had too much blood, and therefore needed aid in ridding itself of it. Bloodletting is one of the oldest and most persistent therapies, and the one most often held up as evidence of the crude barbarity of medicine until the modern period. It continued to be a mainstay of therapeutics until the mid-19th century, and was abandoned only gradually and reluctantly by rank and file practitioners. Patients often demanded it, and many of them reported being helped by having blood let, sometimes so much that the doctor stopped only when the patient was on the point of fainting. As another Hippocratic aphorism put it, ‘For extreme diseases, extreme strictness of treatment is most efficacious’, often made more pungent: ‘Dangerous diseases require dangerous remedies’.
In general, however, humoral therapy was mixed, and included diet, exercise, massage, and other modalities that were aimed at the individual needs of the individual patient. It was this holistic individualism that was the core feature of their medical practice. Although Hippocratic writings contain descriptions of many diseases to which we can give modern labels, they never separated the disease from the individual sufferer. Thus, although we can find accounts of diseases we might call consumption (tuberculosis), stroke, malaria, epilepsy, hysteria, and dysentery; these are presented as events that happened to individual people. They used these experiences to come to generalizations about how to deal with these diseases, presented as aphorisms and what we would now call ‘clinical pearls’. Their humoral explanatory framework always encouraged them to tailor particular treatments to unique cases.
The Hippocratics were also acutely aware that diseases often sweep through a community, affecting the old and young, rich and poor, thin and corpulent, male and female: just those attributes that at the bedside they strove to take into account when making a diagnosis and recommending a therapeutic regimen. In two particularly influential treatises, a series of books on Epidemics, and one entitled Airs, Waters, Places, the Hippocratic writers offered reflections about these wider aspects of disease. Airs, Waters, Places is essentially the foundation statement of Western environmentalism, especially as it relates to health and disease. It offered advice on where to build one’s house (well drained soil, protected from chilling winds), and analysed the health of communities in terms of the environmental factors that impinged on their inhabitants. Like most medical and biological thinking until the late 19th century, it espoused what is now called (anachronistically) ‘Lamarckianism’; that is, the Hippocratics believed that environmental factors could change the basic characteristics of human beings (skin colour, body shape, and so on), and that these changes could be passed on to offspring. This is an optimistic philosophy of human malleability, consonant with the general Hippocratic confidence that their therapeutic regimen had much to offer to its patients. At the same time, their writings are full of occasions when experience taught that the disease was so far advanced or serious that there was little to be done.
